International Journal of Osteoarchaeology

Int. J. Osteoarchaeol. 9: 369 373 (1999)

SHORT REPORT

A Case of Diffuse Idiopathic Skeletal

Hyperostosis (DISH) from a Medieval
Necropolis in Southern Italy
BRUNA REALE, DAMIANO MARCHI AND SILVANA
M. BORGOGNINI TARLI*
Universita` degli Studi di Pisa, Dpt. Di Etologia, Ecologia ed Evoluzione,
Unita` di Antropologia, Via S. Maria 55 -56126 Pisa, Italy
Key words: idiopathic hyperostosis; medieval abbey; southern Italy

Introduction
The subject described here was found in a single
burial (No. 272) of the cemetery pertaining to
the S. Angelo Abbey, located in Montescaglioso, 30 km southwest of Matera (Basilicata, southern Italy). The site was excavated in
1996 under the direction of Dr G. Canosa, the
then Director of the Museo Nazionale D. Ridola of Matera.
The burial was archaeologically dated between 1100 and 1400 AD and appears as a ditch
covered by irregular stones lying under the
southern corridor leading to the A Cloister
(Canosa, personal communication). Both the
corridor and the A Cloister were built after
1400 during work for the expansion of the
perimeter of the abbey, thus suggesting that the
tombs were originally located outside the
boundaries (Venezia, personal communication).
Unfortunately, there is a lack of historical documentation about the use of the cemetery by the
monks and/or by the local population.
The skeleton is fairly complete and in a good
state of preservation, as only part of the skull,
the atlas, axis, sternebrae, most ribs and part of
hand and foot bones are missing.
* Correspondence to: Universita` degli Studi di Pisa, Dpt. Di
Etologia, Ecologia ed Evoluzione, Unita` di Antropologia, Via S.
Maria 55-56126 Pisa, Italy. E-mail: borgognini@discau.unipi.it

CCC 1047482X/99/050369 05$17.50

Copyright 1999 John Wiley & Sons, Ltd.

Sex diagnosis (male) was performed by morphological methods (Phenice, 1969; Ferembach
et al., 1977), age at death (2535 years) was
estimated by the degree of cranial suture closure
(Meindl & Lovejoy, 1985) and by the modifications of the pubic symphysis (Meindl et al.,
1985). Stature (167.9 92.99 cm) was evaluated
by Trotter & Glesers (1952) equations for white
males.

Palaeopathological findings
Skull
A vermicular aspect was observed on the inner
side along the sagittal suture. Signs of porotic
hyperostosis were present on the outer table
near the lambdoid suture.
Vertebral column
This was the most affected skeletal region, with
massive new bone formation on the vertebral
bodies, but without involvement of the articular
surfaces or the intervertebral spaces. In the thoracic section (T6T12) flowing ossifications
were located on the right side of the anterior
longitudinal ligament, appearing as a dense and
continuous line of bumps (Figure 1). In the
Received 26 November 1998
Revised 26 January 1999
Accepted 30 April 1999

370
lumbar section (L1L5), a discontinuous ossification of the anterior longitudinal ligament was
bilateral and showed a candle flame shape. The
cervical section (C3C7) did not show modifications. Ankylosis of the apophyseal and costovertebral joints was not present.
Shoulder girdle and ribs
On the two scapulae ossification of the coracoacromial ligament was bilateral with involve-

B. Reale et al.
ment of both the acromion and the coracoid
process. The whole shoulder girdle showed
arthropic changes. Manubrium sterni showed,
on the left side, calcification of the sternocostal
cartilage. Four of the first ribs on the right side
showed signs of a healed fracture at the level of
the costal angle. Arthropic changes were also
observed at the costovertebral joints.
Upper limbs
The right ulna showed a huge bony spur (14
mm high) located on the olecranon at the
insertion of the triceps brachii muscle (Figure
2). The left ulna had no such formation. The
right radius showed hyperostotic changes on
the radial tuberosity, while the left humerus had
an osteophyte on the medial epicondyle, corresponding to the insertion of the collateral ulnar
ligament. The preserved hand bones (carpal and
metacarpal bones and phalanges) did not show
signs of enthesopathies.
Pelvis
New bone formation with definite and normal
trabeculae, most probably of traumatic origin,
was observed on the right innominate bone
extending for more than half the insertion area
of the gluteus minimus muscle. Bilateral hyperostosis was present at the level of the iliolumbar
ligament (height of the bone spur is 5 mm on
the right side and 7 mm on the left), of the
sacroiliac ligament (spur height 3 mm right and
2 mm left), of the sacrospinous ligament (spur
height 7 mm right and not measurable left), and
of the sacrotuberous ligament (spur height 4
mm right and left). Marked exostoses were
present on the iliac crest, while the ischial
tuberosity had a tufted and wispy aspect
(Resnick et al., 1975).

