CLINICAL CONUNDRUM

Paleopathology in a Thirteenth Century Male fromNewbattle Abbey, ScotlandHELEN BUSH1* AND STUART W. MCDONALD2

1Glasgow Dental School, Glasgow, Scotland, United Kingdom2Laboratory of Human Anatomy, University of Glasgow, Glasgow, Scotland, United Kingdom

THE CONUNDRUM

Newbattle Abbey was founded as a Cistercianmonastery by David I of Scotland in 1140 and dis-solved in 1587 (Butler and Given-Wilson, 1979). Itwas situated in the valley of the South Esk, some7 miles from Edinburgh (Knight, 1999). BetweenJune and September 2000, 127 individuals wereexcavated from the cemetery associated with theAbbey. One of these skeletons, that of a maturemale,1 was distinguished by localised bony pathol-ogy. Look at Figure 1. From your anatomical andclinical knowledge, can you recognise the anatom-ical site and the nature of the pathology? If not, readthe figure legend below and examine Figures 2– 4,then try and work out the likely mechanism bywhich the problem had occurred and its effects.The answers are below.

PALEOPATHOLOGIST’S REPORT

Skeleton 571 was moderately well-preserved incomparison to other skeletal material from the site,although none of the elements was intact except forthe patellae and some carpal and tarsal bones. Radio-carbon dating2 indicated that the subject died in thelate 13th century. The two bony specimens illustrated

in Figures 1–4 show the presence of an unreduceddislocation of the head of the right humerus. Thisinjury is seldom recorded in archaeological material,most probably because it can only be diagnosed if itremains unreduced (Roberts and Manchester, 1995).

The pathological changes to the right scapula aremarked, but the damage to the blade, and the acro-mion and coracoid processes is post-mortem. Themargins of the glenoid cavity are thickened and thearticular surface is porous and irregular (Fig. 1). Asecondary articular surface has been created by thehead of the humerus on the costal surface of thescapula, adjacent to the glenoid cavity. This curvedsurface is a little over 5.5 cm long and approximately3 cm at its widest point. The lower extremity has beenbroken post-mortem so an exact measurement cannotbe made. Bone has been laid down behind this surface(Figs. 2,3), presumably for reinforcement, but the ex-tent to which the blade was affected cannot be deter-mined because most of it has been lost post-mortem.It is not known how much time would be required forsuch a degree of remodeling to occur. Approximatelyhalf of the humeral head has survived and is rough-ened and pitted (Fig. 4), presumably as a result of theabnormal articulation with the anterior surface of thescapula that would not have been covered by cartilage.

1The most reliable and frequently used method for determining the sexof adult bones assesses a number of specific morphological features ofthe pelvis (Phenice, 1969; Bass, 1986). The pelvic bones of Skeleton571 were damaged post-mortem and these features did not survive,with the exception of the sciatic notch, which was narrow. Accord-ingly sex was determined as “probable male” on the basis of thisfeature, three cranial features (the right mastoid process, the nuchalcrest, and both zygomatic arches), and the very robust nature of all ofthe skeletal elements. Because the only feature with which to estimateage that survived was the auricular surface of the ilium, changes towhich indicated an age of �60 years, this individual has been classi-fied simply as “mature.”2Bone from the left calcaneus measured at the University of ArizonaAMS Facility (Code AA-49262 [GU-9952]).

*Correspondence to: Dr. Helen Bush, Glasgow Dental School, 378Sauchiehall Street, Glasgow, G2 3JZ, Scotland, UK.E-mail: H.Bush@dental.gla.ac.uk

Received 28 January 2003; Revised 19 July 2004; Accepted 11August 2004

Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/ca.20080

Clinical Anatomy 18:146–149 (2005)

© 2005 Wiley-Liss, Inc.

