International Journal of Ostcoarcbacology, Vol. 2: 245 -261 (i992)

Pre-Columbian Congenital Syphilis from the Late Antiquity in France GYÖRGY PÀLFI,1 2 4 OLIVIER DUTOUR,1 3 MARC BORREANI,4

JEAN-PIERRE BRUN4 AND JACQUES BERATO4 5

^Laboratoire d'Anthropologie et Préhistoire, Université de Provence, 29, av. R. Schuman, 13621 Aix-en-Provence, France; department of Anthropology, József Attila University, H-6701 Szeged, PO Box 660, Hungary; ^Laboratoire de Géologie du Quaternaire, CNRS, Case 907, 13288 Marseille Cedex 9, France; ^Centre Archéologique du Var, 14, bd. Bazeilles, 83000 Toulon, France; and ^Centre de Rhumatologie Gimelli, 83000 Toulon, France

ABSTRACT Today, exactly 500 years after the discovery of America, there is still a lot of controversy about the history of syphilis in Europe, especially about the Columbian and pre-Columbian hypotheses. . This paper presents evidence for the presence of venereal treponematosis in the late Antiquity in France.

The case that we examined comes from the necropolis of Costebelle (3rd-5th centuries AD; Hyeres, Var, France). Grave no. 1 contained the well-preserved skeleton of a relatively old woman with the skeletal remains of an approximately 7-month-old fetus in her pelvic cavity.

The osseous lesions of the fetal remains can be described in four groups: periosteal appositions on the skull vault (frontal and parietal); signs of periostitis on the long bones (bilateral cortical irregularities, predominantly on the left side, which affect first of all tibiae, femora, fibulae, radii and humeri, particularly in the metaphyseal region); some infraperiosteal detachment reminiscent of an infraperiosteal haematoma surrounding the distal extremity of the left forearm and the left hand; and finally, the irregular lesions of the humeral distal and proximal tibial metaphyses reminded us radiologically of Wimberger's signs.

The most probable diagnosis of all the lesions mentioned above is that of a precocious congenital syphilis. This case consists of an argument against the epidemiological theories about the migration of Treponema pallidum from the New World back to the Old World starting at the end of the 15th century.

Keywords: Treponema pallidum, congenital syphilis, late Antiquity, France.

Introduction

In 1989, du r ing the rescue excavation of an antique rural habitat at the site of Costebelle (Hyeres, Var , France), 26 human burials were d iscovered . A c c o r d i n g to the archaeological data, the cemetery was in use between the 3rd and 5th centuries A D . 1 A n an th ropo log ica l s tudy o f the skeletal remains was under taken b y t w o of us ( O . D u t o u r and J . Berato, 1991).2 A large n u m b e r o f skeletons were incomple te o r fragmentary, w i t h the except ion o f a female skeleton i n a g o o d state of preservat ion f rom grave no . f . T h i s b u r i a l belongs to a g r o u p o f about ten graves under tiles, w h i c h can be dated p r o b a b l y f r o m the 4th cen tu ry AD. '

1047-482X/92/030245-17$ 13.50 © 1992 by John Wi ley & Sons, L t d

T h e most remarkable characteris t ic feature o f this i n h u m a t i o n is the presence of a fetal skeleton in the pe lv ic c av i t y o f the female skeleton. Figure 1 presents the elements o f this re la t ive ly comple te and fa i r ly well-preserved fetal skeleton, w h i c h includes v e r y fragile small pieces such as the t ympan ic annuluses. A c c o r d i n g to different m e t h o d s , 3 - 6 t he age o f t he fetus can be de te rmined as about 7 months (7.7 lunar months) , w i t h a he igh t o f about 40-41 cms. O u r age de t e rmina t ion and the loca l iza t ion o f the fetal skeleton in the pelvic cav i ty o f its mothe r exclude the hypothesis o f a death i n c h i l d b i r t h . 7

T h e s tudy of the maternal skeleton p r o v i d e d some discordant elements w i t h this pregnant c o n d i t i o n : t y p i c a ' lesions o f a precocious

Received 27 January 1992 Accepted 26 June 1992

Figure 1. Remains of the fetal skeleton from grave no. 1.

polyar thros is and signs o f a hyperostosic disease suggest a relatively elderly age. As far as the anthro­pological examination is concerned, the age o f the skeleton can be estimated as 52.75 ± 2.5 years b y the complex m e t h o d . 8 By k n o w i n g the diff icult ies o f age de te rmina t ion i n a d u l t s 9 1 0 and c a r r y i n g o u t a more careful age es t imat ion, we can consider that the w o m a n must have been i n her fifties, so the most probable diagnosis is a late pregnancy . 2

Description

T h e great impor tance o f o u r case—orig ina l because o f the late age o f the g rav id i ty—res ides essentially in the presence o f the pa thologica l lesions o f the fetal skeleton. Figure 2 presents the schema o f a fetal skeleton, i nd i ca t i ng the pathologica l areas.

