A New Approach to Diagnosing Congenital Syphilis Using the Effects of Treatments
p. 155-162
Résumés
The diagnosis of congenital syphilis in skeletal remains is problematic. Remains of infants and children perish, and those who do survive develop skeletal signs that are often minimal or heal. A standard criterion of dental abnormalities associated with congenital syphilis has been developed and is used today, however, variations of these dental abnormalities are not considered. Prior to the introduction of penicillin, mercury was used to treat congenital syphilis. While dental abnormalities associated with mercuric treatments were documented and illustrated during the 19th century, the effects of mercury on dental development have never been considered when examining palaeopathological specimens until recently. This paper summarises a new approach taken by those at the University of Adelaide to assist with the diagnosis of congenital syphilis using the effects of mercuric treatments. Findings of this new approach suggest that mercury produces specific dental abnormalities, different from those produced by the disease (congenital syphilis), which can assist in making a differential diagnosis of the disease. As such this paper summarises this new body of work and highlights its importance in the diagnosis of the disease in paleopathology.
Le diagnostic de la syphilis congénitale sur les ossements demeure encore problématique dans le sens où, dans la majorité des cas, les restes de nourrissons et de jeunes enfants disparaissent et que, lorsqu’ils subsistent, les indices relevés sur les os s’avèrent souvent minimes ou ne sont plus visibles parce qu’ils ont guéri. Un système de critères d’évaluation standardisé des anomalies dentaires liées à la syphilis congénitale a été élaboré et est actuellement utilisé. Pour autant, les variations observées dans ces anomalies ne sont pas encore prises en compte. Avant que l’on ait recours à la pénicilline, les cas de syphilis congénitale étaient traités au mercure et les anomalies dentaires qui y étaient associées ont été, au xixe siècle, répertoriées et illustrées. Cependant, ce n’est que récemment que l’on a commencé à prendre en compte les effets du mercure sur le développement dentaire au cours de l’examen de spécimens paléopathologiques. Cette étude propose la synthèse d’une nouvelle approche menée par l’université d’Adélaïde afin d’aider à établir un diagnostic de la syphilis congénitale au regard des conséquences observées par le traitement au mercure. Les découvertes qui ont découlées de cette nouvelle méthode induisent que le mercure est responsable d’anomalies dentaires particulières, différentes de celles provoquées par la syphilis congénitale, et peuvent se révéler d’une grande utilité au diagnostic différenciel de la syphilis. C’est donc la synthèse de ce nouveau corpus aussi bien que son impact dans le diagnostic paléopathologique qui sont proposés ici.
Texte intégral
Introduction
1The origin of syphilis continues to be a much-debated topic in biological anthropology. The theories on the disease’s origin in the Old World include the pre-Columbian, post-Columbian and Unitarian. The most agreed upon is the post Columbian theory, which argues that Columbus and his crew introduced the disease into the Old World after discovering the New World in 14921. However, there is evidence that supports multiple theories.
2To determine the origins of syphilis, skeletal evidence is used. To make a diagnosis of syphilis, certain characteristics specific to that disease must be present2. Skeletal signs considered characteristic of syphilis include pitting and sclerosis on the outer table of the cranial vault resulting in stellate scaring, and nodes/tissue expansions with superficial cavitation in the long bones3. However, diagnosing syphilis in skeletal remains can be difficult due to the lack of signs/changes to bone in most patients. In rare cases, bone lesions will appear in the primary or secondary stage of syphilis4. It is only during the tertiary stage of the disease, in severe cases, that diagnostic signs of syphilis appear. Another issue is that some bony changes seen in syphilis (lesions on the skull vault and long bones), are also produced by other diseases including tuberculosis, making a diagnosis of syphilis problematic5.
3The same issues are present when making a differential diagnosis of congenital syphilis. Remains of foetuses, infants and children are rarely preserved, and in those that do, variation in bone lesions can occur6. They can be minimal or heal7. However, dental abnormalities caused by the congenital syphilis are considered pathognomonic of the disease. Congenital syphilis interferes with dental processes odontogenesis and amelogenesis during infancy when development of permanent dentition begins. Unlike bone, dentition does not remodel, therefore, once interferences occur during dental development, changes are permanent. The aim of this manuscript is to provide a summary of a new approach taken by those at the University of Adelaide, considering the use of dental abnormalities caused by syphilis treatments (mercury) that can assist in the diagnosis of congenital syphilis.
