AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 115:372379 (2001)

The Upper Paleolithic Triple Burial of Doln Vestonice:

Pathology and Funerary Behavior
Vincenzo Formicola,1* Antonella Pontrandolfi,1 and Jir Svoboda2
1

Department of Ethology, Ecology, and Evolution, University of Pisa, 56126 Pisa, Italy
Archaeological Institute, Czech Academy of Sciences, 66203 Brno, Czech Republic

KEY WORDS

paleopathology; Upper Paleolithic; funerary behavior; Doln Vestonice

ABSTRACT
This work focuses on paleopathological
analysis of one of the skeletons from the Gravettian triple
burial of Doln Vestonice (Moravia) and addresses issues
of Upper Paleolithic funerary behavior. The burial includes the well-preserved skeletons of three young individuals. The skeleton in the middle (DV 15) is pathological
and very problematic to sex; the other two (DV 13 and DV
14) are males and lie in an unusual position. The young
age, the possibility of a simultaneous interment, and the
position of the three specimens have given rise to speculations about the symbolic significance of this spectacular
and intriguing funerary pattern. The pathological condition of the skeleton in the middle further emphasizes its
peculiarity.
Main pathological changes of the DV 15 skeleton include:
asymmetric shortening of the right femur and of left forearm
bones, bowing of the right femur, right humerus, and left
radius, elongation of fibulae, dysplasias of the vertebral col-

umn, and very marked enamel hypoplasias. Scrutiny of the

medical literature suggests that the most likely etiology is
chondrodysplasia calcificans punctata (CCP) complicated by
trauma and early fractures of the upper limbs. CCP is a rare
inherited disorder characterized by stippled ossification of
the epiphyses. The cartilaginous stippling is a transient phenomenon that disappears during infancy, leaving permanent
deformities on affected bones. Among the different forms of
CCP, the X-linked dominant form is that resulting in asymmetric shortening and is lethal during early infancy in
males. Thus, survival of DV 15 until young adult age would
require the specimen to be a female. Clinical findings often
associated with the disease (erythemas, ichthyosis, alopecia,
cataracts, and joint contractures, among others) would emphasize the singular aspect of this individual, pointing to a
condition that should be carefully taken into account when
speculating on the significance of that peculiar burial. Am J
Phys Anthropol 115:372379, 2001. 2001 Wiley-Liss, Inc.

Excavations carried out in 1986 by Klma at the

Gravettian site of Doln Vestonice (Moravia)
brought to light a multiple burial including three
well-preserved skeletons (Fig. 1). The uncalibrated
C14 date obtained from charcoal directly associated
with the burial points to an age of 26,640 110 B.P.,
falling within the time span of several dates from
the same site (Svoboda, 1995). This date places the
finding at an early stage of the Gravettian, a phase
of the Upper Paleolithic rich in artistic and symbolic
expressions which developed in Europe between
30,000 20,000 years ago (Roebroeks et al., 2000).
The three skeletons belong to young individuals
lying in an extended position and covered by burnt
spruce logs and branches, possibly part of a wooden
funeral structure. The individual in the middle (DV
15), placed in first and partly covered by the other
two, shows severe pathological changes and cannot
be confidently sexed morphologically due to pelvic
deformations. The other two skeletons (DV 13 and
DV 14) belong to males and lie in an unusual position: one face down, the other on its side with hands
reaching the pubic region of the skeleton in the
middle. The heads of all three individuals are covered with red ochre, and DV 15 also exhibits powdered ochre around the pubis. Pierced carnivore ca-

nines and ivory beads form part of the

ornamentation of the skulls. However, the association of a singular slate plate with parallel incisions
(Emmerling et al., 1993) and of other objects with
the burial is more difficult to demonstrate. Finally,
analysis of dental traits may indicate genetic relationships among the members of the common grave
(Alt et al., 1997).
Stratigraphic evidence and the absence of perturbation of anatomical connections and associated ornaments suggest a simultaneous burial (Klma,
1987a; Vlcek, 1991) or at least interment of the three
specimens in a short lapse of time, i.e., before the
decay of soft tissues of the individual first buried. In
both cases, the death of three young individuals is
an exceptional event, and a triple burial in itself
represents a very rare funerary pattern during this

2001 WILEY-LISS, INC.

Grant sponsor: Murst; Grant number: Cofin.99; Grant sponsor:

CNR; Grant number: 97.00579.PF36.
*Correspondence to: Dr. Vincenzo Formicola, Department of Ethology, Ecology, and Evolution, University of Pisa, via A. Volta 6, I-56126
Pisa, Italy. E-mail: [email protected]
Received 2 December 1999; accepted 10 April 2001.

