Hydrocephalus in an Anglo-Saxon Child from Eccles

HYDROCEPHALUS IN AN ANGLO-SAXON CHILD FROM ECCLES KEITH MANCHESTER, M.B., B.S., B.Sc., F.R.A.I. DEFINITION Hydrocephalus is defined as any condition in which enlargement of the cerebral ventricular system occurs as a result of an imbalance between production and absorption of cerebrospinal fluid. (Vaughan and McKay 1975). SUMMARY The incomplete skeletal remains of a child who died at the age of 14--16 years are described., The skeleton is of Anglo-Saxon date and is from Eccles, Kent. Cranial features considered diagnostic of hydrocephalus are described. The palaeopathology of hydrocephalus is discussed. ARCHAEOLOGICAL FEATURES The Anglo-Saxon cemetery at Eccles, Kent (N.G.R. TQ 722605) lies to the north-east of the north-eastern wing of the Roman villa. The skeleton described in the present paper was found during excavations by Mr. A.P. Detsicas for the Eccles Excavation Committee. It was found in the middle of the Anglo-Saxon cemetery at a depth of 2 ft. below ground level. Archaeologically, the skeleton is considered to be Anglo-Saxon (Detsicas, A.P., pers. comm.). SKELETAL REMAINS The incomplete skeletal remains are of an individual of age 14-16 years as assessed by epiphyseal union and dental eruption. The sex has not been determined because of the immaturity. The cranium is hyperbrachycephalic. The upper facial index is 47. 9. The nasal index 77 KEITH MANCHESTER PLATE I Norma frontalis showing calvarial Expansion is 49 .4. The orbital index is 65 .1 for the right and 63. 5 for the left side. The platymeric index is 78.8. No pathological post-cra!'}ial feature or asymmetry is noted. The cranium, however, has a somewhat globular appearance (Pl. I). The cranial base is largely absent due to post-mortem loss. Parts of the cranial vault posterior to the right and left lambdoid sutures are missing, and a reconstruction in plaster preserving as closely as possible the presumed contour has been undertaken. However, in view of this some error in cranial osteometry must be accepted. The biporial chord is 138 mm. and the maximum horizontal breadth is about 165 mm. Hence, it is the calvarium which appears enlarged. Although the calvarial expansion is fairly general in distribution, it is parietal expansion, particularly on the right side, which is most marked (Pl. II). The cranial capacity according to Pearson's technique (Comas 1957) is about 1500 cc. The coronal and sagittal sutures are partially united. The extra-cranial surface appears normal. The endocranial surface exhibits fairly prominent markings of the cerebral convolutions, 78 HYDROCEPHALUS IN AN ANGLO-SAXON CHILD FROM ECCLES PLATE II Norma verticalis showing parietal Expansion, particularly on right Side particularly in the anterior cranial fossa. The sulci for the middle meningeal vessels are abnormally deep, those on the left being deeper than those on the right. These features described are indicative of hydrocephalus. DISCUSSION Hydrocephalus is a term which describes an abnormality but which does not, per se, define its cause. Depending upon its cause and age of onset, it may or may not be associated with enlargement of the cranium. In the context of palaeopathology, the diagnosis mainly rests upon the recognition of the abnormal and enlarged cranial shape and size, and the calculated or measured increased cranial capacity. The greater depth· of intracranial vascular sulci and the more pronounced endocranial markings of cerebral cortical convolutions due to increase i n cerebrospinal fluid pressure are indicative of hydrocephalus, but in osteoarchaeological circumstances a diagnosis made on these features alone could only be tentative. It 79 KEITH MANCHESTER has been found that in modern groups most cases of hydrocephalus are acquired and not congenital in origin, and that most cases develop within the first six months of life (Laurence 1958). Hydrocephalus developing later in childhood may not result in appreciable enlargement of the head (Vaughan and McKay 1975). Therefore, those cases of hydrocephalus diagnosed in osteoarchaeological speciments have their origin early in childhood. Congenital hydrocephalus with the possibility of obstructed labour, is not compatible with the survival, either foetal or maternal, in antiquity. Hydrocephalus has a modern incidence of about 1: 1000 in western peoples (Vaughan and McKay 1975), but there is racial variation. In antiquity, however, the abnormality has been recorded as a definite diagnosis in world literature in only eight or so instances (Brothwell 1967) (GejvaU 1960). In Great Britain the only hitherto published case is of Romano-British date from Norton, Yorkshire, and having a cranial capacity of 2600 cc. (Trevor 1950). A modern survey of untreated hydrocephalus has demonstrated