Materials and Method
4The works of those who studied/described dental abnormalities associated with congenital syphilis were analysed. It was then found that Hutchinson (1878) described the effects of mercuric treatment on dental development in cases of congenital syphilis. A search was then conducted of the medical literature on mercury treatment in syphilis/congenital syphilis to determine the types of mercury treatment used, the dose administered, and the extent of which mercury was used to treat the disease. This knowledge was then applied to palaeopathological cases that demonstrated possible dental signs of congenital syphilis to determine whether there were any similarities in the types of dental abnormalities caused by mercury observed by Hutchinson (1878). The aim was to determine whether mercuric treatment produced specific dental abnormalities different from those caused by the disease. Since the effects of congenital syphilitic treatment on dental development have never been considered in paleopathology/biological anthropology, the overall aim of this research was to introduce a new approach in order to assist with a diagnosis of congenital syphilis.
Previous approaches to diagnosing congenital syphilis in skeletal remains
5Interferences during dental processes (odontogenesis/amelogenesis) leave permanent signs on teeth, providing a wealth of information on the health of an individual. Dental abnormalities caused by congenital syphilis have been significant in the diagnosis of the disease. Dental abnormalities caused by congenital syphilis were first described by Jonathan Hutchinson8, Henry Moon9, and Alfred Fournier10. Their descriptions and illustrations of dental abnormalities observed in patients with the congenital syphilis have formed a basis for clinical11 and palaeopathological studies12. Dental abnormalities caused by congenital syphilis itself have been studied for centuries, and eventually Hillson and colleagues (1998) created a standard criterion. Dental abnormalities considered characteristic of the disease include Hutchinson’s incisors, Moon’s molars, Fournier’s molars and permanent canines with sharp groove-like defect around the tip of the cusp13. While these dental signs have been used in many studies to make a diagnosis of congenital syphilis, no one has considered dental variations or the side effects of treatments that have been known of and used for centuries.
Mercury as a form of treatment for syphilis/congenital syphilis
6Mercury has been used to treat syphilis and congenital syphilis for centuries14. Mercury was used in different forms including ointments, teething powders, pills, vapours, oils and solutions15. Different quantities were administered per dose ranging from two grains to ten grains (130mg - 648mg)16. Currently it is accepted that the tolerable weekly intake of methylmercury is 0.0016mg per kilogram of bodyweight for children up to the age of 17 years including developing foetus17. Therefore, the amount of mercury administered to infants and children to treat congenital syphilis was significantly higher than the recommended weekly intake, thus, it would more than likely result in serious developmental effects, including dental defects. Jonathan Hutchinson18 and Henry Moon19, both described and illustrated dental abnormalities caused by mercuric treatments and the variations in dental abnormalities observed in children. It was stated and illustrated that dental abnormalities caused by congenital syphilis itself and mercuric treatments were significantly different from each other. It was the difference in dental abnormalities between the disease and its treatment that developed a new approach.
New approach to diagnosing congenital syphilis in palaeopathological specimens
7Since mercuric treatment was administered to children with congenital syphilis in large quantities that could affect dental development, a new approach was taken to diagnose congenital syphilis in palaeopathological cases from the mid-19th to early 20th centuries.
8The first step was to understand the types of dental abnormalities produced by congenital syphilis and mercury. Hutchinson20 and Moon21 documented and illustrated three types of dental abnormalities associated with congenital syphilis and its treatment: syphilitic teeth, mercurial teeth and syphilitic-mercurial teeth. These are described in detail in Ioannou and colleagues (2016)22.
9Clinical dental abnormalities observed by Hutchinson and Moon were applied and compared to palaeopathological cases who were documented as having died from or suffered from congenital syphilis/syphilis from Australia and the United States. Since these types of dental abnormalities were distinct from each other, these dental characteristics were applied to palaeopathological cases to determine whether similarities were observed between clinical and palaeopathological cases. It was observed that there were similarities in the types of dental abnormalities produced by mercury in the first permanent molars and the incisors23. The occlusal surfaces of the first permanent molars lacked enamel, appeared dirty and rugged, and demonstrated multiple spines/tubercles and pitting. A clear demarcation between diseased and healthy enamel was visible. These characteristics are very similar to Hutchinson’s descriptions/illustrations24.
10Similarities were also evident in the anterior teeth, resembling Hutchinson’s descriptions/illustrations25. Multiple types of hypoplasia were evident in the anterior teeth. Linear/multiple linear enamel hypoplasia defects crossed all anterior teeth at the same level on the buccal and lingual surfaces. Pitting was also a common characteristic. The enamel from the hypoplastic line to the incisal edge/tip of crown was severely hypoplastic. The level of hypoplasia varied among the individuals. This may be associated with the amount of mercury administered, the number of doses administered per week, and the duration of treatment.
Discussion
11Dental abnormalities are an important criterion in the diagnosis of congenital syphilis due to enamel’s inability to remodel. While the use of mercury and its side effects are known and have been documented for centuries26, dental abnormalities only caused by the disease itself were recognised and applied by researchers. Now new research has focused on highlighting and documenting the use of mercury before the introduction of penicillin and its use as a criterion in the diagnosis of congenital syphilis.