PROBABLE INJURY

A new cavity to receive the head of the humerushas formed on the costal surface of the scapulaimmediately medial to the glenoid fossa. It hasclearly resulted from an anterior dislocation of theright shoulder. The position taken up by the hu-meral head suggests that there may have been a tearof the rotator cuff probably involving the supraspi-natus and infraspinatus muscles. Reference to askeleton suggests that, had these two muscles notruptured, impingement of the supraspinatus on thecoracoid process and the infraspinatus on the pos-terior margin of the glenoid cavity would have madesuch a position of the humeral head unlikely. Theposition taken up by the humerus also suggestsrupture or displacement of the long head of biceps,but would be consistent with an intact teres minorand subscapularis. Ruptures of supraspinatus arerelatively common after anterior dislocation of theshoulder and Reeves (1966) reported five instances

in 27 patients aged 18 –77 years. The mechanism ofrupture of the posterior part of the rotator cuff inanterior dislocation was explained by McLaughlinand Cavallaro (1950). Such an injury can resultin either rupture of the cuff muscles or avulsion ofthe tendons from the greater tuberosity. The part ofthe humeral head illustrated in Figure 4 is from theaffected side and shows anatomically normal facetsindicating that the dislocation did not damage thegreater tuberosity. Reeves (1968) found that therotator cuff weakened with age and McLaughlinand Cavallaro (1950) reported that, in shoulder dis-locations, rupture of the rotator cuff was more com-mon after the age of 40 and occurred in about 70%of patients above this age. Younger subjects weremore likely to tear the capsule, labral attachment,and glenohumeral ligaments (McLaughlin andCavallaro, 1950; Reeves, 1968). Rowe and Zarins(1982) found that in patients undergoing surgery forchronic dislocation of the shoulder, the rotator cuffmuscles were so fibrosed together that it was im-possible to differentiate them.

Fig. 1. Lateral view of the glenoid fossa of the right scapula ofthe medieval skeleton. The acromion process has broken off but thespine of the scapula is seen to the left of the illustration. The coracoidprocess is also broken and lies at the superior part of the illustration.The articular surface of the glenoid fossa is irregular, rough, and pitted.Arrows show the secondary articular surface on the costal surface ofthe scapula created by the dislocated head of the humerus.

Fig. 2. Anterior view of the fragment of scapula. Arrows showthe extent of the secondary articular surface. The glenoid cavity (G)and the broken coracoid process (C) are also shown.

Paleopathology in a Thirteenth Century Male 147

SECONDARY SOCKET ANDJOINT MOBILITY

The head of the humerus has lodged in the anglebetween the most lateral part of the costal surface ofthe scapula and the attachment of subscapularis.There was no evidence of a Hills-Sachs lesion (Foy,1993). The large amount of bone that has built up thenew socket may have developed from an organisinghaematoma, the scapular periosteum or from mesen-chymal elements within the subscapularis or its bursa.Such ossification would have been intramembranousin nature so that the new articular surface would havebeen devoid of cartilage. The distinct, non-ankylosed,articular surface suggests retention of mobility of theshoulder. Visser et al. (1999) found that, after anteriordislocation, the axillary nerve was the nerve mostcommonly affected, in about 42% of patients, al-though many recovered. In the study by Neviaser etal. (1993), damage occurred in about 10%. When Mat-sen et al. (1990) reviewed this problem they foundvalues to vary from 1 in 20 to 1 in 3. Although thefunction of the rotator cuff in our subject would be

seriously impaired, there is nothing to suggest thatdeltoid, pectoralis major and latissimus dorsi wouldnot provide mobility. The apposition of the humerusto the blade of the scapula, however, would impair theaction of teres major. We, therefore, suggest that thesubject may well have retained a degree of flexion,extension, abduction, and adduction at the shoulder,although circumduction and medial and lateral rota-tion of the humerus would be less likely. We areunable to explain the pitted articular appearance ofthe articular surfaces of the humerus and the glenoidfossa. Although Yu et al. (1998) have described osteo-chondral defects of the glenoid fossa, we are unable torelate their findings to the surfaces seen in the presentsubject.

POSSIBLE HISTORY

It is assumed that this dislocation was the result oftrauma. The monks at Newbattle were some of thefirst, if not the first, coal miners in Scotland (Knight,1999), so it is tempting to speculate that the injuryoccurred in a mining accident. Another individualfrom the cemetery was found to have suffered an

Fig. 3. Medial view of the fragment of scapula. Arrows show thesecondary articular surface. Note the great thickness of the bonedeposited posterior to it. The coracoid process (C) and spine (S) areshown.