Figure 1. Lateral view (right side) of fused thoracic vertebrae

(T6 T12) of the male subject from Tomb No. 272 of Montescaglioso Abbey (Matera, southern Italy, 11001400 AD).
Note the ossification of the anterior longitudinal ligament and
the intact intervertebral space (white arrows) (scale 1:0.8).

Copyright 1999 John Wiley & Sons, Ltd.

Lower limbs
The femur showed bilateral changes in the hypertrochanteric fossa (insertion of the obturator
externus muscle, spur height 5 mm on the left
and not measurable on the right side), of the
lesser trochanter (insertion of the iliopsoas muscle), and of the linea aspera.
The patella had small osteophytes at the
insertion of the quadriceps femoris muscle. The
tibia showed bilateral enthesopathies on the
Int. J. Osteoarchaeol. 9: 369373 (1999)

DISH in Medieval Abbey

371

Figure 2. Proximal portion of right (left side of the graph) and left ulna of Montescaglioso S. Angelo adult male from Tomb No.
272. Note the bony spur on the right olecranon (white arrow) (scale 1:0.7).

proximal articular surface corresponding to the

insertion of the cruciate ligaments and hyperostotic changes on the lateral intercondylar tubercle. The tibial tuberosity and the interosseous
crests had a normal aspect.
The calcaneum had strong bony spurs at the
insertion of the Achilles tendon (height 10 mm
on the right, 8 mm on the left side). Signs of
plantar bursitis were also present.
The talus, tarsal and metatarsal bones and
phalanges showed slight arthropic changes.

Conclusions
The changes caused by diffuse idiopathic skeletal hyperostosis (DISH) have the greatest similarity to the alterations observed in this case,
especially considering the typical flowing ossification of the anterior longitudinal ligament of
the thoracic vertebrae (Crubezy, 1990), and the
ossification of the iliolumbar, sacroiliac,
sacrospinous and sacrotuberous ligaments (Figure 3). In the long bones of the limbs, the
characteristic bilateral symmetry of the alterations is generally respected, with the exception
Copyright 1999 John Wiley & Sons, Ltd.

of the forearm, where only the right radius and

ulna are affected. The knee, usually involved in
typical DISH cases, showed in this subject only
some changes at the level of the patella. Finally,
the age at death, if not underestimated by the
methods applicable to the skeleton under study,
is relatively young for a typical DISH case. In
spite of these seeming discrepancies, we consider that a diagnosis of DISH is the most
probable for the male skeleton from tomb No.
272 of the S. Angelo abbey.
Among the hypotheses so far advanced on
the aetiology of DISH, Hajkova et al. (1965)
mention a correlation between diabetes mellitus
and DISH, although the disease does not show
a different manifestation in diabetic or non-diabetic patients. According to other authors
(Julkunen et al., 1971), DISH would be associated with obesity and hyperglycaemia. In particular, for a medieval case, Waldron (1985)
suggests a relationship between DISH and religious life, considering the type and amount of
food intake in monks as compared with common people. A similar association between
monastic life, obesity and degenerative joint
disease is reported for three Basque skeletons
Int. J. Osteoarchaeol. 9: 369373 (1999)

372
(de la Rua & Orue, 1993), and supported by
historical data. Unfortunately, our case, although from an abbeys cemetery, cannot be
attributed with certainty to a monk.
Julkunen et al. (1971) note a high prevalence
of DISH among farmers, pointing to the role of
physical strain as a correlate of the disease.
Other authors (Crubezy, 1990) observe an association between DISH and osteoarthritis. More
recently, Arlet & Mazie`res (1985) suggested that
a metabolic imbalance of vitamin A or of its
binding protein might be among the causes of
idiopathic hyperostosis.
On the basis of osteological studies most of
the above hypotheses cannot be supported or
denied, but bone robustness and the development of muscular insertions can give some information about physical stress during life. As a
matter of fact, our male subject showed the
signs of an intense muscular activity, also con-

B. Reale et al.
sidering his relatively young age at death. The
skeletal changes indicative of an initial stage of
the illness (see, for example, the absence of
changes in the cervical section of the spine, the
low number of extraspinal hyperostoses and the
unilateral manifestation in the forearm), would
be in agreement with the estimate of the relatively young age at death, since the pathology
requires a long lapse of time to become strongly
evident. The case under study also points to the
association between DISH and osteoarthritis.

Acknowledgements
Thanks are due to Dr M.G. Canosa, former
Director of the Museo Nazionale D. Ridola of
Matera for entrusting this study, to Drs A.
Canci and V. Formicola for useful discussion
and to Drs M.G. Canosa and P. Venezia for
historical and archaeological data.

References

Figure 3. General distribution of bone and joint involvement in

the adult male subject from Tomb No. 272 of the Montescaglioso S. Angelo abbey (Matera, Southern Italy).

Copyright 1999 John Wiley & Sons, Ltd.

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Int. J. Osteoarchaeol. 9: 369373 (1999)

DISH in Medieval Abbey

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Int. J. Osteoarchaeol. 9: 369373 (1999)