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Apple Down 152 A putative case of syphilis from sixth century AD Anglo-Saxon England.

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Apple Down 152: A Putative Case of Syphilis from
Sixth Century AD Anglo-Saxon England
Garrard Cole* and Tony Waldron
Institute of Archaeology, University College London, London WC1H 0PY, UK
Caries sicca; Periosteal reaction; Gummatous lesions
This report describes a putative case of
a treponemal infection observed on a skeleton of a young
male adult from the Apple Down Anglo-Saxon cemetery
dating to the sixth century AD, accompanied by grave
goods indicative of a high status burial. The skeleton is
well preserved and almost complete. The pathological
evidence includes an extensive area of lytic destruction
to the frontal bone of the skull, widespread profuse bilateral symmetrical periosteal reaction affecting scapulae,
clavicles, arms, legs, hands, feet and ribs. There is also
evidence of gummatous destruction on some of the long
bones. Application of a differential diagnosis of all proba-
ble diseases exhibiting the individual symptoms leads to
a clear conclusion that the person was infected with a
treponemal pathogen. The skeleton shows none of the
stigmata associated with the congenital form of treponemal disease. We propose that the evidence suggests a
possible case of venereal syphilis rather than one of the
endemic forms of treponemal disease. This diagnosis is
based on the geographical pathogen range, the apparent
low prevalence of the disease, significant social upheaval
at the time, the high social status and early age of death
of the individual. Am J Phys Anthropol 144:72–79,
2011. V 2010 Wiley-Liss, Inc.
Syphilis has been described as ‘‘the great mimicker’’
(Peeling and Hook, 2006), ‘‘the great imitator’’ (Ehrlich
and Kricun, 1976), a ‘‘riddle wrapped in a mystery inside
an enigma’’ (Robinson et al., 1999) and ‘‘one of the most
puzzling enigmas in the history of disease’’ (Wells, 1964).
The first pair of comments reflects the wide diversity of
clinical symptoms associated with syphilis and the treponematoses (King and Catterall, 1959). The second pair
illustrates the uncertainty relating to current knowledge
about the origins, mode of worldwide spread and diagnosis of the treponematoses. There are multiple reviews of
the issues relating to treponemal disease, both anthropological and clinical, covering these issues so the reader is
referred to them for full information (see for example
Roman and Roman, 1986; Baker and Armelagos, 1988;
Antal et al., 2002; French, 2007). Only a very brief
summary of the key issues relating to the treponematoses is presented here.
The pathogen responsible for treponemal disease is a
spirochete. Clinically, four treponemal syndromes have
been observed. These conditions are distinguished by
early clinical symptoms, geographical setting, and social
conditions (Hudson, 1946). Venereal syphilis usually only
affects adults and is usually transmitted through sexual
intercourse with a worldwide distribution. The remaining three conditions are pinta, bejel, and yaws. Pinta is
a disease of the tropics and differs from all the other
forms in not ultimately affecting the skeleton. Bejel is a
disease associated with dry, arid environments acquired
orally through kissing or the use of shared utensils. The
initial lesions affect the oral, nasal and pharyngeal mucosa (Farnsworth and Rosen, 2006). Yaws is a disease of
humid tropical environments, acquired through direct
skin to skin contact, bites or other wounds. The primary
lesion takes the form of a pruritic ulcer (Farnsworth and
Rosen, 2006). A congenital form of treponematosis exists
in which the pathogen is passed directly from an
infected pregnant woman to her unborn fetus via the
placenta. Prior to 1984, the pathogens involved were
thought to be Treponema pallidum for venereal syphilis
and T. carateum, T. endemicum and T. pertenue for
pinta, bejel, and yaws, respectively. The treponemes are
indistinguishable microscopically and serologically. In
addition, the later clinical manifestations, with the
exception of pinta, are also indistinguishable (Hackett,
1975). Steinbock (1976) noted that there was partial
cross-immunity between the various forms of treponematosis, leading him to suggest they were not different
species. The results of DNA analyses conducted by
Miao and Fieldsteel (1980) led them to conclude that
T. pallidum and T. pertenue were genetically indistinguishable. In 1984 the pathogens for venereal syphilis,
bejel and yaws were all grouped as subspecies of
T. pallidum, whilst T. carateum was retained as a
distinct species (Smibert, 1984).