12The aim of this new approach was to determine (i) whether dental abnormalities attributed to mercury could be found in skeletal collections and (ii) whether the effects of mercuric treatment could be used to diagnose congenital syphilis. Results of this new approach have indicated that mercury produces distinct dental abnormalities that are considerably different from those produced by congenital syphilis. Similarly to congenital syphilis, mercury can produce dental variations that depend on various factors including the types of chemical compounds used, the dose of mercury administered, time of administration (what age) and duration of treatment.
13Dental abnormalities produced by mercury are distinct from those produced by the congenital syphilis itself, and only occur in individuals who suffered from syphilis. While mercury was trialled in treating tuberculosis and leprosy27, these were unsuccessful. Since this is the case, dental abnormalities associated with mercuric treatments should be used in conjunction with dental abnormalities associated with congenital syphilis itself as criterion for the diagnosis of the disease.
14This new approach is now being considered and used by researchers in various types of dental research28. With regard to its impact in paleopathology and dental anthropology, it will have a significant influence on developing our understanding of medical treatments of the past and may help answer long standing arguments in the research to come.
Notes de bas de page
1 L.-W. Harrison, « The origin of syphilis », The British Journal of Venereal Diseases, 35, 1959, p. 1-7 ; C. Goff, « Syphilis », in D. Brothwell, A.-T. Sandison (dir.), Diseases in Antiquity, Illinois, Charles C. Thomas, 1967 ; B.-J. Baker et al., « The origin and antiquity of syphilis: Paleopathological diagnosis and interpretation [and Comments and Reply] », Current Anthropology, no. 29, 1988, p. 703‑737.
2 C.-J. Hackett, Diagnostic Criteria of Syphilis, Yaws and Treponarid (Treponematoses) and of Some Other Diseases in Dry Bone, Berlin, Spriner-Verlag, 1976 ; G.-J. Armelagos et al., « The science behind pre-Columbian evidence of syphilis in Europe: Research by documentary », Evolutionary Anthropology, no. 21, 2012, p. 50‑57.
3 C.-J. Hackett, op. cit.
4 F.-W. Reynolds, H. Wasserman, « Destructive osseous lesions in early syphilis », Archives of Internal Medicine, no. 69, 1942, p. 263-276 ; K. Hansenk et al., « Bone lesions in early syphilis detected by bone scintigraphy », The British Journal of Venereal Diseases, no. 60, 1984, p. 265-268 ; R.-T. Steinbock, Paleopathological diagnosis and interpretation: Bone diseases in ancient human populations, Springfield, Charles C. Thomas, 1976 ; B.-M. Rothschild, « History of Syphilis », Clinical Infectious Disease, no. 40, 2005, p. 1454-1463.
5 B.-M. Rothschild, G.-M. Heathcote, « Characterization of the skeletal manifestations of the treponemal disease yaws as a population phenomenon », Clinical Infectious Diseases, n° 17, 1993, p. 198-203 ; K.-L. Holloway et al., « Skeletal lesions in human tuberculosis may sometimes heal: An aid to palaeopathological diagnoses », PLOS One, no. 8, (4), 2013, p. e62798.
6 S.-M. Laird, « Late congenital syphilis: An analysis of 115 cases », The British Journal of Venereal Diseases, no. 26, 1950, p. 143-145 ; N.-J. Fiumara et S. Lessell, « Manifestations of late congenital syphilis: An analysis of 271 patients », Archives of Dermatology, no. 102, 1970, p. 78-83.
7 R.-T. Steinbock, op. cit.
8 J. Hutchinson, Transaction of the Pathological Society of London. Including the report of the proceedings for the session 1858-9, London, J.-W. Roche, 1859.
9 H. Moon, On irregular and defective tooth development: Transactions of Odontological Society of Great Britain, London, Wyman & Sons, 1877.
10 A. Fournier, La Syphilis héréditaire tardive : leçons professées, Paris, G. Masson, 1886.
11 N.-J. Fiumara, S. Lessell, op. cit.
12 J. Cavallaro, « Syphilis in Its Relation to Dentition », Dental Cosmos, no. 50, 1908, p. 1161-1174 et p. 1325-1344 ; L.-J. Karnosh, « Histopathology of syphilitic hypoplasia of the teeth », Archives of Dermatology and Syphilology, no. 13, 1926, p. 25-42 ; R.-V. Bradlaw, « The dental stigmata of prenatal syphilis », Oral Surgery, Oral Medicine, Oral Pathology, no. 6, 1953, p. 147-158 ; S. Hillson, S. Bond, « Relationship of enamel hypoplasia to the pattern of tooth crown growth: A discussion », American Journal of Physical Anthropology, no. 104, 1997, p. 89‑104.
