AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 124:189 198 (2004)
Double Child Burial From Sunghir (Russia): Pathology
and Inferences for Upper Paleolithic Funerary Practices
Vincenzo Formicola1* and Alexandra P. Buzhilova2
1
Department of Ethology, Ecology, and Evolution, University of Pisa, 56126 Pisa, Italy
2
Department of Physical Anthropology, Institute of Archaeology of RAS, 117036 Moscow, Russia
KEY WORDS paleopathology; Upper Paleolithic; funerary behavior; Sunghir
ABSTRACT The double child burial from Sunghir
(Russia) is a spectacular Mid Upper Palaeolithic funerary
example dated to about 24,000 BP. A boy (Sunghir 2) and
a girl (Sunghir 3), about 1213 and 9 10 years old, re-
spectively, were buried at the same time, head to head,
covered by red ocher and ornamented with extraordinarily
rich grave goods. Examination of the two skeletons reveals
that the Sunghir 3 femora are short and exhibit marked
antero-posterior bowing. The two femora do not show any
asymmetry in the degree of shortening and bowing. Bow-
ing affects the whole diaphysis and shows a regularly
incurved prole, with the highest point at midshaft. Pa-
thology is conned to the femora, and no other part of this
well-preserved specimen shows abnormality. The isolated
nature of the Sunghir 3 anomalies points to cases reported
in the medical literature under the label of congenital
bowing of long bones (CBLB). These are a group of rare
conditions exhibiting localized, sometimes bilateral, bow-
ing and shortening which are nonspecic and may result
from different causes, including abnormalities of the pri-
Sunghir is an open site on the left bank of the
Klyasma River near the town of Vladimir, about 200
km northwest of Moscow, providing very early evi-
dence of the expansion of anatomically modern hu-
mans to such high latitudes. This large site, inhab-
ited seasonally by people belonging to the
Kostjonky-Streleskaya culture, yielded an impres-
sive array of archaeological and paleontological ma-
terial that has provided important information on
physical anthropology, funerary behavior, food man-
agement, subsistence, and settlement strategies of
Mid Upper Paleolithic Russian plains populations
(Zubov and Kharitonov, 1984; Bader, 1998; Alexeeva
and Bader, 2000).
The double child burial (Sunghir 2 and 3), one of
the most spectacular and elaborate Upper Paleo-
lithic funerary examples, was found in 1969 in the
southwestern part of the site, 3 m from the adult
male burial (Sunghir 1) (Bader, 1970). The two chil-
dren were buried head to head in supine position in
a long, narrow, and shallow grave dug into the per-
mafrost (Fig. 1). The skeletons were covered with
red ocher and accompanied by extraordinarily rich
and unique grave goods. Thousands of ivory beads,
2004 WILEY-LISS, INC.
mary cartilaginous anlage (i.e., the aggregation of cells
representing the rst trace of an organ). Localized ossi-
cation disturbances, possibly linked to a diabetic maternal
condition, might explain the shortening and the coinci-
dence of maximum midshaft curvature with the position of
the primary ossication center, as well as the lack of
involvement of other skeletal parts. This scenario, rather
than other possibilities (early bilateral midshaft fracture,
acute plastic bowing deformities, or faulty fetal posture),
provides the most likely explanation for the Sunghir 3
femoral deformities. The intriguing combination of a
pathological condition apparent since birth with a spec-
tacular burial of unusually positioned young individuals of
different sexes recalls signicant aspects of the triple
burial from the contemporary site of Doln Vestonice
(Moravia), evoking a patterned relationship between
physical abnormality and extraordinary Upper Paleolithic
funerary behavior. Am J Phys Anthropol 124:189 198,
2004. 2004 Wiley-Liss, Inc.
probably sewn onto clothes, long spears of straight-
ened mammoth tusks (one of which is 240 cm long),
ivory daggers, hundreds of perforated arctic fox ca-
nines, pierced antler rods, bracelets, ivory animal
carvings, ivory pins, and disc-shaped pendants were
part of the ornamentation of the burial (Fig. 2). A
human femur shaft (Sunghir 4) lled with ocher,
found on the left side of the Sunghir 2 skeleton, has
also been considered associated with the burial.
Long bone samples taken from the two skeletons
provided 14C (AMS) uncalibrated dates of 23,830
Grant sponsor: MIUR; Grant number: Con 01; Grant sponsor:
CNR; Grant number: 01.00473.PF36; Grant sponsor: Bioanthropo-
logical Foundation (1998 1999).