All the treponemal conditions respond well to penicillin. The widespread use of this antibiotic has greatly
reduced the incidence of treponemal disease, though
there does seem to be a resurgence, possibly associated
with the presence of AIDS (Cross et al., 2005; Farnsworth and Rosen, 2006). The modern geographical distributions of these diseases therefore do not necessarily
reflect the distribution in the distant past. This, in conjunction with the clinical similarities already mentioned,
C 2010
*Correspondence to: Garrard Cole, Institute of Archaeology, University College London, 31-34 Gordon Square, London WC1H 0PY,
United Kingdom. E-mail:
Received 23 March 2010; accepted 28 May 2010
DOI 10.1002/ajpa.21371
Published online 18 August 2010 in Wiley Online Library
Fig. 1. Site location map for the Anglo-Saxon cemetery at Apple Down.
complicates diagnosis of the disease in an archaeological
With the exception of congenital syphilis, the clinical
progression of treponemal disease has three active
stages. The first, or primary stage, lasts a few weeks
starting closely after the initial inoculation. The symptoms are usually painless and may not be noticed as
they resolve fairly quickly. The secondary stage follows
after a short interval and is marked by an extensive
skin rash. The secondary symptoms again resolve spontaneously. This stage is in turn followed by an extended
latent period, which may be followed by the tertiary
stage. The duration of the latent stage is very variable,
with a range of three to 30 years (Robinson et al., 1999).
The secondary stage may be marked by bone pain, but
usually there are only slight skeletal changes visible on
x-ray (McPhee, 1984). It is in the tertiary stage that the
observable skeletal changes occur, affecting only about
15% of all cases of untreated syphilis (Robinson et al.,
1999). It can thus be seen that the observable paleopathological lesions represent only a small proportion of
the total population affected by syphilis.
The Anglo-Saxon cemetery known as Apple Down is
located on the chalk downlands near Compton in West
Sussex, England (see Fig. 1). The site was discovered
accidentally by metal detectorists and the subsequent
excavations were reported in Volume 7 of the Chichester
Excavations series (Down and Welch, 1990). The site
contained a mixture of contemporaneous inhumation
and cremation burials. The 121 inhumation burials were
aligned both north-south and east-west. A significant
proportion of the inhumation burials were accompanied
by grave goods, which were used to provide dating
evidence for the period of use of the cemetery. This
evidence suggests that the cemetery was in use from
about the late fifth or early sixth century AD until the
late seventh century (Down and Welch, 1990).
This report considers a single skeleton recovered from
an inhumation burial; the sole occupant associated with
grave 152. The excavation report contains a very brief
report on the human remains. It describes the skeleton
as the remains of ‘‘a young man’’, severely affected by a
disease or condition as a result of which many of his
bones had swollen shafts with a thick spongy looking
surface. The bones affected were two thoracic vertebrae,
most of the right, but not the left, ribs, the lower ends
of the humeri and both lower arms and hands; the pelvis
above the acetabulae, and all the leg and foot bones,
particularly the lower legs (Harman, 1990).
The skeleton was well preserved, lacking only parts of
the sternum, the sacrum, the body of right scapula, the
right maxilla, the base of the skull and the right frontal
bones. The distal phalanges and some of the middle
phalanges of the feet were also missing. The bone itself
was also in very good condition, with excellent preservation of surface detail and markings, although the
skull, pelvis and sacrum have suffered excavation
damage (see Fig. 2).
The skeleton was assessed for age, sex, and stature
using current standard osteological techniques (WEA,
The operational definition for tertiary treponemal
disease used in this analysis is based on the strictest
definition, requiring the presence of caries sicca (Hackett,
1983), a widespread bilateral symmetrical deposition of
periosteal new bone (Steinbock, 1976) and the presence
American Journal of Physical Anthropology
Fig. 2. Skeleton 152, Apple Down showing bones present and condition of preservation.
of post-cranial gummatous lesions (Resnick and Niwayama,
1995). The definition used to test for the presence of congenital syphilis requires the presence of Hutchinson’s
incisors and/or Mulberry molars and the presence of
bowed saber tibia (Waldron, 2009).