13 J. Hutchinson, op. cit. ; H. Moon, op. cit. ; A. Fournier, op. cit. ; S. Hillson et al., « Dental defects of congenital syphilis », American Journal of Physical Anthropology, no. 107, 1998, p. 25-40.
14 F. Buret, Syphilis in Ancient and Prehistoric Times, Philadelphie, The F.A. Davis Company, 1891 ; S.-C. Martin, Hieronymus Fracastor’s Syphilis from the Original Latin: A Translation in Prose of This Immortal Poem, Saint Louis, The Philmar Company, 1911 ; E.-H. Hudson, « Historical approach to the terminology of syphilis », Archives of Dermatology, no. 84, 1961, p. 545-562.
15 S.-T. Smith, « On the treatment of secondary syphilis by mercury », Lancet, no. 43, 1844, p. 556 ; M.-L. Heidingsfeld, « Injection treatment of syphilis by means of a new mercurial formula », JAMA, no. 11, 1902, p. 598-6016 ; W.-R. Ramsey et M.-R. Ziegler, « The relative efficiency of the different mercurial preparations in the treatment of congenital syphilis in infants and children: As determined by a quantitative analysis of the mercury eliminated in the urine », American Journal of Diseases of Children, no. 16, 1918, p. 299-306.
16 F. Warner, « East London hospital for children: Cases of congenital syphilis », Lancet, no. 117, 1881, p. 173-174 ; J. Hutchinson, Syphilis, London, Cassell and Company, 1887 ; T. Cornbleet, « The use of colloidal calomel ointment in dermatology », Journal of the American Medical Association, no. 113, 1939, p. 1804-1806.
17 World Health Organization, Preventing disease through healthy environments: Exposure to mercury: A major public health concern, 2007 (www.who.int/phe/news/Mercury-flyer.pdf, consulté le 15 octobre 2018).
18 J. Hutchinson, Illustrations of clinical surgery consisting of plates, photographs, woodcuts, diagrams etc.: Illustration surgical diseases, symptoms and accidents, also operative and other methods of treatment, with descriptive letterpress, vol. 1, London, J. & A. Churchill, 1878.
19 H. Moon, « Dental surgery », in T. Bryant (dir.), A manual for the practice of surgery, London, J. & A. Churchill, 1884.
20 J. Hutchinson, Illustrations of clinical surgery consisting of plates, photographs, woodcuts, diagrams etc., op. cit. ; J. Hutchinson, Syphilis, op. cit.
21 H. Moon, « Dental surgery », art. cit.
22 S. Ioannou et al., « Diagnosing congenital syphilis using Hutchinson’s method: Differentiating between syphilitic, mercurial, and syphilitic-mercurial dental defects », American Journal of Physical Anthropology, no. 159, 2016, p. 617-629.
23 S. Ioannou et al., « Diagnosis of Mercurial Teeth in a Possible Case of Congenital Syphilis and Tuberculosis in a 19th century Child Skeleton », Journal of Anthropology, 2015, p. 1-11 ; S. Ioannou et M. Henneberg, « Dental signs attributed to congenital syphilis and its treatments in the Hamann-Todd Skeletal Collection », Anthropological Review, no. 80, 2017, p. 449-465 ; S. Ioannou et al., « Five cases of dental anomalies attributed to congenital syphilis from early 20th century American Anatomical Collections », Dental Anthropology, no. 30, 2017, p. 25-37.
24 J. Hutchinson, Illustrations of clinical surgery consisting of plates, photographs, woodcuts, diagrams etc., op. cit.
25 S. Ioannou, M. Henneberg, « Dental signs attributed to congenital syphilis and its treatments in the Hamann-Todd Skeletal Collection », art. cit. ; S. Ioannou et al., « Five cases of dental anomalies attributed to congenital syphilis from early 20th century American Anatomical Collections », art. cit.
26 L.-J. Goldwater, Mercury: A history of quicksilver, Baltimore, York Press, 1972; R.-M. Swiderski, Quicksilver: A history of the use, lore and effects of mercury, Jefferson, MacFarland and Company, 2008.
27 B.-L. Wright., « The treatment of tuberculosis by the administration of mercury at the United States naval hospital, New Fort Lyon, Colo », Journal of the American Medical Association, no. LI, (22), 1908, p. 1854-1856 ; E.-F. Neve, « Leprosy in Kashmir: it’s distribution and etiology », Lancet, no. 134, 1889, p. 999-1000.
28 I. Towle et al., « Amelogenesis imperfecta in the dentition of a wild chimpanzee », Journal of Medical Primatology, no. 47, 2018, p. 117-119 ; J.-W. Walser iii et al., « Volcanoes, medicine, and monasticism: Investigating mercury exposure in medieval Iceland », International Journal of Osteoarchaeology, 2018, p. 1-14.
Auteur
Biological Anthropology and Comparative Anatomy Research Unit, The University of Adelaide, Adelaide, South Australia
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