Discussion

Earliest Cranio-Encephalic Trauma from the Levantine Middle Palaeolithic: 3D Reappraisal of the Qafzeh 11 Skull, Consequences of Pediatric Brain Damage on Individual Life Condition and Social Care Hélène Coqueugniot1,2*, Olivier Dutour1,3,4, Baruch Arensburg5, Henri Duday1,3,

Bernard Vandermeersch1, Anne-marie Tillier1,6

1 Unité Mixte de Recherche 5199 – De la Préhistoire à l’Actuel: Culture, Environnement et Anthropologie (PACEA), Centre National de la Recherche Scientifique (CNRS) –

Université de Bordeaux, Pessac, France, 2 Department of Human Evolution, Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany, 3 Laboratoire

d’Anthropologie biologique Paul Broca, Ecole Pratique des Hautes Etudes (EPHE), Paris, France, 4 Department of Anthropology, University of Western Ontario, London,

Ontario, Canada, 5 Department of Anatomy and Anthropology, Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel, 6 Museum of Archaeology and

Anthropology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America

Abstract

The Qafzeh site (Lower Galilee, Israel) has yielded the largest Levantine hominin collection from Middle Palaeolithic layers which were dated to circa 90–100 kyrs BP or to marine isotope stage 5b–c. Within the hominin sample, Qafzeh 11, circa 12– 13 yrs old at death, presents a skull lesion previously attributed to a healed trauma. Three dimensional imaging methods allowed us to better explore this lesion which appeared as being a frontal bone depressed fracture, associated with brain damage. Furthermore the endocranial volume, smaller than expected for dental age, supports the hypothesis of a growth delay due to traumatic brain injury. This trauma did not affect the typical human brain morphology pattern of the right frontal and left occipital petalia. It is highly probable that this young individual suffered from personality and neurological troubles directly related to focal cerebral damage. Interestingly this young individual benefited of a unique funerary practice among the south-western Asian burials dated to Middle Palaeolithic.

Citation: Coqueugniot H, Dutour O, Arensburg B, Duday H, Vandermeersch B, et al. (2014) Earliest Cranio-Encephalic Trauma from the Levantine Middle Palaeolithic: 3D Reappraisal of the Qafzeh 11 Skull, Consequences of Pediatric Brain Damage on Individual Life Condition and Social Care. PLoS ONE 9(7): e102822. doi:10.1371/journal.pone.0102822

Editor: David Frayer, University of Kansas, United States of America

Received March 20, 2014; Accepted June 21, 2014; Published July 23, 2014

Copyright: � 2014 Coqueugniot et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This research has been financially supported by the Irene Levi Sala Care Archaeological Foundation (http://prehistory.org.il/?page_id = 894). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: The authors have declared that no competing interests exist.

* Email: [email protected]

Introduction

Relevant information about Middle Palaeolithic societies can be

obtained from paleopathological investigations. Identification of

skeletal abnormalities and degenerative joint disease, as well as

evidence for bone lesions caused by trauma, can provide insights

into the adaptation patterns and social behavior of these early

nomadic hunter-gatherers. With regard to south-western Asia, the

first pathological data, to our knowledge, were those brought in

1939 by McCown and Keith’s original description of the Mount

Carmel people. During the last three decades, new attempts

emerged in the studies of near eastern fossil record, related to

enrichment in the fossil hominin sample. In this perspective, fossil

specimens have benefited from new paleopathological investiga-

tions.

Among Levantine Middle Palaeolithic hominins, evidence of

cranial traumatic lesions was provided by McCown and Keith [1]

in their description of the partial skeletons from the Skhul Cave.

According to these authors, the Skhul 1 child exhibits a depressed

area in the mid-line of the frontal bone nearby the glabellar region

which was interpreted [1] (pp 309–310) as consequence of a blow.

These authors also mentioned the presence of a perforation and

fracture of the right temporal in the roof of the ear which could

result from an impact. However, the paleopathological condition

of these two cranial lesions remains unclear as the authors

themselves concluded [1] that both injuries ‘‘.. were inflicted at

death or not unlikely at some time soon after death’’. In an

unpublished study, three of us (AmT, HD and BA) were not able

to conclude if frontal and temporal changes observed on this fossil

were pathological or taphonomical. McCown and Keith [1] (p

281) also drew attention to the presence of an injury ‘‘caused by a

glancing blow at, or soon after death’’ in the left parieto-occipital

area of the Skhul IX adult skull.