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STONICE PATHOLOGY AND FUNERARY BEHAVIOR

373

Epiphysial fusion and dental development indicate that these remains belong to a young adult
individual. In agreement with previous analyses (Vlcek, 1991, 1997; Jelnek, 1992), we suggest an age of
about 20 years. The same parameters yield a
slightly younger age (1719 years) for the other two
specimens, DV 14 being the youngest.
While based on morphology of well-preserved hip
bones a general agreement exists that DV 13 and 14
are males, the sex of DV 15 is problematic and
different determinations have been proposed by
Vlcek (1991), Jelnek (1992), and Novotny (1992). As
already pointed out by these authors, the main difficulty lies in an admixture of male and female characteristics exhibited by the pelvis, possibly linked to
the pathological state of the skeleton. Thus, a reliable sex diagnosis cannot be obtained on purely anatomical grounds.
The main pathological changes are mostly restricted to the postcranium and include:

Fig. 1. Gravettian triple burial found at open-air site of Doln

Vestonice (Moravia). The skeleton in the middle is pathological.
From left to right: DV 13, DV 15, and DV 14.

time period, with an analog only at Barma Grande

(Grimaldi caves) (Verneau, 1906; Formicola, 1990).
Moreover, the position of the hands of DV 13, and
more importantly the prone position of DV 14, are
very unusual.
The young age and position of the specimens and
their possible simultaneous interment have given
rise to speculations concerning the symbolic significance of this burial (Klma, 1987a). The skeletal
deformations of the specimen in the middle further
emphasize the peculiarity of this burial pattern. Funerary behavior reflects both aspects of social life
and beliefs of past populations. Inferring these aspects requires a holistic approach that brings together paleoethnological, paleopathological, and anthropological data. Thus, the paleopathological
study of DV 15 combines the traditional focus on
history of the diseases and on reconstruction of life
conditions of past populations, with the additional
goal of addressing issues of Upper Paleolithic funerary behavior.
In this paper we seek a diagnosis of the pathology
manifest in DV 15.
THE SKELETON DOLNI VESTONICE 15
The skeleton DV 15 is nearly complete and in an
overall good state of preservation. Major damage
(mainly due to crushing) affects the vertebral bodies,
sacrum, and scapulae. In addition, parts of the skull
base and of the palate, nasal bones, left mandibular
incisors, sternum, and most of the hand and foot
bones are missing.

Asymmetric shortening of the femur, with the

right side 16 mm shorter than the left (bicondylar
length, right 367 mm; left 383 mm) (Fig. 2a,b);
Anterior bowing of the upper third of right femoral
shaft (Fig. 2c);
Mild coxa vara (neck-shaft angle on right side
11) (Fig. 2a), and retroversion of the head (5);
Elongation of both fibulae relative to tibial length,
i.e., fibular length is equal to or slightly exceeds that
of the tibia (Martin n. 1 of right and left fibula 339
and 337 mm, respectively; Martin n. 1 of right and
left tibia 337 and 337 mm, respectively) (Fig. 2d);
Medial incurving of the distal one-third right humerus. At the point of curvature there is an anomalous increase of the diaphyseal circumference (Fig.
3a);
Slight dorsal bowing of the proximal diaphysis of
the left radius and bony callus formation on the
distal diaphysis of the ipsilateral ulna. Both left
forearm bones are short relative to their counterparts (8 9 mm, respectively) (Fig. 3b,c); and
Diffuse enamel hypoplasias, particularly marked
on upper and lower first molars (Fig. 4). Their position on the tooth crowns suggests that a severe disruption took place around 18 months of age.
Additionally, the vertebral column exhibits scoliosis, misshapen spinous processes of the fourth and
fifth lumbar vertebrae, and hypoplastic development of lateral portions of the sacrum. Superior
pubic rami are short.
Radiographic examination of the bones reveals
no signs of fracture or abnormalities of the bony
structure, except thickening of the humeral compacta at the point of shaft curvature and of the
distal diaphysis of the left ulna (Fig. 5). No Harris
lines are detectable, possibly due to a long remodeling period.