*Correspondence to: Dr. Vincenzo Formicola, Dipartimento di Eto-
logia, Ecologia ed Evoluzione, University of Pisa, via A. Volta 6,
I-56126 Pisa, Italy. E-mail: vformi@discau.unipi.it
Received 24 May 2002; accepted 16 December 2002.
DOI 10.1002/ajpa.10273
Published online 3 November 2003 in Wiley InterScience (www.
interscience.wiley.com).
190 V. FORMICOLA AND A.P. BUZHILOVA
Fig. 1. Double child burial from Sunghir (Russia). Note long ivory spears and rich grave goods. Pathological specimen (Sunghir 3)
is at right.
Fig. 2. Close-up of skulls of children, showing rich ornamen-
tation including ivory beads, pins, and disc-shaped pendants and
perforated fox canines.
220 BP and of 24,100 240 BP, respectively, for
Sunghir 2 and Sunghir 3 (Pettitt and Bader, 2000).
These dates are in agreement with archaeological
evidence indicating simultaneity in the inhumation
of the two children.
The richness of the grave goods, the unusual head
to head positioning of the skeletons (the only known
example in the Upper Paleolithic), and the simulta-
neous inhumation of two children make the double
burial unique. Additionally, one of the children
(Sunghir 3) exhibits a bilateral deformity of the fem-
ora that are short and markedly antero-posteriorly
bowed (Bukhman, 1984; Buzhilova, 2000a). The
Sunghir 3 pathological condition further under-
scores the peculiarity of this burial. It has been
suggested that the complexity and richness exhib-
ited by some Upper Paleolithic burials are indicative
of selected individuals (Oliva, 2000; Mussi, 2001),
and that physical abnormality is one of the possible
factors involved in selective and spectacular burial
practices from that period (Formicola et al., 2001).
This scenario adds a new dimension to the present
paleopathological study.
This study aims to diagnose the disease affecting
Sunghir 3, and to provide clues about the history of
diseases and life conditions of early anatomically
modern humans in Europe. Moreover, the combina-
tion of archaeological and paleopathological data af-
fords a unique possibility to shed light on ideological
aspects of Mid Upper Paleolithic funerary behavior.
THE SUNGHIR 3 SKELETON
State of preservation
The Sunghir 3 skeleton is in a good state of pres-
ervation, considering the fragility of subadult bones.
It includes a nearly complete, well-reconstructed
skull with a mixed dentition. The thoracic region is
represented by nearly complete clavicles and hip
bones, incomplete scapulae, fragmentary sternum
and ribs, and a vertebral column lacking only a few
elements. Humeri and ulnae are slightly incomplete,
particularly at the epiphyses, while the radii exhibit
fairly poor preservation. Femora are the best-pre-
served long bones and show only minor damage; the
tibiae are slightly incomplete; the right bula lacks
the upper metaphysis, while the left bula is repre-
sented only by the middle portion of the diaphysis.
Hand and foot bones include many elements of the
two sides and of their proximal, mesial, and distal
anatomical components.
The other skeleton found in the same burial
(Sunghir 2), here taken into account only for com-
parative purposes, is also in a good state of preser-
vation, allowing, as in the Sunghir 3 case, reliable
measurements for the large majority of bones
(Buzhilova and Lebedinskaya, 2000; Kozlovskaya
and Mednikova, 2000).
Sex and age
From one of the rst reports (Zubov and Khari-
tonov, 1984), the two specimens have been consid-
ered male (Sunghir 2) and female (Sunghir 3) on the
basis of hip bone morphology (sciatic notch, pubic
length, and general proportions). More recent work
on the pelvis and on general characteristics of the
skeletons of the two children (Bruzek and Novotny,
1993; Mednikova et al., 2000; Nikityuk and Khari-
tonov, 2000) concurred with these attributions. Re-
cent DNA investigations conrmed the osteological
evidence for sex (Poltoraus et al., 2000). Results of
these analyses indicate the presence of locus DYZ1,
 SUNGHIR PATHOLOGY AND FUNERARY BEHAVIOR 191
linked to the Y chromosome, in bone samples from
Sunghir 2 and the adult male Sunghir 1, but not in
Sunghir 3. Based on generally good levels of DNA
found in the Sunghir remains, the authors attribute
the negative result obtained for Sunghir 3 to an XX
karyotype, rather than to Y-chromosome degrada-
tion.