Later, in his original study of the Shanidar hominins from Iraqi

Kurdistan, Trinkaus [2] provided a description of several

pathological conditions displayed by one of the individuals,

Shanidar 1. This adult individual sustained, among several skeletal

lesions, a crushing skull fracture which involved the frontal process

of the left zygomatic bone and the lateral margin of the left orbit.

This ante-mortem traumatic injury most probably caused

blindness of the left eye [2].

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Within the Qafzeh hominin sample from lower Galilee, the skull

of the adult Qafzeh 6 shows a concave indentation of the outer

table of the frontal bone, without a fracture, in the area of the left

supra-orbital region [3]. Such a condition can result from either

trauma due to an accidental self-hurt or a blow to the head due to

inter-personal violence. One of the immature individuals from the

site, Qafzeh 11, presents a skull lesion previously attributed to

healed trauma [4–6]. The goal of this study is to reappraise the

Qafzeh 11 impact wound using 3D imaging methods, to better

understand the pathological condition that affected this young

individual. Indeed, 3D reconstructions applied to paleopathology

allow us to better explore inner bone lesions, to evaluate their

impact on soft tissues and to estimate volumetric data contributing

to fossil reconstruction and preservation [7–9].

Material

The Qafzeh site has yielded the largest hominin collection

(N = 27, including partial eight skeletons, isolated bones and teeth)

from Middle Palaeolithic layers in south-western Asia (e.g. [6,10–

11]). The Middle Palaeolithic sequence (units XVII to XXIII) was

dated by a combination of electron spin resonance and

thermoluminescence methods to circa 90–100 kyrs BP or to

marine isotope stage 5b–c [12–13]. Human remains were

discovered at the front of the cave’s entrance in layers that

contain a low density of lithic artifacts, a huge assemblage of

micromammals and a few hearths. Within the Mousterian lithic

assemblage [14–16], centripetal and/or bi-directional prepara-

tions prevail and the typical products are side scrapers, large oval

flakes and quadrangular Levallois flakes. The makers of the

Mousterian lithic industries at Qafzeh are identified as early

anatomically modern humans [6,10,17].

A majority of the Qafzeh individuals fails to attain reproductive

adulthood and among them, Qafzeh 11 is of special interest. It

represents a single specimen recovered from layer XXIII, at the

bottom of the Mousterian sequence, while most of the fossil human

sample originates from layer XVII. A large stone damaged the

trunk, pelvic area and lower limbs. Age at death of Qafzeh 11 was

estimated circa 12–13 yrs while the sex remains unknown [5]. The

partial skeleton of Qafzeh 11 is characterized by a combination of

morphological traits in which modern features prevail, in

comparisons with other Palaeolithic children [5–6]. Cranial

morphology shows changes affecting the vault symmetry and base

angulation; however their interpretation in terms of peri- or post-

mortem changes remains unclear [6].

Besides these changes, Qafzeh 11 presents a cranial lesion

previously attributed to a healed trauma [4–5]. This lesion is

characterized by an anterior depression on the right side of the

frontal squama. It is limited forwards by a healed fracture line,

which ends up to an oval shaped hole. The latter has been

attributed to a taphonomical change [4–5]. Healing process led to

small thin bone remodelling, the frailty of it explaining its post-

mortem loss (figure 1). Regarding the overall shape of the bone

lesion and x-ray examination, the diagnosis of traumatic skeletal

injury indeed prevails over that of an epidermoid bone cyst [3].

Surprisingly, comparative analysis between Qafzeh 11 and

another child from same site, Qafzeh 10 younger in individual

age (circa 6 years old), reveals that Qafzeh 11 had the smallest

endocranial volume, respectively 1273648 cc and 1251648 cc

[6].

Methods

Specimen number Q11

Repository information Department of Anatomy and Anthropology, Faculty of Med-

icine, Sackler School of Medicine building Tel Aviv University,

Ramat Aviv, Israel.

Authority giving permission of study Professor Israel Hershkovitz, curator of the collection, head of

the Department. Last author (Am.T.) obtained his authorization

for studying all the immature individuals from the Qafzeh site.

The curator of this collection does agree the publication. There is

no permit number.

Endocranial volume (EV) was estimated to set Qafzeh 11 within

a normal modern variability of brain size growth, using two

methods. EV was firstly calculated using equations recently

proposed [18]; then an attempt of direct EV measurement on

virtual endocast (see below) was performed although the skull base

is damaged. For comparison, we used a modern data set issued

from a digital bone library of immature skulls [18]. This sample

comes from the identified osteological collection of Strasbourg

University, France [19]. The EV values of Qafzeh 11 were

compared to those available for other specimens (adult and

immature) from the same site based upon cranial dimensions of

Qafzeh 6, 9 and 10 [6,10].