The individual was clearly male, based on a range
of cranial and pelvic nonmetric traits (Buikstra and
Ubelaker, 1994). Metrical data based on measurements
of the humeral head diameter (Dittrick and Suchey,
1986), the radial head diameter (Berrizbeitia, 1989) and
the femoral head diameter (Dittrick and Suchey, 1986)
confirmed the male attribution.
The individual had also clearly died young. The
epiphysis at the sternal end of the clavicle was partially
fused and the pelvic rim also appeared to have recently
fused (Owings-Webb and Suchey, 1985); the synchondrosis between the basal part of the occipital bone and
the basal part of the sphenoid was not present. The individual had only one erupted third molar which was on
the left side of the mandible and the occlusal surface
was at a similar level to the adjacent slightly worn
second molar. Primary dentine was visible at the location of the cusps of both mandibular first molars, along
with sufficient wear on the cusps of the second molars to
produce a yellowish tint. This corresponds to a development stage of 18–24 years (Miles, 1962). The pubic symphysis matched Stage 1 of the os pubis development
sequence (Meindl et al., 1985) and the auricular surface
matched the lower end of Stage 1 of the relevant
development sequence (Lovejoy et al., 1985). These
factors taken together suggest that 20–25 years is a
valid development stage for this individual.
Final achieved height at death was estimated from the
maximum length of the femur, according to the method
of Trotter and Gleser (1952, 1958). All the long bones
relevant to these methods were fully fused. The femoral
length was 505 mm, corresponding to an estimated
stature of 181.5 cm, based on data for white males with
a standard error of plus or minus 3.9 cm (Bass, 1995).
These data correspond reasonably well with those given
by Harman (1990).
The skeleton exhibits an extensive distribution of
pathological lesions as shown in Figure 3. The cranium
had been fragmented during excavation and subsequently partially reconstructed (see Fig. 4). The most
prominent feature was an area of erosion on the frontal
American Journal of Physical Anthropology
Fig. 3. Distribution of lesions showing general bilateral
symmetry of periosteal new bone. Hatched, elements missing;
black, pathological lesions.
bone with extensive destruction of the outer table, the
diploe, and possibly the inner table. This erosion
manifested as an irregular lytic margin on the outer
table with undercut edges and extensive loss of diploe.
Ellipsoidal lytic lesions of the diploe were visible in the
cross section of the lesion. Three surviving fragments of
cranium from within this lesion comprised irregular
regions of inner table with heavily eroded diploe. Some
of the fragments had small isolated islands of diploe and
Fig. 5. Fragments of left frontal bone: left: ectocranial view
shows destruction of outer table and diploe, along with an
island of surviving outer table; right: endocranial view of same
fragments showing fine porosity. Arrows show outer table
Fig. 4. Reconstructed skull showing lytic lesions and confluent pit clusters. Arrows show confluent pit clusters.
an intact outer table (see Fig. 5). While most of the
margin of the inner table of the fragments and the main
lesion were marked by fresh breaks, a small area to the
left front of the lesion on the cranium was an old break,
indicating perforation through the cranium was present
prior to excavation. The margin of the main erosion was
marked by a number of small distinctive sublesions in
the outer table, comprising groups of small pits having a
apparent sclerotic margin clustered around a small
region of intact outer table. Some of these sublesions
were present in isolation at other parts of the frontal
bone (see Fig. 6). One of the islands of outer table in the
cranium fragments also appeared to be the residue of
such a lesion. The major lesion was clearly demarcated
on the left side of the frontal bone. Unfortunately the
right side of the lesion has been lost as the result of
excavation damage.
There is evidence of slight periosteal reaction and
porosity on the inner table close to the periphery of the
main lesion. There are multiple regions of slight activity
on the left and right frontal bones, the left and right
parietal bones, the occipital bone, and the squamous
part of the right temporal bone. The greater part of the
left temporal bone has been lost taphonomically. The
active areas have numerous small serpinigous grooves
on the endocranial surface of the inner table. The
activity on the parietal bone is concentrated close to the
middle meningeal vessels.