Regarding ages, both cases show complete ab-
sence of epiphysial closure and a lack of fusion
among hip bone components (Mednikova et al.,
2000). However, Sunghir 3 is clearly younger than
Sunghir 2, as evidenced by dental development.
Sunghir 2 shows only permanent teeth, while Sung-
hir 3 still preserves part of the deciduous dentition.
Based on dental maturation (deciduous molars still
in place except for the rst upper left, second molars
at the alveolar plane, and third molars not visible),
the age of Sunghir 3 can be estimated at around
9 10 years (Zubov, 2000). The dental age of Sunghir
2 is more advanced (incomplete eruption of second
lower premolars, second upper molars, and right
lower canine, third molars still included, but the
cusps of maxillary M3 already visible), and can be
estimated at around 1213 years (Zubov, 2000).
Pathology
Examination of the two skeletons reveals that
while bone development in Sunghir 2 is apparently
normal in shape and dimensions, the Sunghir 3 fem-
ora are short and markedly bowed antero-posteri-
orly (Fig. 3). Pathology is conned to the femora, and
no other part of this well-preserved skeleton shows
any abnormality. No abnormality can be found in Fig. 3. Lateral view of Sunghir 2 (left) and Sunghir 3 (right)
femora. Comparison emphasizes differences in length and bowing
Sunghir 3 craniofacial morphology and develop- between femora of two children.
ment. The height of the vertebral bodies and clavicle
length suggest a well-developed thorax, and the pel-
vic and scapular girdles as well as the preserved 84.6, respectively) and close also to the mean value
hand and foot remains appear normal. The lengths reported by Trinkaus et al. (2001). The longitudinal
of upper limb bones and tibiae, compared to modern growth data of the femur and tibia provided by
samples (Maresh, 1955; Anderson et al., 1964), are Anderson et al. (1964) on a sample of 67 boys and 67
within the normal range of variation for that age, girls suggest that the comparison of tibio-femoral
show a regular shape, and appear relatively robust. ratios of children with adult data should not intro-
On the other hand, the femora are short and exhibit duce any strong bias. Assuming that a ratio similar
a strong curvature in lateral view. The bowing is to that found in early Upper Paleolithic samples
symmetric, affects the whole diaphysis, and shows a would have characterized Sunghir 3, we suggest a
regularly incurved antero-posterior prole with the shortening of around 3 cm (i.e., 8 9%).
highest point at midshaft (Fig. 4). For both femora, Regarding other aspects of Sunghir 3s femoral
the curvature in the sagittal plane can be estimated morphology and structure, the proximal and distal
at around 35. metaphyses are normal in shape and dimensions,
Femoral shortening is more difcult to quantify and show radiographically dense cortical bone
but is apparent upon rst inspection, in comparison (Bukhman, 1984) and a regular trabecular pattern
with data on modern children and in relation to (Buzhilova, 2000a; Mednikova, 2000). Angular as-
tibial length. The crural index (Martin and Saller, pects of the femora, including anteversion of the
1957), i.e., the ratio between tibia length (Martin n head (12) and condylo-diaphyseal angle (10,
1 316 mm) and femur maximum length (Martin n with epiphyses positioned on the metaphyses), are
1 343 mm), is abnormally high (92.1), exceeding within the normal range of variation, while the collo-
by more than 3 s.d. that exhibited by early Upper diaphyseal angle is rather high (138). Although a
Paleolithic populations (M 84.9, n 19, s.d. 1.9) high angle may indicate low levels of locomotor ac-
(Trinkaus et al., 2001). It should be noted that the tivity (Anderson and Trinkaus, 1998), muscle inser-
ratios shown by the other child (Sunghir 2) and by tions and the cortical thickness of the femora and
the adult male (Sunghir 1) are very similar (85.3 and tibiae do not support this interpretation and sug-
192 V. FORMICOLA AND A.P. BUZHILOVA

Fig. 4. Antero-posterior (left) and medio-lateral (right) views of Sunghir 3 femora. Note perfectly symmetrical appearance of
deformities, marked development of antero-posterior midshaft diameter, and normal shape of upper and lower extremities of femora.

gest, instead, the biomechanical effects of an altered
loading pattern. Additional changes affect the mid-
shaft, where an exceptional development of the an-
tero-posterior diameter and a reorganization of di-
aphyseal contours can be observed. This results in
an abnormally high pilasteric index (over 170) not
associated, however, with a marked projection of the
linea aspera.