Following advances provided by digital 3D reconstructions, CT-

scans of the Qafzeh 11 skull were carried out to reassess the

traumatic condition which affected the adolescent during his/her

life. These 3D reconstructions of Qafzeh 11 allow: (i) to precisely

visualize 3D aspects of the internal and external surfaces of the

cranial vault and of inner structures in the area of the pathological

condition, (ii) to evaluate the potential impact of skull damage on

the brain and (iii) to localize this impact on the brain surface.

Qafzeh 11 skull was CT scanned at the Carmel Medical Center,

Haifa, Israel on a Brillance iCT 256, Philips Medical system

(Cleveland, Ohio) with an isometric voxel size of 0.67 mm. Other

acquisition parameters are 120 kV for voltage and 298 mA for

current.

3D reconstructions of skull and endocast were performed using

TIVMI software program [20] that is based on HMH (Half

Maximum Height) algorithm [21] and applied to bone 3D

reconstructions [22]. It has proved to be more precise and reliable

for 3D measurements than other software programs currently

implementing different algorithms for 3D reconstructions [23].

Besides providing additional estimation of the endocranial volume,

virtual reconstruction allowed us to localize the impact of the

cranial lesion on the brain surface, taking as a reference a 3D

reconstruction of extant human brain [24] and checking the

accurate correspondences of their anatomical landmarks [25].

Measurements of the endocast were taken using these

landmarks and metric tools implemented in TIVMI. The cranium

was horizontally oriented according to the ‘‘mean transverse

plane’’ adapted from the original Frankfurt plane to study

morphometry on digitalized skulls [26]; mean sagittal and coronal

planes were drawn according to this method.

Results

The endocranial volume of Qafzeh 11 ranges from 1283.44 to

1333.18 cc using updated formulas [18]. Previously, values

ranging from 1251648 cc to 1303646 cc [6] were obtained

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Figure 1. The Qafzeh 11 skull. a: norma facialis. b: norma inferior. c: norma superior. d: close-up view of the frontal lesion (healed fracture line is visible on the right side of the hole while fracturing lines above and below the hole are corresponding to post-mortem alteration). Black arrows on a and c indicate location of the lesion. doi:10.1371/journal.pone.0102822.g001

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using other equations [27]. EV value obtained from virtual

endocast is slightly lower (1200 cc), but as anterior part of the skull

base is missing, the endocranial virtual reconstruction is not

complete.

The proportional endocranial volume (PEV) of Qafzeh 11,

based upon EV values calculated from recent formulas, corre-

sponds to 81–86% of the EV values of mature individuals from the

site (Qafzeh 6 and 9). When considering dental maturation of this

individual (giving an age estimation of about 12–13 years), this

PEV value is smaller than expected in comparison with modern

endocranial growth pattern defined by Coqueugniot and Hublin

[18]. PEV value of Qafzeh 11 actually corresponds to values from

younger children (4–6 years). For the same site, the PEV value of

Qafzeh 10 child (estimated to be 6 years old from dental

maturation) falls within the present modern range (86–88%) for

the corresponding age (figure 2). Therefore, it appears that the

small endocranial volume of Qafzeh 11 cannot be considered as

normal relative to its dental age. Growth retardation in cranio-

encephalic development can be proposed from this result.

The 3D reconstructed calvaria clearly evidenced a depressed

skull fracture of the right part of the frontal bone in the process of

healing (figure 3A). It is located on the right part of the frontal

squama just above the pterionic area. The depressed fragment of

the frontal bone has a quadrangular shape (size:

29.7623.4626.5611.7 mm); the posterior face is delineated by

the coronal suture, the anterior face is near the frontal boss as well

as the upper face which lies at 31.8 mm from the frontal midline.

The fractured fragment is depressed forwards. Its anterior face

penetrates endocranially whereas the posterior face is shifted

outwards, dislocating the coronal suture and causing a sutural

separation (figure 3B). Other fracture lines, different from

taphonomic fracturing, can be identified although they are less

obviously visible due to the bone remodelling of healing process.

This is shown by a star-like aspect of fracture lines radiating from

the impact area. This type of fracture, that can be related to a

blunt force trauma, clinically corresponds to cranio-encephalic

wound and raises the question of its impact on the brain.