Figure 2. Schema of the fetal skeleton (except the ribs and vertebrae), Indicating pathological areas (after Tillier and Duday 3 9 ) . Hatched: normal bones; black: affected bones; white: missing bones.

T h e osseous lesions o f the fetal remains can be descr ibed in four groups: periosteal apposit ions o n the skul l vaul t ; signs o f periost i t is o n the l o n g bones; some infraperiosteal detachment w i t h para­diaphyseal ca lc i f ica t ion; loss o f metaphyseal substance o f the l o n g bones.

T h e periosteal appositions o f the skul l vaul t can be observed o n the r i g h t hemi f ron ta l (Figures 3 and 4) and o n b o t h parietals (Figures 5 and 6). T h e extensive new bone fo rma t ion , deve lop ing i n the f o r m o f i r regular apposit ions, is macroscopica l ly and rad io log ica l ly w e l l detectable (Figure 7). Several l y t i c loc i (Figure 8) are surrounded b y the above-ment ioned periosteal apposit ions o n the cranial fragments (Figure 7). Bo th t empora l bones are affected b y l y t i c lesions and periosteal

Figure 5. Fragment of the right parietal.

Figure 6. The left parietal bone.

apposit ions. T h e left maxil la presents des t ruct ive lesions and signs o f new bone formation, especially in the alveolar reg ion (Figure 9). T h e c r o w n o f the incisor shows superficial i r regular i t ies . T h e n in th , tenth and eleventh ribs o n the left side have

some destructive changes and superficial calcifica­t ions (Figures 10 and 11).

T h e co r t i ca l i r regular i t ies o f the l o n g bones (Figures 12-15) are widespread, bi lateral and w i t h a left-side dominance . T h e affected bones are the

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Figure 5. Fragment of the right parietal.

Figure 6. The left parietal bone.

apposit ions. T h e left maxi l la presents des t ruc t ive lesions and signs of new bone formation, especially in the alveolar reg ion (Figure 9). T h e c r o w n o f the inc isor shows superficial i r regular i t ies . T h e n in th , tenth and eleventh ribs o n the left side have

some destructive changes and superficial calcifica­t ions (Figures 10 and 11).

T h e co r t i c a l i r regular i t ies o f the l o n g bones (Figures 12-15) are widespread, bi lateral and w i t h a left-side dominance . T h e affected bones are the

250 G. Pàlfi et al.

Figure 9. New bone formation and superficial irregularities on the alveolar region of the left maxilla.

Figure 10. The ninth, tenth and eleventh left ribs.

t ib iae , femora , f ibulae , r a d i i and h u m e r i , par t icu lar ly in the metaphyseal region (Figure 16).

T h e distal e x t r e m i t y o f the bones o f the left forearm are su r rounded b y a c i rcumferen t i a l paradiaphyseal ca lc i f ica t ion (Figures 17 and 18).

T h e new bone fo rma t ion , w h i c h can be seen c lear ly rad io logica l ly (Figure 19), shows an aspect of infraperiosteal de tachment reminiscent o f an extended infraperiosteal haematoma. T h e bones o f the left hand (Figure 20) and the bones of the

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Figure 11. Periosteal appositions on the tenth left rib.

left foo t (Figure 21) are affected b y the same process.

T h e irregular loss o f substance is present in the metaphyseal regions o f the left humerus (Figure 22), ulna, radius and t ib ia (Figure 23). O n the left side there is a loss of the external part of the p r o x i m a l t i b i a l metaphysis; jus t be low this a l tera t ion, a co r t i ca l lacuna can be observed (Figure 24). A l t h o u g h we cannot f i n d such characteris t ic bone loss o n the r i g h t side, the p r o x i m a l end o f the r i g h t t ib ia presents the signs o f an os teo ly t ic metaphyseal lesion (Figure 25). Radio logica l ly , these lesions show a bi la teral n o t c h e d aspect, more accentuated o n the left p r o x i m a l t i b i a l metaphysis (Figure 19).

Figure 12. The right femur.