Radiographic examination in the medio-lateral
view provides additional information on bone re-
modeling, showing buttressing of the posterior com-
pacta, which gradually increases towards the point
of highest curvature (Fig. 5). At this point, the thick-
ness of the posterior wall of the compacta reaches
the value found in the adult male (Sunghir 1) (15
mm) and largely exceeds that exhibited by the other
child (Sunghir 2) (9 mm) (Mednikova, 2000).
DIFFERENTIAL DIAGNOSIS
Femoral deformities affecting Sunghir 3 were rst
mentioned in a short report about the radiographic
appearance of the childrens skeletons (Bukhman,
1984). The report referred to a congenital condition
of uncertain origin. Preliminary investigations, car-
ried out in the broader context of physiological and
occupational stress exhibited by the two children
(Buzhilova, 2000a), support a congenital etiology for
the anomalous bending of the femora. Our differen-
tial diagnosis will begin by examining this latter
possibility more in depth.
A congenital etiology?
Based on clinical features and radiographic ap-
pearance, the diagnosis of the most common causes
of congenital abnormalities involving bowing of the
long bones can be precise. However, most of those
syndromes are characterized either by diffused bow-
ing, frequently associated with additional skeletal
anomalies (e.g., osteogenesis imperfecta, Fuhr-
manns dysplasia, Antley-Bixler syndrome, achon-
droplasia, femoral hypoplasia unusual facies syn-
drome, hypophosphatasia, or mild forms of
camptomelic syndrome), or do not typically affect
the femora (e.g., Blounts disease, neurobromato-
sis, or congenital pseudoarthrosis), or mainly affect
the femoral metaphyses (e.g., metaphyseal chondro-
dysplasias; see Wynne-Davies et al., 1985; Beighton,
1988; Resnick, 1995). Thus, none of these diseases
provides a likely explanation for the condition of
Sunghir 3, where the pathological changes are con-
ned to the femoral diaphyses.
 SUNGHIR PATHOLOGY AND FUNERARY BEHAVIOR
Fig. 5. Sungir 3 femoral radiographs in antero-posterior and
medio-lateral view, showing buttressing of posterior compacta.
(Scale in cm.)
Also unlikely are unique syndromes (e.g., Conway,
1958; Bain and Barret, 1959; Dunn and Aponte,
1962; Rath and Thalhammer, 1967; Stuve and Wied-
man, 1971; Mahloudji et al., 1974; Eliachar et al.,
1975; Stevenson, 1982; Maclean et al., 1983; Burton
et al., 1986), in which shortening and bowing of the
femora are associated with other deformities. Recent
attempts to better delineate some of those conditions
(Prasad et al., 2000; Spranger et al., 2000) reempha-
sized the symptomatic nature of a variety of cases
exhibiting bowing of the long bones. Many of those
cases were grouped under the general title of con-
genital bowing of long bones (CBLB), meant as
nonspecic manifestations of a great number of con-
ditions (Kozlowsky et al., 1978; Hall and Spranger,
1980). Patients with CBLB were sorted into three
major groups by Hall and Spranger (1980). One of
those (group 1) included patients in whom bowing
was conned to the femora, in the absence of me-
taphyseal and epiphyseal abnormalities. However,
craniofacial malformations (scaphocephaly, macro-
cephaly, and micrognatia) and talipes equinovarus
are the rule, making the attribution of the Sunghir 3
case to this group unlikely.
193
Additional cases of CBLB reported by Kozlowsky
et al. (1978) include a subgroup referred to as bi-
lateral femoral bowing, in whom bowing is the pre-
dominant or only sign of the disease. Four patients
exhibiting short and bowed femora belong to this
category and deserve particular attention. Case 5 is
an adult woman showing shortened, sclerotic,
slightly bowed femora and unequal lower limb
length. Case 6, her daughter, is a 4-month-old girl
with extremely short and broad femora and minor
pelvic changes. Case 7 is a 6-year-old girl exhibiting
short and bowed femora, hypoplastic capital epiph-
yses, a pronounced coxa vara, and hand malforma-
tions. Case 8 is a 14-month-old boy brought to the
hospital because of shortness of stature which re-
sulted from shortening and bowing of the femora. No
other radiological abnormalities were found. Unfor-
tunately, there are no follow-up examinations of this
case, one of the most intriguing among those listed
by Kozlowsky et al. (1978).