that 50 per cent of such children die, mostly within the first 18 months of life. It is a reasonable assumption that similar mortality was present in antiquity. Therefore, the almost impossible task of diagnosing the abnormality in the fragmentary and broken skeletal remains of infants from archaeological sites probably accounts for the considerable rarity of the disease in palaeopathological records. In this same modern study Laurence noted (op. cit.) that 46 per cent of children with hydrocephalus had a spontaneous arrest of the disease between the ages of 9 months and 2 years. These children then survived and 57 per cent were found to be in the normal range of intelligence quotient; there is no correlation between head size and intellectual dysfunction. Hence, those cases found in older children or adults in osteoarchaeological circumstances will be representative of arrested hydrocephalus, the hitherto undetermined pathological aetiology of which first dl;!veloped in early childhood. Because today most survivors are educable, the cases in antiquity probably fulfilled a useful role in the society in which they lived if mental impairment alone is considered. However, it is found that only 33 per cent of survivors are free from significant physical handicap. In palaeopathology the physical handicap most likely to be recognised is spasticity and joint contracture. The latter may be recognised by the eventual osseous fusion of the contracted joint. The former may possibly be recognised by a marked asymmetry in limb bone size and reduction in the surface marking of muscle attachment. Such asymmetry has been noted on the left side of an Egyptian male aged 30 years of the Roman period (Derry 1913). The cranial capacity estimated in this case was 2901 cc. The 80 HYDROCEPHALUS IN AN ANGLO-SAXON CHILD FROM ECCLES suggestion given in this case was of progressive left-sided paralysis, and it was also noted that there was cranial asymmetry, the right side being more prominent than the left. This, it was suggested, was due to a differential pressure increase within the skull. Similar cranial asyummetry has been observed in the present case from Eccles, but there is no evidence of post-cranial asymmetry. In contrast to modern groups, diagnosis of precise aetiology of hydrocephalus in antiquity is not possible. However, some speculation on aetiology in antiquity is justified. A case of hydrocephalus in a 16-18 year old male from Westerhus was noted to have distension of the hypophyseal fossa. An unspecified abnormality of the hypophysis was suggested as the cause of hydrocephalus in this case (Gejvall 1960). It is probable that in antiquity survival with hydrocephalus due to the congenital malformations was not likely beyond infancy. Although in modern practice hydrocephalus may be a result of intracranial infection, in antiquity an initial bacterial infection may have been fatal before the development of cranial deformity. Perhaps we should not forget the survivor from toxoplasmosis, either congenital or acquired, which may result in hydrocephalus. In this respect, too, it may be of significance with reference to palaeopathology that undercooked meat may be a source of this protozoan parasitic infestation. In this present Anglo-Saxon case under consideration, the child died at the age of 14-16 years. It is suggested that the cause of the hydrocephalus in this case may have been an intracranial tumour, which by its growth would account for the cranial asymmetry, both intracranially and in contour, and also the early death of the victim. ACKNOWLEDGEMENTS I am grateful to Mr. A.P. Detsicas, for permission to publish this case; to Professor W.J. Moore, for his comments on the cranium; to the Department of Photography, University of Bradford, for the photographs; to Zoe Taylor, for typing the manuscript; and to my wife Ann, for her patience and comments. REFERENCES Brothwell 1967 D.R. Brothwell, 'Major congenital Anomalies of the Skeleton: Evidence from earlier Populations', in D.R. Brothwell and A.T. Sandisson (Eds.), Diseases in Antiquity, Illinois 1967, 423-44. 81 Comas 1957 Derry 1913 Ge jvall 1960 Laurence 1958 Trevor 1950 Vaughan and McKay 1975 KEITH MANCHESTER J. Comas, Manual of physical Anthropology. D.E. Derry, 'A Case of Hydrocephalus in an Egyptian of the Roman Period', Journ. Anat. Soc. Lond., xlviii (19 .. ), 436-58. N.G. Gejvall, Westerhus. Medieval Population and Church in the light of skeletal Remains, Lund 1960. K.M. Laurence. 'The natural History of Hydrocephalus', The Lancet (1958), 1152--4. J.C. Trevor, 'Notes on the human Remains of Romano-British Date from Norton, Yorkshire' in The Roman Pottery at Norton, East Yorkshire (Roman Malton and District Report no. 7.). 1950. V.C. Vaughan and R.J. McKay, Textbook of Paediatrics. 82