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is as representative as that from the sternum. Thedifficulties of bone-marrow biopsy have inevitablyheld up progress, and little more is now known aboutnormal ranges and other vital matters than two yearsago.4 When bone-marrow studies in anaemia ofchildhood become as much part of routine as theyhave become in studies of adult blood disease, weshall soon have a reasonable idea of the range ofnormal variation and what constitute pathologicaldeviations. It is also likely that new syndromes willcome to light, and a good example is the megaloblasticanaemia of infancy, a case of which is reported inthis issue by HUTCHISON and MAcARTHUR. Thiscondition, first recognised by ZUELZER and OGDENin 1946, cannot be diagnosed without marrow studies.

In young children the commonest causes of anaemiaare infection and defective nutrition, perhaps 70-90%of - all anaemic children fall into these groups.The diagnostic problems arise with the remainder,particularly when the anaemia is normocytic ormacrocytic. The likely causes of primary blood diseasein a child are acute leukaemia, aplastic or " aregenera-tive " anaemia, haemolytic anaemia, unrecognisedcoeliac disease, and the megaloblastic anaemia of

infancy. With the exception of coeliac disease, theseconditions have different marrow pictures and oftencannot be certainly distinguished without bone-marrowbiopsy. In coeliac disease the bone-marrow shows anormoblastic picture for a long time, even when thecolour-index is over 1, but it is only when a megalo-blastic picture is present that any response fromfolic acid can -be expected. The leukaemias are oftendifficult to diagnose in children from the peripheralblood alone, and then the marrow provides the

indispensable diagnostic clue by showing large numbersof immature cells like myeloblasts. Here again thenormal lymphocytosis has to be reckoned with, andlymphocytosis in the marrow of a child has not thesame diagnostic significance as it has in the adult.

Hæmolytic anaemia can occur in acute and chronicforms in childhood, apart from the now thoroughlyexplored type caused by Rh incompatibility ; con-

genital haemolytic anaemia, with its typical alterationof red-cell fragility, has been diagnosed in the firsttwo years of life ; cases resembling the acquired typeof adult life do appear from time to time ; the bone-marrow in all these cases shows a typical normoblastichyperplasia whatever the peripheral blood picturemay be.

Of late years the general physician has been findingit difficult to keep up with advances in diagnosis andtreatment in all fields. The same difficulty is now

beginning to affect the pædiatrician. For instance,the possibility that some children with congenitalheart disease are fit subjects for surgical treatmentwhereas others are not has led to the setting up inenlightened centres of special clinics in which the

paediatrician and the cardiologist cooperate. It maywell be that similar cooperation is needed betweenthe paediatrician and those physicians who have madea special study of hæmatology. As long ago as 1927the -late Dr. K. D. BLACKFAN started a specialhaematological clinic at the Boston Infants’ andChildren’s Hospital, and Dr. L. K. DIAMOND carriesit on : they considered that the long-term personal

4. Ibid, 1947, i, 146.

observation that this clinic allowed was invaluable.There are signs that such integration of effort is

badly needed. Thus, the latest edition of a deservedlypopular English psediatric textbook shows no evidencethat its author has heard of recent views on redblood-cell formation and the classification of anaemias." Blunderbuss " treatment is still far too common inthe treatment of anaemia of childhood. New hsema-

tological diagnostic techniques that will, in properhands, give important information are now availableto the paediatrician. It seems worth while consideringpractical methods of enabling the best use to be madeof them.

HydrocephalusTHOUGH the physical features, of hydrocephalus

have been familiar to physicians from the earliesttimes, interest in the condition was formerly confinedfor the most, part to those who collected monstrosities.It was not until the early part of this century thatgrowing knowledge of intracranial hydrodynamics,stimulated neurologists and neurosurgeons to intensivestudy of the mechanisms that may cause hydro-cephalus. Much has thus been learned, includingmuch that is useful in treatment ; but the isolatedworker in special departments has rarely seen enough(or sufficiently diverse) cases to present a compre-hensive account of the pathology. Prof. DOROTHYRussELL’s monograph 1 goes far to remedy this

deficiency : drawing her material from large generalhospitals and from busy neurosurgical clinics, she hasbeen able to investigate cases that might otherwisehave been consigned to the archives of obstetrics,paediatrics, neurosurgery, and general pathology. Theresults of her researches will interest a wide circle ofclinicians who are. faced with this admittedlydepressing problem.