The left side of the nasal aperture showed signs of a
slight periosteal reaction, although the margin of the
aperture was still sharp; the right side of the aperture
has been lost during excavation. There is a small region
of more substantial periosteal reaction on the inferior
margin of the left zygomatico-maxillary suture. The
surviving right maxillary sinus has a very irregular
internal surface, with multiple serpinigous grooves. The
palatine process of the maxilla shows extensive fine
porosity, but the palatine bone has been fragmented and
partly lost. A small area of periosteal reaction is present
surrounding the mental foramen on the right side of
the mandible extending medially across the line of the
mandibular symphysis. There is periosteal reaction at
Fig. 6. Close-up image of confluent clusters of pits superior
to and medial of left supraorbital margin.
the insertion of the masseter, and superior to the foramen
of the mylohyoidal groove, on both the left and right rami
of the mandible.
There is only one third molar, visible on the left side
of the mandible. It is fully erupted and the occlusal
surface is level with that of the adjacent second molar.
The right mandible also has a deciduous second molar
which is fully erupted and heavily worn. An x-ray of the
mandible revealed that the right permanent second
premolar is absent. The dentition is in very good condition, showing almost no dental calculus and there is
minimal evidence for linear enamel hypoplasia (Hillson,
1996). The permanent teeth do show some linear
features on the buccal face, but these are very slight.
The most prominent pathological feature is the presence of a widespread and pervasive periosteal reaction
on the postcranial skeleton. The distribution is bilaterally symmetrical, with the exception of the ribs. Of the
ribs, only the right ribs appear to be affected, and some
ribs more extensively than others. The new bone is more
prominent towards the sternal end of the affected ribs.
American Journal of Physical Anthropology
Fig. 7. Fortuitous taphonomic break of distal left fibula
shaft showing multiple layers of periosteal new bone.
The appearance of the new bone varies from a brownish
colored growth with a rough sandpaper-like texture to a
more robust deposit looking more like molten wax. These
appearances seem to reflect areas of active deposition
versus areas of remodeling of older growths of new bone.
The affected bones generally appear to be swollen in
shape and size, with the exception of the distal lateral
aspect of the left humerus which shows a distinct
narrowing of the shaft from lateral to distal.
The bone deposited on the scapulae, the ribs, the left
humerus, and distal tibiae is of the more active type,
while the new bone on the superior and inferior faces of
the clavicles, both ulnae and radii, the femurs, proximal
tibiae, and fibulae has an older remodeled appearance.
There are small areas of more active bone deposition
within these older areas, especially on the distal tibia.
X-rays taken of the shafts of all major long bones show
multiple layers of lucency and sclerosis. A postexcavation break across the distal end of the left fibula allows
the internal structure of the new bone to be observed
(see Fig. 7). There are four or more distinct denser layers
of new bone separated by layers of very low density,
each layer enveloping and enlarging the previous layer,
maintaining the overall cross-sectional shape.
Bilateral symmetrical changes were also observed on
both the hands and the feet. The first metacarpal, fifth
metacarpal, and multiple proximal phalanges of both
hands exhibited prolific diaphyseal thickening and
prominent layers of remodeled new bone. Similar thickening and deposits of bone were observed on the first,
fourth and fifth metatarsals of both feet.
Several of the bones show regions of irregular variation in thickness of the periosteal new bone. These
include the posterior midshaft of the left radius, the
lateral side of the left humerus, and the medial side of
the distal right tibia. These regions seem to have a
sclerotic border and the periosteal bone appears to
extend across the base of the lesions (see Fig. 8). These
characteristics are suggestive of gummatous lesions.
All the joints at the articulations of the long bones
appear to be normal and the spine also appears largely
unaffected. The cervical spine has no obvious pathology.