Anatomical structures can be identified on the virtual endocast

of Qafzeh 11 reconstructed by one of us (HC), despite missing

parts, taphonomic fragmentation and post-mortem skull deforma-

tion (figures 3, 4). Normal cerebral hemispheres display an

asymmetric development (figures 4A,B,E) characterized by a

differential protrusion of one hemisphere relative to the other,

known as petalia [25,28]. The right frontal lobe protrudes in front

of the left by 1.71 mm. In addition the right frontal bec is more

extended downwards than the left one. By contrast, the left

occipital lobe projects 1.79 mm behind the right one. Yet, the

occipital asymmetry known as Yakovlevian torque [28–29] cannot

Figure 2. Proportional endocranial volume (PEV) of specimens Qafzeh 11 and 10 plotted on modern PEV from identified immature osteological collection (Coqueugniot and Hublin, 2012). Arrows represent PEV variation range. doi:10.1371/journal.pone.0102822.g002

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be assessed here. Besides the right frontal petalia and left occipital

one, the right frontal lobe is wider than the left and the left

occipital lobe wider than the right. Interestingly, the two

hemispheres are similar in length (153.7 mm at left and

153.6 mm at right).

Middle meningeal artery imprints are clearly visible on the left

side of Qafzeh 11 endocast, showing the prevalence of the anterior

branches (bregmatic and obelic) and lack of anastomosis

(figure 4C), as previously described [6]. The imprint of the

inferior frontal gyrus is visible on both sides. On the left it is

possible to distinguish its reliefs (pars triangularis, pars opercularis

and pars orbitalis) as well as those of the middle frontal gyrus and

anterior central gyrus. On the right side, the imprint of the

depressed fracture is localized upwards to the imprint of the

inferior frontal gyrus. It may involve the posterior part of the

middle frontal gyrus and the anterior part of the anterior central

gyrus.

Comparison of the fossil virtual endocast with 3D reconstruc-

tion of digitized brain [24], confirms that the cranial depressed

fracture observed on Qafzeh 11 (figures 3, 4D) only corresponds to

the frontal area of the brain, forward to the central sulcus

(Rolandic fissure) and upwards from the Sylvian fissure. The

depressed skull fracture is localized forward to the precentral gyrus

(primary motor cortex) and slightly behind the prefrontal cortex.

The depressed fragment stretches over the middle part of the three

frontal gyri. The corresponding brain areas are responsible for

psychomotricity i.e. Brodmann areas 6 and 8 [30]. These areas

control movement, rules for performing specific tasks, manage-

ment of uncertainty, visual attention and eye movements [31].

The lesion may have affected the orbital part of inferior frontal

gyrus (area 44) that is involved in speech language production on

the left side (Broca’s area), but seems to be involved in social

communications on both sides.

Discussion

When a pathological condition is recognized in skeletal remains,

the nature of the bone damage or injury is sometimes not easy to

determine precisely. Peri-mortem trauma can be difficult to

differentiate from skeletal post-mortem changes due to taphonom-

ic processes (e.g. [32]). Cases of serious cranial trauma are seldom

documented in the human Upper Pleistocene fossil record from

south-western Asia (e.g. [2–5]) and Western Europe [33–34].

Zollikoffer et al. [33] asserted that the cranial injury displayed by

the Neanderthal St-Césaire 1 resulted from an act ‘‘of intragroup,

interpersonal violence’’ but did not cause the immediate death.

Examining the pathological condition of Krapina 34.7 parietal

fragment, Mann and Monge shared the same statement, i.e. the

serious trauma ‘‘was not a mortal wound’’; however they

concluded that its cause ‘‘appears to one of an accident associated

with life style of living and sleeping in caves’’ [34].

In his original description of the healed trauma which affected

Qafzeh 11, Dastugue [4] mentioned that the skull fracture was not

lethal, related to a minor trauma and only localized on the skull

vault. According to him, this so-called ‘‘benign fracture’’ did not

have significant repercussions and occurred when Qafzeh 11 was

young. Furthermore, the healing response had probably not

undergone its complete trajectory before the death of the

adolescent [4]. Dastugue concluded that the cause of death was

unknown.