The list of Kozlowsky et al. (1978) also contains an
additional subgroup of CBLB, the so-called Caffey
variety attributed to fetal compression and faulty
positioning. Reports by Caffey (1947) and Angle
(1954) point to the localized bilateral involvement of
lower and/or upper limb bones, and a lack of associ-
ation with other anomalies. As far as the femora are
concerned, Chapple and Davidson (1941) mentioned
a case of bilateral lateral bowing in an infant who
assumed the position of comfort with the legs
crossed in such a way that each foot rested in the
concavity of the opposite femur. Laterally dislocated
hips and shallow acetabula support the idea that
fetal posture was responsible for these changes. It is
important to note that, in cases of bilateral femoral
involvement, the curvature is invariably directed
laterally (Chapple and Davidson, 1941; Silverman,
1985). The anterior bowing shown by the Sunghir 3
femora and the very favorable prognosis of Caffey
variety of CBLB, whose symptoms usually disap-
pear shortly after birth, speak against a mechanical
etiology. Additionally, this etiology would not ex-
plain the Sunghir 3 short femora.
In the broadest sense, bowing resulting from me-
chanical forces is due to trauma, i.e., a trauma to a
degree lower than breaking stress (Angle, 1954;
Swischuk and John, 1995; Stuart-Macadam et al.,
1998), which brings in another possible etiology.
A traumatic etiology?
Focal bowing of limb bones may result from
trauma of varying severity (Swischuk and John,
1995). Longitudinal compressive forces, insufcient
to break the bone but strong enough to exceed its
elastic limits, result in a clinical entity known as
acute plastic bowing deformity (APBD) (Borden,
1975). While APBD is found in adults and children,
the structural properties of infantile bones make the
latter more prone to those deformities (Aponte and
Ghiatas, 1989; Zionts et al., 1984). Lower arm bones
are the most frequently affected (Naga and Broad-
194 V. FORMICOLA AND A.P. BUZHILOVA
rick, 1977; Resnick et al., 1995), but in a few in-
stances, APBD has been found in lower limb bones,
including the femora (Cail et al., 1978; Zionts et al.,
1984). Due to the low severity of the deformity, a
generally broad curvature involving most of the
shaft and accentuating the usual curvature of the
bone, and the absence of typical fracture lines, this
injury easily escapes attention (Komara et al., 1986).
In spite of a few vague resemblances, the marked
bilateral curvature of the Sunghir 3 femora and,
more importantly, the associated shortening never
observed in cases of APBD make this diagnosis very
unlikely.
A possible explanation for traumatic involvement
might be found in an early conventional fracture of
the middle third of the diaphysis, i.e., the site of the
maximum bowing deformity in Sunghir 3. Fractures
of the femoral shaft are relatively frequent in chil-
dren as a result of a major direct or indirect trauma
(Ogden, 1982; Tachdijan, 1990). Moreover, the fe-
mur is a bone frequently affected by birth injuries,
as a consequence of wrong obstetrical maneuvers,
particularly in cases of breech presentation (Bar-
bieri et al., 1971; Clarke and Young, 1982; Nadas et
al., 1993; Resnick et al., 1995). In both cases, the
most common site is the middle third (Daum et al.,
1969; Grifn et al., 1972; Schedl and Fasol, 1981).
Following a femoral shaft fracture, the tendency for
the proximal fragment is to be pulled into exion by
the iliopsoas muscle, while the distal fragment is
drawn proximally by the hamstrings and quadriceps
femoris (Ogden, 1982; Tachdijan, 1990). Conse-
quently, antero-posterior angulation, overriding of
the fragments, and shortening are the rule, and
orthopedic treatment is required to minimize those
initial malpositions before immobilization.
A plethora of orthopedic cases have shown that
the healing process in children is very rapid, leaving
no permanent traces in the bones. Residual displace-
ments remaining after treatment can be expected to
undergo correction with growth and remodeling
(Riden, 1935; Madsen, 1955; Grifn et al., 1972;
Hagglund et al., 1983; Tachdijan, 1990). Interest-
ingly, in many instances, accelerated growth, result-
ing in overgrowth of the injured limb, may follow a
femoral fracture in children, as a probable effect of
increased vascularity associated with healing
(Blount and Schaefer, 1944; Laher and Herzog,
1978; Ogden, 2000). In a very few cases, however,
follow-up examination of injured children shows
that problems of shortening and of angular deformi-
ties remain (Conwell, 1929; Riden, 1935; Madsen,
1955; Schenk, 1957; Dameron and Thompson, 1959;
Dromer and Penndorf, 1967; Teutsch, 1969). Among
those, the case described by Hagglund et al. (1988)
deserves particular attention, as it permits evalua-
tion of the evolution of the fracture and correction of
the deformity after a long lapse of time.