The lumbar and lower thoracic vertebrae show signs of
taphonomic damage. The thoracic vertebrae T7 to T9
inclusive exhibit slight deposits of new bone on the right
American Journal of Physical Anthropology
Fig. 8. Gummatous lesions on left radius: top: x-ray view
showing sclerotic margin to gummatous lesions; bottom: photograph of irregular gummatous lesions penetrating through periosteal new bone into the normal cortex. Arrows match lesions
from x-ray to photograph.
side of the bodies. There is a small amount of woven
bone on the left pedicle of T11. There are large florid
marginal osteophytes on the lower right side of L3 and
L5, along with zones of woven bone on the right side of
the body and pedicles of L3 to L5 inclusive. There is a
moderate marginal osteophyte on the left side of the
upper face of the first sacral vertebrae and woven bone
on the superior surface of the left ala.
The pathology of the skeleton from grave 152 is
dominated by the widespread bilaterally symmetrical
presence of active and remodeled periosteal new bone,
coupled with distinctive lesions to the frontal bone of the
cranium and gummatous lesions to some of the long
The differential diagnosis for lytic cranial lesions
includes Langerhans’ cell histiocytosis (in the form of
Hand-Schüller-Christian disease or eosinophilic granuloma), giant cell tumor, skeletal metastases, multiple
myeloma, hyperparathyroidism (Resnick and Niwayama,
1995) and early caries sicca (Hackett, 1983). HandSchüller-Christian disease can be excluded as it predominately affects children and the associated cranial
lesions have well-defined margins. The cranial lesions
arising from eosinophilic granuloma are similar to those
of Hand-Schüller-Christian disease. Giant cell tumors
typically affect middle aged adults and the disease rarely
affects the skull. The cranial lesions are usually found at
the sphenoid or temporal bones. Both skeletal metastases and multiple myeloma commonly affect the skull,
and the resultant lesions originate within the diploe
expanding symmetrically to destroy both inner and outer
table. The cranial lesions associated with hyperparathyroidism are described as having a ‘‘salt and pepper’’
The cranial lesions are comprised of multiple discrete
clusters of pits in both the inner and outer table encircling an island of intact cortex. In the central area of the
frontal bone, these pits appear to have grown sufficiently
large in size to create an extensive area of lytic destruction with the occasional preservation of intact islands of
outer table and diploe. A skull from a known case of
syphilis, held as item RCSPC/S 50a.3 at the Royal
College of Surgeons of England in London, shows an
intermediate stage where the pits have enlarged sufficiently to create an annulus of lytic destruction around
the central island without the merging of nearby clusters. These skulls both correspond to the illustrations
representing Stages 1–3 of the caries sicca sequence
described by Hackett (1983). The skull of the case present can therefore be classified as exhibiting early caries
sicca, suggesting a treponemal origin for the condition.
The differential diagnosis for periosteal new bone is
very extensive. A list of possible conditions is shown in
Table 1 (Waldron, 2009). A number of the possibilities
are diseases of childhood or infancy and none of the
characteristics of the other conditions fits with the distribution in our case which closely matches that described
by Steinbock (1976) in his analysis of skeletal manifestations of venereal and non-venereal treponematoses.
Ehrlich and Kricun (1976) note that the new bone deposited in treponematoses can be laminated or solid in
appearance. They also note the presence of perpendicular speculated bone in some cases. This can also be found
in the aggressive osteosarcoma discussed above (Resnick
and Niwayama, 1995) but the presence of multiple
affected bones serves to exclude it. Thus, the pattern
and form of periosteal new bone exhibited in this case
closely matches that produced by a treponemal infection.
Two conditions may give rise to gummatous lesions:
cutaneous tuberculosis and treponemal disease (Resnick
and Niwayama, 1995). Gummatous lesions form a
rare secondary complication to cutaneous tuberculosis
(Terranova et al., 2008).
The overall conclusion is that a treponemal condition is
the only disease that can completely explain the pattern
of lytic cranial lesions, widespread bilateral symmetrical
periosteal new bone and gummatous lesions.