3D reconstructions clearly show that the Qafzeh 11 skull

fracture was not a simple one. Indeed, this frontal bone fracture

appears to be compound, with a broken piece of frontal squama

that is depressed, isolated forwards by a linear fracture and

backwards by sutural diastasis. As previously mentioned [4], this

fracture type generally results from a blunt force trauma (getting

struck or kicked in the head by heavy and blunt material,

accidentally or intentionally with weapon). This type of trauma

can be interpreted as resulting from interpersonal violence, but as

has been demonstrated by paediatricians, complex cranial

fractures like this one can also occur accidentally [35]. Contrary

to the assumption of a non-serious wound made previously [4], the

depressed fracture of Qafzeh 11 skull that can be considered as at

least a moderate traumatic brain injury (TBI) [36], actually

presents a high level of risk for brain damages (intra-cranial

haemorrhages, diverse types of central nervous system lesions such

as concussion, contusion, laceration, which can lead to destruction

of brain tissue or cerebral scar). Besides the neurological damages

due to focal brain lesion in the right frontal area, more precisely

the areas 6 and 8. These areas are responsible for psychomotricity

which may have led to troubles for controlling movement,

difficulties for performing specific tasks, managing uncertainty,

visual attention and eye movements and possibly the right area 44

(that seems also to be involved in oral communication as the left

Broca’s area, that is specialized in speech production). It is highly

probable this young individual suffered also from personality

changes due to traumatic brain injury. This personality distur-

bance is thought to be directly related to brain trauma and appears

to be very frequent: 65% in severe to mild/moderate TBI,

according to Max et al. [36]) but according to McAllister [37]

‘‘virtually all individuals who survive moderate and severe TBI are

left with significant long-term neurobehavioral sequelae’’. These

troubles are characterized by a ‘‘distress or impairment in social,

occupational, or other important areas of functioning’’ and

manifested in children as a ‘‘marked deviation from normal

development’’ [36].

Two methods have confirmed the small endocranial volume of

Qafzeh 11. The virtual reconstructed endocranial volume provides

an underestimated value due to the lack of anterior part of skull

base which technically limits endocast segmentation and therefore

makes its complete virtual reconstruction speculative. Recently,

Kondo et al. [38] proposed a semi-virtual reconstruction of the

Qafzeh 9 endocast. They obtained a EV value of 1411–1477 cc

that is smaller than the initial estimation of 1508–1554 cc [10] and

the mean value of 1531 cc provided by Holloway et al. [25].

Considering that (i) EV virtual values appear to be smaller than

calculated ones for the base- damaged Qafzeh 9 and 11 skulls, (ii)

virtual EV are not available for other specimens of the site (Qafzeh

10 and 6), we prefer using estimated EV value calculated from

formulae.

As for Qafzeh 11, EV values are nevertheless consistent each

other and corroborate a small endocranial volume related to

individual age whatever the method used. This can be interpreted

as growth retardation due to the trauma. Indeed, generalized

Figure 3. Superior view of Qafzeh 11 3D reconstructed skull showing the depressed fracture on the frontal’s right side. The skull vault appears in transparency and the virtual endocranial cast in pink. A: general view. B: close up view of the trauma area. 1: anterior part of the frontal bone depressed fracture penetrating the endocranial volume. 2: irregular shape of virtual endocranial surface indicating brain damage. 3: diastasis of the right coronal suture. doi:10.1371/journal.pone.0102822.g003

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Figure 4. Virtual endocast of Qafzeh 11. A: norma frontalis. B: norma superior. C: left norma lateralis. D: right norma lateralis. E: norma basilaris. doi:10.1371/journal.pone.0102822.g004

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atrophic changes resulting in reduced overall brain volume has

been documented in moderate-to-severe pediatric traumatic brain

injury [39–40]. In addition to this focal effect on brain, a general

growth retardation due to post-traumatic endocrine disturbance

[41] could be raised here.

Hemispheric asymmetry is present on Qafzeh 11. This feature

has already been described on fossil hominins (e.g. [25,29,42–43])

including Qafzeh 9 [38] and among extant populations (e.g.

[28,44]). Therefore, despite the depressed frontal fracture that had

probably impacted the underlying brain tissue of Qafzeh 11

frontal lobe, the physiological hemispheric asymmetric pattern was

not affected.

As Qafzeh 11 has a PEV corresponding to a 4–6 years old

modern child, we hypothesize that the trauma occurred at or

before this age. Among skeletal indicators of growth disturbance

and stress during childhood, is the manifestation of growth arrest

lines (Harris lines) in the metaphyseal region of the long bones.

These non-specific stress indicators usually vanish during life.