These ndings match the results of other reports
documenting only partial improvement of marked
initial shortening and strong curvature (Irani et al.,
1976; Corry and Nicol, 1995). Based on those obser-
vations, it is apparent that a fracture of the middle
third of the diaphysis can result in permanent de-
formities resembling those shown by Sunghir 3. In
that case, absence of signs of repair would suggest a
long period of remodeling, i.e., a fracture suffered at
a very early age, and possibly a birth fracture.
Trauma or congenital condition?
Follow-up examination of femoral fractures in
children shows that, while length discrepancies
mostly result from overgrowth of the injured limb
(Hougaard, 1989; Tachdijan, 1990; Ogden, 2000), in
a very few cases initial shortening and bowing de-
formities can persist. With that in mind, the marked
deformity exhibited by Sunghir 3, compared to mod-
ern orthopedic cases, could be explained by the ab-
sence of treatment or by erroneous positioning of the
injured limb. For instance, Tachdjian (1990) warned
against placing the hip in extension because it would
increase the angulation of the fragments due to the
pull of the iliopsoas muscle. Possible relationships
between femoral shortening and angulation follow-
ing an infantile fracture (Hougaard, 1989) might
provide additional support for a traumatic etiology
of the shortening and bowing of the Sunghir 3 fem-
ora.
As previously pointed out, there are no right-left
differences in degree of shortening and bowing of the
two femora, which are fully comparable from metri-
cal and morphological points of view. Thus a diag-
nosis of femoral fracture would entail a rather un-
likely assumption, i.e., that a similar kind of
fracture affected both diaphyses at the same level
and at the same time, and that the healing process
followed the same remodeling pattern. The litera-
ture concerning follow-up examinations of bilateral
femoral shaft fractures in children is poor, but two
cases reported by Burdick and Siris (1923) exhibited
different degrees of deformity. Moreover, injuries to
the growing femoral shaft seem to affect bone den-
sity negatively (Leppala et al., 1999) which, in con-
trast, is very high in Sunghir 3 (Bukhman, 1984).
Thus, there are several points that do not fully t a
traumatic scenario. Additionally, the marked bow-
ing and shortening in Sunghir 3 also rule out inju-
ries of lesser severity, i.e., longitudinal compressive
loads resulting in APBD or intrauterine mechanical
forces.
With regards to a congenital etiology, a scrutiny of
disorders characterized by bowing shows that the
Sunghir 3 condition does not belong to the group of
diseases falling into a recognizable pattern. How-
ever, a few cases in which femoral bowing and short-
ening were the predominant or only signs of the
disease were reported by Kozlowsky et al. (1978) and
Hall and Spranger (1980), and were included among
those rare unclassiable disruptions falling under
the general title of CBLB. Rarity and diversity of
manifestations of CBLB make evaluation of the ex-
act nature and pathogenesis of these deformities
 SUNGHIR PATHOLOGY AND FUNERARY BEHAVIOR
difcult. According to the point of view expressed by
Hall and Spanger (1980), and more recently by
Spranger et al. (2000), the bowing and shortening
are nonspecic and may result from different
causes. Among those, following Nogami et al. (1986),
are included abnormalities of the primary cartilagi-
nous anlage (i.e., the aggregation of cells represent-
ing the rst trace of an organ). This hypothesis is
particularly interesting in the present case study,
considering that the mid-diaphysis (i.e., the site
where the anomalous antero-posterior bending is at
its maximum) coincides with the position of the pri-
mary ossication center. Relationships between
bending and shortening with early cartilage anom-
alies were rst suggested by Badgley et al. (1952),
who discussed congenital bowing of tibia, and by
Newell and Durbin (1976), who presented the case of
a girl born with bowing of one tibia and of both
femora. Thus, disturbances in the ossication pro-
cess in the mid-diaphysis would explain shortening
and midshaft curvature, as well as the absence of
metaphyseal or epiphyseal abnormalities and of
other diffused anomalies.
Findings by Hitti et al. (1994) lend further support
to this theory, with an intriguing discussion of mac-
roscopic and microscopic aspects of femoral bowing
and shortening in a fetus. Macroscopically, the de-
formity is bilateral and symmetrical in appearance,
affects the middle of the diaphysis, and is not asso-
ciated with other anomalies. Microscopic examina-
tion reveals an anomalous intramembranous ossi-
cation of the mid-diaphysis, while sections taken
proximally and distally from the center show normal
endochondral ossication. This suggests that ossi-
cation of the mid-diaphysis took place in a mal-
formed mesenchymal model, as an effect of transient
inhibition of chondrogenesis, and resulted in short-
ening and angulation of the femora.