Late stage pinta does not progress to affect the skeleton
(Meyer et al., 2002). The clear absence of Hutchinson’s
TABLE 1. Differential diagnosis for periosteal new bone
Physiological growth
Caffey’s disease
Venous stasis
Skeletal metastases
Hypertrophic pulmonary osteoarthropathy
Hypervitaminosis A
Thyroid acropachy
Menkes’ syndrome
Camaruti-Engelmann disease
incisors, mulberry molars and saber tibia allows congenital syphilis to be excluded from the differential diagnosis. Whilst attempts have been made to differentiate
yaws, bejel, and syphilis based on patterns of periosteal
reaction (Rothschild and Rothschild, 1995, 1996), these
are not convincing (Roberts, 2000). Steinbock (1976) has
produced distribution charts for skeletal lesions for the
various treponematoses, which appear to suggest there
may be observable differences. However, the distribution
shown for venereal syphilis (Fig. 41 in Steinbock, 1976)
does not match the corresponding textual description of
the distribution on the following page. This text suggests
that the fibula is affected somewhat less than the tibia
but more than the clavicle. However, the Figure suggests
that the fibula is unaffected, enhancing an apparent
difference between syphilis and yaws (Fig. 58 in Steinbock, 1976). This erroneous diagrammatic representation
is repeated by others (Buckley and Dias, 2002; Reichs,
Heleft (1944) has claimed that late stage yaws and
syphilis can be differentiated in clinical cases based on
differences in onset and presentation of bone pain, but
the general consensus is that the variants can only be
distinguished on a geographical and cultural basis. Yaws
is thus considered a contagious disease of the hot, humid
tropics, whilst bejel is a disease of hot dry desert areas
(Farnsworth and Rosen, 2006). Geographical considerations tend to suggest that both these conditions can
be excluded, leaving venereal syphilis as a possible
diagnosis for this particular case.
A number of workers have successfully identified bacterial DNA, such as Mycobacterium leprae (Taylor et al.,
2006) and Mycobacterium tuberculosis (Mays and Taylor,
2003), in archaeological skeletal remains. Early work by
Kolman et al. (1999) claiming identification of Treponema pallidum subsp. pallidum has not been replicated
by later workers (Bouwman and Brown, 2005; Barnes
and Thomas, 2006, Von Hunnius et al., 2007). All of the
latter three groups conclude that treponemal DNA is
unlikely to survive in archaeological bone. This is
consistent with current thinking on the biological mechanisms behind the skeletal response in tertiary treponemal infection. The florid skeletal proliferative response
in the presence of very low numbers of treponemal
pathogens (Robinson et al., 1999) is thought to be a
delayed-type hypersensitivity response (Klein and
Monjan, 1983). It may be that the variation of condition
expressed in the tertiary stage is more a reflection of
variation in the individual immune response rather than
variation associated with the different treponematoses.
Thus it seems that DNA analysis is unable to answer
questions relating to identification of treponemal
bacteria species in archaeological material but perhaps a
better chance of confirming a diagnosis might be achieved
if treponemal antibodies could be recovered from the
TABLE 2. Early cases of treponemal disease from mainland Britain (PNB, periosteal new bone)
Kingston on Hull
Apple Down
Mid 15th C
Unstratified (13–15th C)
Mid 6th C
Caries sicca
Widespread bilateral PNB
Caries sicca
Caries sicca; Mulberry molars
Caries sicca; Tibial PNB
Widespread PNB
Caries sicca; Widespread bilateral PNB
Caries sicca; Widespread bilateral PNB; Gumma
Dawes and Magilton, 1980
Stirland, 1991, 1994
Roberts, 1994
Cardy, 1997
Evans, 2000; Miller, 2000
Mays et al., 2003
Mays et al., 2003
This report
American Journal of Physical Anthropology
skeletal remains. These considerations have an impact on
the work carried out combining DNA analysis and paleopathology carried out by De Melo et al. (2010).
A number of sites containing remains exhibiting treponemal disease and dating from the pre-Colombian period
have been reported in the literature (summarized in
Table 2). These sites are York (Dawes and Magilton,
1980), Norwich (Stirland, 1991, 1994), Gloucester
(Roberts, 1994), Whithorn (Cardy, 1997), Kingston on
Hull (Evans, 2000; Miller, 2000), Rivenhall (Mays et al.,
2003) and Ipswich (Mays et al., 2003). The case under
consideration was recovered from a well-defined grave
oriented north-south, cut 0.5 m into the natural chalk.