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V. FORMICOLA ET AL.

Fig. 2. Lower limb bones of DV 15: right (a) and left (b) femur in anterior view, right femur in lateral view (c), and right and left
fibulae and tibiae (d). Note shortening and bowing of right femur, varus deformation of its neck, and relative elongation of fibulae.

DIFFERENTIAL DIAGNOSIS
The early hypotheses
The skeleton of DV 15 has not yet been thoroughly
investigated from a paleopathological point of view.
However, two hypotheses have been proposed to explain the observed bone deformations:
1) hemiparalysis of the right side, possibly resulting
from encephalitis suffered in early life (Klma,
1987b); or
2) a rachitic condition (Jelnek, 1992).
Both diagnoses are unlikely. In particular, the
well-developed muscular insertions, the normal degree of lateralization, and the thickness of cortical
tissue argue against the first possibility, while the
absence of bowing of tibiae and fibulae, i.e., the
bones generally showing the most obvious manifestations of rickets, is inconsistent with the latter
diagnosis.
Another hypothesis has been suggested by Kuklk
(1992), who attributes the deformities of the right
femur to a congenital disease of poorly known etiology: proximal femoral focal deficiency (PFFD).
PFFD is a disease characterized by unilateral shortening of the femur due to failure of normal development of a portion of the proximal femur (Resnick,
1995a). Four classes of defects, based on femoral and
acetabular abnormalities, have been proposed (Aitken, 1969). In the milder forms (class A), the femur

is short, incurved, and affected by subtrochanteric

varus deformation. The femoral head is regularly
connected to the shaft, and the acetabulum is almost
normal. In the remaining forms (classes B, C, and
D), connections between the femoral head and shaft
are lacking and, in increasing order of severity, the
shaft, head, and acetabulum are dysplastic or absent
(see Fig. 90-23 in Resnick, 1995a).
Regarding Aitkens class A, it is important to note
that the shaft is very short (Fixsen and Lloyd-Roberts, 1974; Epps, 1983; Gillespie and Torode, 1983).
Thus, the moderate bilateral asymmetry exhibited
by DV 15 (about 4%, calculated as rt lt/(rt lt)/2)
speaks against such an attribution. However, Amstutz (1969) and Hamanishi (1980) further subdivided class A into subtypes including cases previously indicated as femoral hypoplasia with coxa
vara (Ring, 1960). In these cases, the shortening of
the affected femur is less than 10%. According to
Hamanishi (1980) and Resnick (1995a), the lack of
discontinuity between two syndromes (femoral hypoplasia and PFFD) suggests a single clinical entity
with different degrees of expression that is referred
to as congenital short femur (CSF). Independently
from the severity of shortening, however, the femur
is laterally bowed and varus deformity develops in
the subtrochanteric shaft (Levinson et al., 1977;
Pavlov et al., 1980; Boden et al., 1989; Resnick,
1995a). Additionally, associated anomalies with
PFFD/CSF include hypoplastic development of the

DOLNI VE
STONICE PATHOLOGY AND FUNERARY BEHAVIOR

Fig. 4.
molar.

375

Marked enamel hypoplasias on DV 15s first lower

Fig. 5. Radiographs of femoral and humeral diaphyses of DV

15 at point of curvature and of left ulna and radius.

varus deformity at the level of the femoral neck, and

more generally the absence of other stigmata associated with the disease do not support a diagnosis of
PFFD/CSF.
Towards a diagnosis
Fig. 3. Upper limb bones of DV 15: anterior views of right and
left humeri (a), and medial views of right and left radii (b) and
ulnae (c). Note bowing of right humerus and left radius, callus
formation on left distal ulna (arrows), and shortening of left lower
arm bones.

lesser trochanter, and absence or hypoplasia of the

ipsilateral fibula and hemimelia of upper limb
bones, particularly of the ulna (Panting and Williams, 1978; Schatz and Kopits, 1978; Hillmann et
al., 1987; Boden et al., 1989).
None of the diagnostic features listed above is
exhibited by DV 15. Specifically, sagittal bowing,