This scenario, rather than an early bilateral frac-
ture, represents a more likely cause of the Sunghir 3
femoral deformities, and provides a better explana-
tion of their localized, symmetrical appearance. In-
terestingly, Hitti et al. (1994) suggested a link be-
tween the observed inhibition of chondrogenesis
shown by the fetus and the diabetic condition of the
mother. Experimental observations and clinical
data demonstrated that abnormal glucose levels are
deleterious to cartilage development (Leonard et al.,
1989), and that infants of diabetic mothers are sub-
ject to delayed ossication and skeletal defects, es-
pecially in bones of endochondral ossication
(Kucera, 1971; Jovanovic et al., 1986).
Thus, the diagnosis of Sunghir 3 pathology pre-
sents very early evidence of CBLB, possibly linked to
a maternal diabetic condition.
PATHOLOGY AND FUNERARY BEHAVIOR
Pathology is only one of the components that
make the double burial from Sunghir unique. Ex-
traordinarily rich grave goods, the young age of the
two specimens, the simultaneity of inhumation, and
195
the position of the skeletons signicantly add to its
uniqueness. Importance, peculiarity, and possible
relationships among single components are best
evaluated in the archaeological and paleopathologi-
cal context of the time period.
The burial dates to the Mid Upper Paleolithic, a
period marking the appearance of formal ceremonial
burials frequently exhibiting high levels of orna-
mentation. Even in that context, the richness of the
double child burial from Sunghir is outstanding and
surpasses that found in even the most ornamented
Upper Paleolithic skeletons, such as the adult male
from the same site (Sunghir 1) (Bader, 1967) or Il
Principe from the Arene Candide cave (Italy) (Car-
dini, 1942). It was noted that the preparation of
beads alone required thousands of hours (White,
1993), as would have the other ivory items. Such
ornamentation and grave goods clearly imply that
this burial was perceived as very important.
It is surprising that such a prestigious treatment
was devoted to two children, particularly in a period
during which child burials are extremely infrequent.
The recently discovered Lagar Velho child (Duarte
et al., 1999) is the only additional well-recognizable
formal child burial from that period in a sample
counting more than 20 single and multiple burials of
adults and/or adolescents. With regard to ornamen-
tation, the sediment and skeleton from Lagar Velho
are heavily stained with red ocher, but the only
associated items are two Littorina shells and four
pierced canines of deer (Zilhao and Trinkaus, 2003).
Following the pattern commonly seen in Upper
Paleolithic burials, the Lagar Velho child was placed
on his back with the arms along the trunk. The
Sunghir children have the same positioning but dif-
fer from all Upper Paleolithic multiple burials in
that, in the latter, the skeletons were placed side by
side. The head to head positioning of Sunghir adds
another element of uniqueness to this burial. This
unusual positioning can be interpreted in two differ-
ent ways. A simple explanation is that it results
from the constraints represented by grave goods in
common to the two children, i.e., the long ivory
spears, one of them 2.40 m long, placed by their
sides (Fig. 1). Another perspective is provided by an
ivory gure representing two humans aligned head
to head, found in Gagarino, an additional Mid Upper
Paleolithic site from the region around Moscow
(Tarassov, 1971). This intriguing gure, and the as-
sumption that a sophisticated set of beliefs is em-
bedded in many ceremonial burials as well as in
complex works of art (Clottes, 2000; Mussi et al.,
2000), suggest a formalized pattern connecting fu-
nerary behavior and artistic representation (Ko-
zlovskaya, 2000).
Archaeological evidence and the absence of per-
turbations of the two skeletons and/or of associated
items leave no doubt about the simultaneity of the
inhumation. The simultaneous death of two children
may be the result of an epidemic disease or an acci-
dent. However, multiple burials are not infrequent
196 V. FORMICOLA AND A.P. BUZHILOVA
during the Mid Upper Paleolithic and during the
Upper Paleolithic in general. In those cases, and
more in particular in those that include young indi-
viduals (e.g., Barma Grande, Predmost, Sunghir,
and Doln Vestonice) (Formicola, 1988; Klma, 1991; from the dysmorphic skeleton Doln Vestonice 15
Buzhilova, 2000b; Formicola et al., 2001), it seems
legitimate to question whether natural causes could
offer the only proper explanation for a simultaneous
death (Jelnek, 1991; Frayer, 1997).