Discussion

T h e first i m p o r t a n t step in a palaeopathological analysis, especially in o u r case, is t o discuss the possibi l i ty o f t aphonomic processes. T h e posit ive lesions (periosteal apposit ions, paradiaphyseal c a l c i f i c a t i o n s , e t c . ) are, i n o u r o p i n i o n , indisputable and t hey have to be considered as in vivo processes. T h e p a l a e o p a t h o l o g i c a l in te rp re ta t ion o f the os teo ly t ic lesions is more d i f f i cu l t . H o w e v e r , we can observe that these

Figure 17. Circumferential paradlaphyseal calcification of the bones of the left Figure 18. Osteolytic and proliferative changes of the left ulna and radius, forearm.

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Figure 20. Ankyloses of the bones of the left hand caused by paradiaphyseal calcification.

Figure 21. Severe pathological alterations of the left

Figure 22. Metaphyseal loss of substance of the left humerus.

al bones.

processes are, i n al l o f the cases, associated in the same area o f the bone w i t h per ios t i t ic lesions. Fur the rmore , i t is possible to observe, near the des t ruc t ive area o f the left t ib ia , a co r t i ca l lacuna tha t cannot be considered as a pos t -mor tem alteration (Figure 25).

T h e loss o f the t rabecular bone general ly represents a we l l -de l imi ted aspect (Figures 15 and 23). In the distal par t o f the left humerus , the des t ruc t ion o f the metaphysis c lear ly shows that an inner smoo th surface has taken the place o f the n o r m a l t rabecular bone (Figure 22). T h i s s t rong ly suggests the loca t ion o f a metaphyseal abscess. T h e general aspect o f this lesion corresponds to an infect ious process. I t is not iceable tha t the o ther l o n g bones are w e l l preserved.

T h e argument o f t a p h o n o m i c processes is, i n this c o n d i t i o n , grea t ly weakened. W e are thus conf ident that these destruct ive lesions are indeed due t o pa thologica l processes. There fo re , the pa laeopa tho log ica l analysis reveals osseous alterations o f an ev ident ly infectious or ig in in this 4 t h - c e n t u r y f e t u s . " 1 2 A e t i o l o g i c a l l y , all the infect ious agents unable to pass t h r o u g h the placental bar r ie r can be ignored . In different ial diagnosis, infect ious agents capable o f causing an intra-uterine infect ion must be taken in to account.

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Figure 25. Osteolytic metaphyseal lesion on the proximal end of the right tibia.

A m o n g the viruses penet ra t ing the placenta, rubel la , cy tomegalo- and toxoplasmovi rus can cause osseous consequences, b u t always in the form of a specific calcification disorder or a general decrease o f b o n y m i n e r a l i z a t i o n . 1 3

Conce rn ing bacterial pathogens associated w i t h in t ra-uter ine infect ions, Listeria monocytogenes, Treponema pallidum, Mycobacterium tuberculosis and Campylobacter fetus are the most frequent causal agents. Bacterial infections o f transplacental o r ig in may result i n in t rau ter ine fetal death, abo r t i on , p rematur i ty , in t rauter ine g r o w t h re tardat ion or a congeni ta l i n f e c t i o n . 1 4

Early in gestation, listeriosis results in fetal death and abortion. D u r i n g the final months of pregnancy, placental and fetal infection becomes disseminated and the fetus has widespread lesions in the intestines and lungs, as w e l l as in the l iver . T h e presence o f a small mononuclear cell granulomata w i t h central necrosis is character is t ic . 1 5

T h e usual c l in ica l p ic ture o f Campylobacter infect ion includes abort ions, meningoencephalit is and p rematu r i ty , based o n repor ted cases. Congeni ta l tuberculosis is decidedly rare. Lesions may be found in the placenta and l iver o r in the respiratory t r a c t . 1 6

A p a r t f rom the above-mentioned bacterial infections o f transplacental o r ig in , o n l y infect ion w i t h Treponema pallidum (causing congenital syphilis) may produce detectable and distinguishable osteological symptoms beside other severe fetal d i s ea ses . 1 3 1 6 1 7 Congenital syphil i t ic infection may result i n fetal death, severe disease or an apparently asymptomatic i n f a n t . 1 5 Syphi l is - l inked fetal death happens most frequently between the 6 th and 8th months o f the p regnancy . 1 8