Using asymmetric shortening of the long bones as

a key trait in the search for the etiology of the
disease, we have identified a few additional conditions including caudal regression syndrome, femoral
hypoplasia with unusual facies syndrome, and chondrodysplasia calcificans punctata. The first two syndromes share characteristics and both show a strong
relationship with maternal diabetes. In particular,
it has been found that high levels of insulinemia in
the fetus of a diabetic mother can result in a wide
variety of congenital anomalies, including abnormal
growth, and soft-tissue and skeletal abnormalities
(Resnick, 1995b).

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V. FORMICOLA ET AL.

Two patterns of malformations have been identified and referred to as caudal regression syndrome
(CRS) and femoral hypoplasia with unusual facies
syndrome (FH-UFS). Both result in postural deformities of the lower extremities, sometimes involving
asymmetric development of the femur (Johnson et
al., 1983; Guidera et al., 1991). However, the severity of femoral hypoplasia and its frequent association with radio-ulnar or radio-humeral synostosis
(Daentl et al., 1975) make a diagnosis of FH-UFS
very unlikely in DV 15. CRS is equally unlikely,
considering that this syndrome also involves sacral
agenesis of variable but generally severe intensity,
hip dislocations, and foot deformities (Resnick,
1995a).
The third syndrome, chondrodysplasia calcificans
punctata (CCP), is an inherited form of multiple
epiphysial dysplasia characterized by stippled calcifications in some areas of enchondral bone formation. Tubular bones, particularly the femur and humerus, and the vertebrae are among the most
frequently affected elements. The disease ranges
from a severe rhizomelic form resulting in stillbirth
or death within the first months of life to a milder
disorder, sometimes showing asymmetrical limb
shortening (Goldman, 1995). In cases of survival,
calcifications disappear by age 13 years (Hyndman
et al., 1976; Goldman, 1995), but there may be residual deformity. Correlation between severity of
stippling and residual deformity has been pointed
out (Comings et al., 1968; Spranger et al., 1971;
Silengo et al., 1980).
Different types of CCP have been recognized on
the basis of phenotype, mode of inheritance, and
gene defect localization (Goldman, 1995):
Rhizomelic, autosomal-recessive: lethal.
X-linked dominant (Conradi-Hunermann disease):
lethal for males, but associated with a good prognosis for females.
X-linked recessive (Curry type): normal survival.
X-linked recessive (Sheffield type): normal survival.
Tibia-metacarpal type: normal survival.
All the different types of CCP exhibit symmetric
shortening of the limbs, with the exception of the
X-linked dominant form, characterized by asymmetric involvement. Focal disruption of the growth
plate, varying from bone to bone, is the likely cause
of the asymmetrical nature of the changes (Rimoin
et al., 1976). The diagnosis is usually made during
the first year of life, based on the peculiar appearance of the newborn and radiographic examination.
However, despite the early disappearance of stippling, recognition of skeletal and soft-tissue anomalies allows diagnosis later in life (Comings et al.,
1968; Hyndman et al., 1976). The disease has a
highly variable clinical expression, as stressed by
many authors (Silengo et al., 1980; Manzke et al.,
1980; Mueller et al., 1985), who cite the existence

within a single family of individuals mildly and severely affected.