Upper Paleolithic people are generally described
as healthy (Formicola and Giannecchini, 1999;
Riel-Salvatore and Clark, 2001), and pathological
changes affecting Mid Upper Paleolithic remains are
mostly the result of traumatic injuries (Trinkaus et
al., 2001). On the contrary, the Sunghir 3 anomalies
may have been apparent at birth and possibly more
marked than at time of death, considering that
symptoms generally improve in infants affected by
CBLB (Newell and Durbin, 1976; Kapur and van
Vloten, 1986). Moreover, the diverse nature of man-
ifestations of CBLB suggests the possibility of addi-
tional nonskeletal anomalies (e.g., cutaneous dim-
ples on the thighs; see Angle, 1954; Rupperecht and
Manitz, 1973; Cisarik et al., 1999).
The pathological condition of Sunghir 3, and its
association with many spectacular and peculiar ele-
ments, recall the pattern exhibited by the triple
burial from the Gravettian site of Doln Vestonice in
Moravia. The burial includes three young individu-
als richly ornamented, buried at the same time in an
unusual position (Kma, 1987). The skeleton in the
middle (DV 15) is markedly dismorphic because of
trauma and an inherited disease, which probably
also resulted in soft-tissues anomalies (Formicola et
al., 2001). The Sunghir and Doln Vestonice burials
share signicant elements: both are multiple burials
of young individuals, of different sexes, interred at
the same time; they show unusual positioning of the
skeletons, and include an abnormal individual.
Those associations reassert the possibility of ideo-
logical connections between abnormality and ex-
traordinary funerary patterns stressed elsewhere
(Formicola et al., 2001).
CONCLUSIONS
Scrutiny of the medical literature suggests that
the femoral deformities affecting Sunghir 3 belong
to a group of rare, unclassiable conditions falling
under the general title of CBLB. These anomalies
involve localized bowing and shortening of the long
bones, are nonspecic, and may result from different
causes. In the case study, symmetrical shortening,
midshaft curvature, and the absence of other skele-
tal anomalies point to disturbances in the mid-di-
aphysis ossication process, possibly linked to a ma-
ternal diabetic condition. Thus, the Sunghir 3
pathology provides very early evidence of CBLB,
going back about 24,000 years ago, as well as clues
about the antiquity of diabetes.
Macroscopic examination and radiographic analy-
sis of Sunghir 3 skeleton show a healthy, relatively
robust structure, well-remodeled by muscular activ-
ity. This indicates that femoral deformities did not
prevent this girl from engaging in an active life.
Interestingly, the same conclusions were drawn
(Trinkaus et al., 2001).
The intriguing combination of physical abnormal-
ities with the spectacular burial pattern shown by
the double child burial from Sunghir recalls in many
signicant elements the contemporary triple burial
from Doln Vestonice. This suggests that abnormal-
ity was part of a complex belief system reected by
sophisticated ritual activity and highly developed
symbolism evident in the Mid Upper Paleolithic
record (Roebroeks et al., 2000). The severe deformi-
ties affecting Romito 2, an adolescent dwarf from the
Late Upper Paleolithic of southern Italy, found in a
double burial with an adult female in a cave rich in
parietal art (Frayer et al., 1988), lend further sup-
port to this hypothesis and point to the spread of
those beliefs among Upper Paleolithic societies
through time and space.
ACKNOWLEDGMENTS
Thanks are due to T.I. Alexeeva and N.O. Bader
for the scientic support and encouragement given
to this work. We also acknowledge T. Balueva and L.
Veselovskaya for having made the material avail-
able, and all the staff of the Laboratory of Anthro-
pological Reconstruction in Moscow for their spirit of
collaboration. Thanks are also due to M. Koz-
lovskaya and M. Mednikova for fruitful discussion
and for providing data, radiographs, and photo-
graphs. Photographs appearing in Figure 1 and 2
are from Bader (1998). Finally, V.F. expresss his
gratitude to all those people whose friendly attitude
made this collaboration and his stay in Moscow par-
ticularly pleasant. Last but not least, the manu-
script beneted from comments and suggestions
provided by the editor and reviewers, as well as from
the patient editing by one of the reviewers. We are
particularly indebted to him for having minimized
the effects of our raids into the English language!
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