T h e bone lesions in syphi l i t i c fetuses are characteristic and widespread in the body. Syphili t ic os teochondr i t i s , os teomyel i t i s and osteitis, and syph i l i t i c periost i t is are the most c o m m o n types o f l e s i o n s . 1 6 1 9 ' 2 0 S y p h i l i t i c os teochondr i t i s is charac ter ized b y the presence o f lesions at the j u n c t i o n o f the metaphysis and epiphyseal carti lage. The re , submetaphyseal rarefact ion and loss o f bone cor tex occur , especially in the l o n g bones o f the l imbs . T h e areas o f rarefact ion tha t may be seen in many of the l o n g bones and especially at the upper aspect o f the t ibiae are ca l led 'Wimberger ' s s i g n ' . 2 0 2 1 In cases o f fetal syph i l i t i c os teochondr i t i s , sclerosing i r regular granulation tissues can be produced between bone and carti lage. Infraperiosteal haematomas may ra re ly o c c u r . 1 8 Os teomyel i t i s and osteitis, as s h o w n b y resorp t ion o f various parts o f the ends o f the bones as w e l l as o f the shaft and cor tex , may also o c c u r . 1 5 Periostitis is ra re ly seen as the o n l y lesion present; i t often occurs w i t h advanced os teochondr i t i s and affects ma in ly t ibiae, h u m e r i and o the r l o n g bones o f the s k e l e t o n . 1 9 , 2 2

T h e r e are few references in the l i tera ture to periost i t is o r o the r lesions due to congeni ta l syphi l is o n the fetal skul l , b u t some rare cases o f localized periosteal th ickening o f the cranial bones w i t h necrosis have been descr ibed b y a few a u t h o r s . 1 8 2 0 2 3

In the present case, the detected osseous alterations cor respond to the c r i t e r ia o f an ear ly congeni ta l syphilis,- the m o r p h o l o g y and the pat tern o f the per ios t i t ic changes and osseous resorptions are ident ica l w i t h the cases presented

Pre-Columbian Syphilis from Prance 259

b y N a b a r r o 2 0 (Figures 16, 17, 19 and 25). T h e loss o f substances and the rarefactions o f some long bones, no tab ly at the upper aspect o f the left t ibia , present the characteristic Wimberger ' s sign rad io log ica l ly (Figure 19) . 2 1 A l t h o u g h the r igh t -hand side alterations are not so developed as those on the left, the X- ray p ic tu re c lear ly reveals the b i la tera l i ty o f Wimberge r ' s sign in the t ibiae, w h i c h is one o f the most characterist ic c r i te r ia o f congeni ta l syph i l i t i c o s t e o c h o n d r i t i s . 2 0 2 2

T h e infraperiosteal de tachment (Figures 17-19) is reminiscent o f an infraperiosteal haematoma. T h e pathologica l alterations seen o n the skul l fragments can be explained as a possible case o f the re la t ive ly rare cranial loca l iza t ion o f the syph i l i t i c disease (Figures 3 - 9 ) . 2 3 There fo re , the most probable diagnosis o f the above-ment ioned fetal lesions is one o f a precocious congeni ta l syphi l is .

W e can suppor t the ae t io logy o f a venereal syphil is , because non-venereal treponematoses, a priori, do no t cause in t rau ter ine i n f e c t i o n s . 2 4

Treponemas o f yaws, endemic syphi l is o r p in ta cannot pass th rough the placenta and do not cause any fetal d i so rde r s . 2 5

Treponemas are k n o w n t o cross f r o m the maternal to the fetal c i rcu la t ion as early as the 9 th week of gestation. In fact, the mother herself is most infectious to the fetus in early disease, and almost every pregnancy in the first year o f infec t ion w i l l be i n v o l v e d . Later pregnancies w i l l be affected less f requent ly and less severely and after 4 years there is l i t t l e danger, even i f the w o m a n has no t been t r e a t e d . 2 6

As the osseous manifestations o f ter t iary syphilis develop signif icant ly later, i t is no t surpr is ing that the maternal skeleton does no t present any syphi l i t ic alterations. K n o w i n g the archaeological con tex t o f ou r subject, we ar r ive at a basic quest ion: as the above-ment ioned skeletons are dated f rom the 4 th c e n t u r y (or, say, f r o m the p e r i o d o f the 3 r d - 5 t h centuries) AD, these pathologica l alterations present evidence for the presence o f syphi l is i n Europe, n o t a b l y in the Medi te r ranean Basin, i n the A n t i q u i t y .