Skeletal changes found associated with femur
asymmetry include varus deformity of the femoral
neck (Hyndman et al., 1976; Silengo et al., 1980),
asymmetric development of both forearm bones
(Manzke et al., 1980; Mueller et al., 1985), scoliosis
and vertebral anomalies (Goldman, 1995; Happle,
1979), and elongation of the fibulae (Josephson and
Oriatti, 1961; Jerre, 1962; Wynne Davies et al.,
1985). Thus, a diagnosis of X-linked dominant CCP
is supported by the asymmetric shortening of the
femur, radius, and ulna, coxa vara, scoliosis, and
relative elongation of fibulae.
Saddle nose (flat nasal bridge) and contractures
at the level of the hip and knee represent additional
skeletal anomalies observed clinically (Happle,
1979; Manzke et al., 1980; Goldman, 1995). In DV
15, the presence of a flat nasal bridge cannot be
confirmed, given the absence of nasal bones, but this
feature tends to become less evident with age (Sheffield et al., 1976). As far as contractures are concerned, there are no traces left on the bones.
Stature, depending on the severity of the disease,
can vary from normal to very short (Spranger et al.,
1971; Silengo et al., 1980). In DV 15, the stature of
about 150 cm obtained from the femur and tibia is
short both when compared with the few Gravettian
female remains from Moravia and with the whole
European Early Upper Paleolithic female sample
(Formicola and Giannecchini, 1999).
Finally, the very marked enamel hypoplasias
shown by DV 15s first molars point to dramatic
perturbations in health status during early life
(around age 18 months, based on the position of the
defects on tooth crowns), a very critical period for
children affected by CCP (Lischi and Menichini,
1967; Sheffield et al., 1976; Silengo et al., 1980).
The main obstacle in accepting CCP as the only
possible etiology lies with the presence of bowing
deformities. These changes are part of the lethal
rhizomelic form, but are not typically associated
with the X-linked dominant form of CCP. Considering that bowing of long bones is only occasionally
found in subjects affected by that form of the disease
(Kampf, 1939; Brogdon and Crow, 1958; Weber,
1958; Andersen and Justensen, 1987; Mason and
Kozlowsky, 1973; Wynne-Davies et al., 1985), this
condition can hardly be responsible for the simultaneous incurving of humerus, radius, and femur. The
involvement of other factors is required to justify the
observed pathological pattern. Traumatic injuries
provide a likely explanation.
The old orthopedic literature reports that a few
cases of congenital abnormalities of long bones were
initially regarded as healed birth or intrauterine
fractures (Ring, 1959). Such injuries are related to
different factors, including breech presentation and
labor difficulties (Behrman and Mangurten, 1977;
Resnick et al., 1995), and result initially in severe
shortening and bowing deformities. In these cases,

DOLNI VE
STONICE PATHOLOGY AND FUNERARY BEHAVIOR

as well as in cases of fractures suffered by very

young children, follow-up examinations show
marked corrections and improvements of both
changes in the absence of signs of repair, due to a
long period of remodeling (Ride`n, 1935; Madsen,
1955; Bakalim and Wilppula, 1972; Vahvanen and
Aalto, 1978; Hagglund et al., 1988; Tachdijan, 1990).
It has also been shown that the tendency toward
spontaneous correction of angular deformities and of
length discrepancies is great, and that even severe
displacements left to heal in an anatomically bad
position have a good prognosis.
As far as the humerus is concerned, a supracondylar fracture is a rather common injury in children
and is produced by a fall on the hand with the elbow
in hyperextension. Interestingly, the residual deformation often results in varus deviation, as in DV 15.
Varus deviation is a consequence both of the direction of the fracturing force (French, 1959; Graham,
1967) and of the pull of the strong pronator teres
muscle in absence of the opposed action of the biceps
brachii muscle due to the break in the humerus
(Tachdijan, 1990).
Acute plastic bowing deformities (APBD) are an
additional entity recently recognized by orthopedists
(Borden, 1974; Cail et al., 1978; Price, 1996), and
consist of broad bowing of the shaft with a shape
representing an exaggeration of the usual curvature. The mechanism responsible for these bowing
deformities lies in strong compressive longitudinal
forces applied to both ends of naturally curved long
bones. Stress ranging between elastic and fracture
limits causes bending that remains after stress is
removed. Lower arm bones are the bones most frequently involved, typically a result from a fall onto
an outstretched hand (Naga and Broadrick, 1977;
Stuart-MacAdam et al., 1998). In many instances,
the fracture of one of the lower arm bones is associated with APBD of the other bone (Borden, 1975;
Crowe and Swischuck, 1977; Resnick et al., 1995;
Price, 1996).
Bowing of the left radius and callus formation
shown by the ipsilateral ulna of DV 15 are consistent
with a scenario involving, respectively, APBD and a
healed early fracture. As already pointed out, varus
deviation affecting the right humerus might also
result from a very early injury. This hypothesis is
also supported by the anomalous shape and thickening of the compacta of the humerus at the point of
curvature. More problematic is referring the incurving of the femur to the same etiology in the absence
of the changes shown by humerus and ulna. Moreover, referring whole bowing deformities to a sequel
of trauma would not explain the additional anomalies exhibited by DV 15 (asymmetric development of
femur and of lower arm bones, elongation of fibulae).
Finally, as already pointed out, bowing of long bones
has been occasionally found in the X-linked dominant form of CCP; regarding the femur specifically,
the radiograph of a bowed femur in an affected girl

377

is reported in a textbook on skeletal dysplasias (Fig.