Unfortunately, the preservation state of long bones does not allow

any kind of investigation in the case of Qafzeh 11. Pathological

alterations of the dental enamel, such as transverse linear enamel

hypoplasia (LEH), are also employed in the assessment of

physiological stress events and growth disturbances during

childhood (e.g. [45–48]). Presence of enamel hypoplasia on three

lower teeth of Qafzeh 11 (right and left first molars, right second

molar) was previously described by Skinner [49]. However, data

collected on the specimen by one of us (AmT) point to the lack of

LEH on the permanent upper and lower teeth and on the isolated

germs of upper third molars as well [3]. Both lower right M1 and

M2 indeed present a different enamel coloration above the cervix,

located at the same height of the two crowns. This alteration is

most probably of taphonomic origin and we suggest that the skull

trauma didn’t impact M1 and M2 complete crown formation,

indicating that it probably occurred around 6 years of age.

In sum, the Qafzeh 11 child represents, to our knowledge, the

oldest documented human case of severe cranial trauma available

from south-western Asia, dated to 90–100 kyrs BP. The adult

Shanidar 1 skull exhibits an indisputable evidence of trauma, that

was sometimes interpreted as a consequence of interpersonal

violence [2,50] but the specimen is probably more recent [51]. For

Qafzeh 11, the exact circumstances surrounding the injury remain

unknown, although this kind of injury generally results from a

blunt force trauma.

Whatever the origin and severity of a given pathological

condition observed on human Middle Palaeolithic hominins,

speculations were made with regard to its consequences on

individual life conditions and social status, in terms of disability,

impairment and social care. Consequently, these questions are

widening the debate introducing notions of altruism and

compassion in prehistoric human communities and their possible

role in human life history (e.g. [2,52–58]).

In this respect, it is crucial to assemble biological and

pathological data with cultural observations and their subsequent

interpretations. For the Qafzeh 11 subadult, it is now clear that

severe cranio-encephalic trauma experienced during childhood,

deeply impacted his/her cognitive and social communication

skills. Interestingly Qafzeh 11 benefited from special social

attention at his/her death, as shown from archaeological details.

The Qafzeh 11 skeleton, recovered at the bottom of the

Mousterian sequence in front of the entrance of the cave, revealed

that the corpse was originally lying in a pit on its back, the head

turned to the right with upper limbs flexed [59]. The hands

maintained their anatomical configuration and were lying together

near the face western-oriented. The pelvic region and the lower

limbs extended to the south from the skull, were post-deposition-

ally damaged by a large stone. Besides this, there was a complete

lack of mixing or bone displacement with an absence of animal

scavenging traces. Furthermore, two deer antlers were lying on the

upper part of the adolescent’s chest, near his/her face and they

were in close contact with the palmar side of the hand bones

(figure 5). Such a hand location, within the original body spatial

arrangement, attested a funerary offering and not an accidental

incorporation. All these observations strongly support the inter-

pretation of a deliberate, ceremonial burial for Qafzeh 11.

At Qafzeh several other burials occur [59–62], but Qafzeh 11

represents a unique case of differential treatment with convincing

evidence for ritual behavior. We interpret the Qafzeh 11 burial as

resulting from a ritual practice applied to a young individual who

experienced a severe cranial trauma most probably followed by

significant neurological and psychological disorders, including

troubles in social communication. These biological and archaeo-

logical evidences reflect an elaborate social behavior among the

Qafzeh Middle Palaeolithic people.

Acknowledgments

This study was made possible by the field work done at Qafzeh Cave by a

team led by one of us (B.V.) and supported by the French Ministry of

Foreign Affairs. We are deeply grateful to Professor I. Hershkovitz (Tel

Aviv University), for access to the fossil, and technical assistance. We thank

Professor N. Peled (Carmel Medical Center, Haifa, Israel) for providing

helpful technical support for access to the medical scanner. Thanks are also

due to V. Slon (Tel Aviv University) for help in collecting digital data. The

authors are greatly indebted to B. Dutailly (UMR 5199 PACEA) who has

developed TIVMI software program for anthropology, helped and advised

us constantly throughout the development of this work.

Author Contributions

Conceived and designed the experiments: HC OD BA HD BV AmT.

Performed the experiments: HC. Analyzed the data: HC OD AmT.

Contributed reagents/materials/analysis tools: HC BA BV AmT. Wrote

the paper: HC OD AmT.

Figure 5. Partial view of the Qafzeh 11 burial showing the deposit of the red deer antlers in close contact with the child skeleton (cast). doi:10.1371/journal.pone.0102822.g005

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