Fig. 4. Fragment of the head of the right humerus. The articularsurface is porous and pitted. The facets for supraspinatus (S), infraspi-natus (I), and teres minor (T) are visible.

148 Bush and McDonald

avulsion fracture of the spinous process of the sixththoracic (T6) vertebra (Bush, unpublished) that wouldhave been caused by a sudden muscle contraction.This type of fracture has been related to occupation.When it occurs at the level of C7-T1 it is known as a“clay-shoveller’s fracture” (Roberts and Manchester,1995).

We cannot tell whether any attempt had beenmade to reduce the joint. Shoulder reduction wasdescribed by Hippocrates in the 5th century BC (Foy,1993), and medieval practitioners would have hadknowledge of the management of dislocations (Siraisi,1990). New and high standards of the care of the sickwere set in the “golden era of Scottish monasticism,”between the early 12th and early 13th centuries (But-ler and Given-Wilson, 1979). There was an infirmaryat Newbattle but, of course, the injury may not havebeen sustained in the Abbey’s vicinity. Even if it was,reduction becomes more difficult after only 1 hr, be-cause of the onset of muscle spasm (Foy, 1993). Itseems likely that this man would have suffered severeacute pain, and he may have experienced chronic painin the years after the dislocation occurred.

ACKNOWLEDGMENTS

We are grateful for the support of J. Gooder and C.Clark of AOC Scotland. The excavations were fundedby the MJ Gleeson Group plc.

REFERENCES

Bass WM. 1986. Human osteology: a laboratory and field man-ual of the human skeleton. 2nd edition. Missouri Archaeo-logical Society.

Butler L, Given-Wilson C. 1979. Medieval monasteries ofGreat Britain. London: Michael Joseph. p 127, 406.

Foy MA. 1993. Acute dislocation of the glenohumeral joint. In:Kelly IG, editor. The practice of shoulder surgery. Oxford:Butterworth-Heinemann. p 139–162.

Knight K. 1999. The Catholic encyclopedia. Vol. X. On-lineedition www.newadvent.org/cathen/10781a.htm [accessed16 July 2004].

McLaughlin HL, Cavallaro WU. 1950. Primary anterior dislo-cation of the shoulder. Am J Surg 15:615–621.

Matsen FA, Thomas SC, Rockwood CA. 1990. Glenohu-meral instability. In: Rockwood CA, Matsen FA, editors.The shoulder. Vol. 1. Philadelphia: W.B. Saunders Co.p 567.

Neviaser RJ, Neviaser TJ, Neviaser JS. 1993. Anterior disloca-tion of the shoulder and rotator cuff rupture. Clin OrthopRel Res 291:103–106.

Phenice TW. 1969. A newly developed visual method of sexingthe os pubis. Am J Phys Anthropol 30:297–302.

Reeves B. 1966. Arthrography of the shoulder. J Bone JointSurg 48B:424–435.

Reeves B. 1968. Experiments on the tensile strength of theanterior capsular structures of the shoulder in man. J BoneJoint Surg 50B:858–865.

Roberts C, Manchester K. 1995. The archaeology of disease.2nd ed. Ithaca: Cornell University Press. p 78, 87.

Rowe CR, Zarins B. 1982. Chronic unreduced dislocations ofthe shoulder. J Bone Joint Surg 64A:494–505.

Siraisi NG. 1990. Medieval and Early Renaissance medicine.Chicago: The University of Chicago Press. p 155.

Visser CPJ, Coene LNJEM, Brand R, Tavy DLJ. 1999. Theincidence of nerve injury in anterior dislocation of theshoulder and its influence on functional recovery: a pro-spective clinical and EMG study. J Bone Joint Surg 81B:679 – 685.

Yu JS, Greenway G, Resnick D. 1998. Osteochondral defect ofthe glenoid fossa: cross-sectional imaging features. Radiol-ogy 206:35–40.

Paleopathology in a Thirteenth Century Male 149