4.23 in Wynne-Davies et al., 1985).
In conclusion, the combination of CCP and trauma
provides the most likely explanation for the pathological pattern exhibited by DV 15. In particular,
while the X-linked dominant form of CCP is probably responsible for most of the changes, bowing deformations of the upper limb bones likely result from
traumatic injuries suffered during early life.
FINAL CONSIDERATIONS
While examples of traumatic injuries to limb
bones are not uncommon in the Upper Paleolithic
record, DV 15 provides very early evidence of CCP in
the paleontological material and increases our
knowledge on the history of inherited disorders. The
diagnosis of CCP, however, has important implications going beyond mere paleopathological value.
Specifically, the diagnosis implies that the DV 15
skeleton belongs to a female, considering that the
asymmetric shortening is typical of the X-linked
dominant form, which is lethal during early infancy
in males. Moreover, the diagnosis provides clues
about therapeutic knowledge of Upper Paleolithic
populations, since the survival of similarly affected
children is very problematic in the absence of adequate treatment and care. Recurrent infections of
the respiratory and gastrointestinal tracts, respiratory and feeding difficulties, and failure to thrive are
among the most frequent causes of health disturbances (Mosekilde, 1952; Mason and Kozlowsky,
1973; Sheffield et al., 1976; Goldman, 1995). The
extremely severe enamel hypoplasias dated to a very
early stage of DV 15s life provide a likely record of
at least one of those disruptions.
The diagnosis also suggests the possibility that
DV 15 experienced some kind of soft-tissue anomalies, since cataracts, epicanthus, erythemas, icthyosis, and alopecia are frequently associated clinical
findings (Happle, 1979; Manzke et al., 1980; Kozlowsky et al., 1988; Goldman, 1995). Thus, skeletal
deformations, as well as the other stigmata of the
disease, emphasize the singular aspect and the diversity of this individual, pointing to a condition
that should be taken into account when speculating
on the significance of this burial.
The Upper Paleolithic fossil record includes other
cases of diseases resulting in physical deformations
significantly associated with peculiar funerary contexts. Undoubtedly the most emblematic case is the
Romito (Calabria, Italy) chondrodystrophic dwarf
buried together with an old woman in a cave important for its expressions of mobiliary and parietal art
(Frayer et al., 1988). Also in Italy, in the Arene
Candide necropolis, rich in ornamental and symbolic
objects (Cardini, 1980), a few skeletons show
changes that are probably due to an inherited form
of rickets (Formicola, 1995). A further example
comes from Gravettian Moravia, where spectacular
grave goods, including an articulated ivory male
figure (Jelnek et al., 1959), were found associated

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V. FORMICOLA ET AL.

with the poorly preserved skeleton Brno 2. Only a

few fragmentary parts of the postcranial bones are
preserved, but what remains is affected by very severe periostitis (Oliva, 2000). Finally, one of the two
children from the Gravettian site of Sunghir, found
buried head to head with extremely rich grave goods
(Bader, 1970), exhibits bowing of the femora (Bukhman, 1984; Buzhilova, 2000). The etiology of this
deformity is not clear, but the burial emphasizes
issues of social perception of diversity and of the role
of these individuals in their society. Rich ornamentation, elaborate funerary behavior, and site of inhumation shed light on ideological aspects,
strengthening the idea that a few Upper Paleolithic
burials included selected individuals and that physical diversity may have played a role in selective
burial patterns from that period.
ACKNOWLEDGMENTS
Radiographs were kindly provided by E. Trinkaus.
We also acknowledge V. Alekshin for information
and reprints on Sunghir material. Thanks are also
due to an anonymous referee for careful comments
and suggestions.
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