T h e r e has been m u c h con t rove r sy about the p a l a e o p a t h o l o g i c a l o r i g i n , h i s t o r y a n d ep idemio logy o f syphi l i s . W e k n o w at least three hypotheses, namely the p r e -Co lumbian , C o l u m b i a n , and U n i t a r i a n , 2 7 * 2 9 w h i c h a t t empt

to explain the o r i g i n and spread o f syphi l i s . As far as the geographical o r i g i n o f the disease is concerned , the t w o fundamenta l ly opposed theories are the p r e - C o l u m b i a n and C o l u m b i a n hypotheses. T h e first one (or the ' f irst ones', i n c l u d i n g t h e h y p o t h e s e s o f C o c k b u r n , 3 0

H a c k e t t 3 1 o r B r o t h w e l l 3 2 ) argues tha t syphi l is — i n venereal o r i n endemic f o r m — w a s present i n Europe f r o m the A n t i q u i t y . T h e C o l u m b i a n hypothesis says tha t syphi l is o r ig ina ted in the Amer icas and was ca r r i ed o u t to Europe b y Columbus's crew in 1493. T h e latter was kept alive for a l o n g t ime b y the p o v e r t y o f p r e - C o l u m b i a n os teoarchaeologica l data a b o u t syph i l i s i n E u r o p e 3 3 a n d t he l a rge r n u m b e r o f w e l l -documented cases in the N e w W o r l d . 2 9 ' 3 4 3 5 T h i s unevenness in the n u m b e r o f cases l ed several a u t h o r s , s u c h as G r m e k 3 3 o r Baker a n d A r m e l a g o s , 2 7 t o s u p p o r t t h e C o l u m b i a n hypothesis . In o u r o p i n i o n , however , i t is dangerous to base hypotheses o n a lack o f data. T h e case o f possible p r e - C o l u m b i a n t reponema-tosis in medieval Br i ta in , pub l i shed recen t ly b y S t i r l a n d , 3 6 a n d o u r p resen t w o r k c o n t a i n arguments against the C o l u m b i a n t h e o r y .

C o n c l u s i o n

T h i s case makes four o r ig ina l points . T h e first results f r o m the r a r i t y o f ant ique fetal remains, the second f r o m the pa r t i cu l a r i t y o f a late pregnancy and the t h i r d f r o m the presence o f the osseous lesions o f the fetus related t o a syph i l i t i c i n f ec t ion . T h e f o u r t h represents a new contra­d i c t o r y a rgument against the ep idemio log ica l theories c o n c e r n i n g the mig ra t ion o f Treponema pallidum f r o m the N e w W o r l d back to the O l d W o r l d , beg inn ing at the end o f the 15th c e n t u r y and f o l l o w i n g the new h u m a n in te rcon t inen ta l exchanges. Simultaneously, the presented case o f precocious congeni ta l syphi l is i n this fetus f r o m the late A n t i q u i t y const i tutes a new argument , w h i c h reinforces the theories l i n k e d t o the pre-C o l u m b i a n presence o f syphilis i n the O l d W o r l d .

These new data are in perfect agreement w i t h the e v o l u t i o n a r y m o d e l proposed b y H a c k e t t , 3 1

w h i c h proposed the presence o f venereal t repo-nematosis in the Mediterranean Basin f rom the first centuries A D .

260 G. Pàlfi et al.

Several skeletal examples o f treponematosis f rom the pre-Columbian N e w W o r l d have already been r e p o r t e d . 2 7 However , dist inguishing syphilis f rom yaws o n the basis o f skeletal pa tho logy appears t o be u n r e l i a b l e . 2 9 3 7

Since lesions o f congeni ta l syphi l is are notable b y the i r absence in the p r e - C o l u m b i a n N e w W o r l d , yaws or endemic syphi l is is more l i k e l y ae t i o log i ca l l y than venereal s y p h i l i s . 3 8 T h e poss ib i l i ty o f a p re -Co lumbian N e w W o r l d venereal treponematosis cannot be dismissed o n the basis o f the lack o f data, however .

T h e aim of the present study is neither to create a fundamenta l ly new t h e o r y no r to suppor t one o f the above-ment ioned hypotheses, b u t to g ive new data o n the palaeopathology o f syphi l is and on the debate o n the or igins o f this venereal disease b y the presentat ion o f an i m p o r t a n t osteoarchaeological case.

Acknowledgements

This research was supported by grants from the Hungarian Foundation 'Pro Renovanda Cultura Hungáriáé and from the Ministry of Foreign Affairs in France. The authors wish to acknowledge the assistance of D r P. du Lac ( C H U , Marseille) for radiological analysis and Dr M . Panuel ( C H U , Marseille) for helpful discussion.

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Erratum

The first sentence o f the page 258 presents a typing error. The correct sentence is the fo l lowing:

"Among the viruses penetrating the placenta, rubella-, cytomegalovirus, and toxoplasmosis can cause osseous consequences, but always in the form o f a specific calcification disorder or a general decrease of

bony mineralization.1 ^ "

The Authors