The grave cut and fill showed no sign of reuse. The body
was accompanied by a number of early Anglo-Saxon
grave goods, leading Down and Welch (1990) to propose
an early to mid sixth century AD date for the burial.
The grave goods assemblage formed one of the richest
male assemblages on the site, suggesting the person
held high status. There is no obvious archaeological
evidence to suggest the burial was made at a time significantly later than the period of the artifacts. The AngloSaxon period was also a time of significant social
upheaval. The highly organized and militarized RomanoBritish society, with a strong focus on large urban
centers gave way to a society based on dispersed small
scale settlement. Cities such as Winchester appear to
have been abandoned to a large extent in the early
Anglo-Saxon period. Larger occupation centers appeared
with the re-emergence of kingdoms in the seventh
century and the establishment of trading centers such as
Hamwic in the eighth century AD (Welch, 1992).
Endemic syphilis is thought to arise in conditions of
poor sanitation and hygiene, as might be present in
small rural settlements (Turner, 1937). Modern investigations also suggest that the endemic treponematoses
have a very high prevalence (Guthe et al., 1953; Murray
et al., 1956). The alternative, venereal syphilis, is
usually acquired through sexual intercourse in adults, or
as congenital syphilis in the child of an affected mother.
The incidence of venereal syphilis seems to increase
dramatically in times of war or social upheaval (Idsøe
and Guthe, 1967). Even taking the low rate of progression to fully expressed tertiary treponematosis into
account, the very low prevalence of treponemal disease
in the English archaeological record would seem to
mitigate against the endemic form and in favor of the
venereal form of the disease. The very variable and
potentially protracted timescale for the onset of the tertiary stage makes it difficult to propose at what age the
person was infected. While the venereal form of treponematosis is normally acquired through sexual contact, it
can be acquired as the result of kissing a person who
has active oral lesions (Bangsberg and Rein, 1998).
Whilst the date of the skeleton is well defined in
archaeological term, based on grave good typologies, this
might be improved by use of C14 dating. The early
Anglo-Saxon period was a time of rapid change in society, and a time of migration from the continent. Stable
isotope analysis could possibly to help identify the origins of this individual. The fortuitous presence of a
retained deciduous tooth would allow access to environmental information from the early childhood of the person. Finally, given the confidence in the diagnosis of treAmerican Journal of Physical Anthropology
ponemal disease, it would be interesting to attempt to
confirm the diagnosis using antibody analyses rather
than the bacterial DNA itself.
The individual discussed in this case was recovered as
a well-preserved and almost complete skeleton with both
cranial and postcranial elements. The differential diagnosis for the extensive set of pathological lesions present
on the individual lead to a conclusion that the cause was
a treponemal infection. The skeleton shows none of the
stigmata associated with the congenital form of treponemal disease. We propose that the evidence suggests a
possible case of venereal syphilis rather than one of the
endemic forms of treponemal disease, although some
may still prefer the alternative diagnosis of bejel. The
diagnosis of syphilis is based on the geographical pathogen range, the apparent low prevalence of the disease,
the high social status of the individual, social upheaval
at the time and the early age of death of the individual.
Despite the evidence outlined in this report, the enigma
of syphilis still remains.
We would like to thank Tracey Clark and Anooshka
Rawden of Chichester District Museum, Chichester for
kindly allowing us access to this skeleton from the Apple
Down collection. We would also like to thank Dr. Rob
Symmons, Curator of Archaeology, Fishbourne Museum,
Fishbourne, for his assistance in taking x-rays of the
skeleton. Milly Farrell, Assistant Curator, Royal College
of Surgeons of England and Martyn Cooke, Head of Conservation, Royal College of Surgeons of England kindly
granted access to the clinical material held at the Royal
College of Surgeons of England. We would also like to
thank the three anonymous reviewers for their helpful
comments and suggestions on how to improve this
Antal GM, Lukehart SA, Meheus AZ. 2002. The endemic treponematoses. Microbes Infect 4:83–94.
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