Professor RussELL is convinced that the cause of

hydrocephalus is almost always obstruction of thecirculation of the cerebrospinal fluid. In many cases.

gross lesions such as neoplasms are an obvious explana-tion of this obstruction. In others the site may beobvious but the nature of the obstruction -may requirecareful investigation : for example, narrowing of theaqueduct of Sylvius is a common cause of hydro-cephalus, but without microscopical study one cannotalways say whether this is a congenital stenosis, ordivision ("forking ") of the aqueduct into a numberof minute channels, or the result of gliosis around theaqueduct. An important group of cases is that inwhich hydrocephalus results from leptomeningitis :the subarachnoid space may be diffusely matted upwith unobtrusive adhesions, especially in the cisternaambiens and at the base of the cerebral hemispheres,and the fluid may therefore be hindered from reachingthe arachnoid villi where most of the absorptiontakes place. In such cases there is great ventriculardilatation, often with distension of the subarachnoidspace in the posterior fossa. Now that so manypatients recover from pyogenic meningitis, one mightexpect to see this sequel often ; yet so far it hasseemed to be very rare. But, as the process may be

- chronic, it may prove of more importance in the future.What most clinicians will want to know is whether

any more hopeful light can be thrown on " con-

1. Spec. Rep. Ser. med. Res. Coun., Lond. no. 265. H.M. StationeryOffice. 1949. Pp. 138. 6s.

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genital" hydrocephalus. In some of these, cases,hydroo’ephalus is present at birth and is due, amongother causes, to developmental abnormalities of theaqueduct ; but Professor RUSSELL believes that thereare also some in which it develops in early infancy asa result of unrecognised (and usually untreated)meningitis from which the child recovers. More use oflumbar puncture in unexplained pyrexial illnessesof infancy would lead to the diagnosis and treatmentof the meningitis and might prevent the hydrocephalus.Even in the other kinds of " congenital " hydro-cephalus the hypothesis of obstruction justifies someoptimism, or at least more optimism than the previousopinion that hydrocephalus is an irreparable mal-development probably associated with other develop-mental abnormalities. In ventriculography we havea technique that will often indicate the site of theobstruction during life ; and surgery provides severalmeasures that may deal with obstruction. With

hydrocephalus in adults a simple decompression mayoccasionally ease things just enough to establish orrestore an adequate circulation of the cerebrospinalfluid ; but usually something more is necessary, andthe introduction of ventriculostomy by STOOKEYand SCARFF was a great technical advance. Inthis operation a fistula is made between the thirdventricle and the subarachnoid space at the base ofthe brain so that the fluid does not have to passthrough the aqueduct, fourth ventricle, and posteriorfossa, or cisterna ambiens, thus bypassing anyobstruction in those parts. For success, however,the cisterna chiasmaticus must be patent, and thiscondition is not always fulfilled. In seeking an

alternative, TORKILDSEN has devised the ingeniousprocedure of ventriculocisternostomy in whicha tube is passed from the lateral ventricle to

the cisterna magna, which allows the fluid to bypassthe foramina of Monro, third ventricle, aqueduct, andfourth ventricle. This operation is widely practisednowadays because it is feasible in many cases whereventriculostomy would be difficult or impossible-e.g., in hydrocephalus due to tumour of the thirdventricle.

Though these procedures often succeed in adults,it is a disappointing fact that they are usuallyineffective in infancy-in the so-called congenitalcases. Decompressions and bypassing operationscannot deal with diffuse obstructions in the sub-arachnoid space due to meningitis or birth h2emor-rhage ; and even where the primary lesion is amenableto treatment (for example, where it is a membraneover the foramen of Magendie) the subarachnoidspace may be obliterated by long-standing ventriculardistension. For these reasons attempts have beenmade to deal with the problem from the other end,by diminishing the secretion of cerebrospinal fluid.DANDY 2 tried excision of the choroid plexus by openoperation, but this was a formidable procedure,attended by a high mortality-rate, and it has beenlargely discarded. More recently PUTNAM 3 andSCARFF,4 among others, have tried destruction of alarge part of the choroid plexus by endoscopic electro-coagulation, and some success has been reported.This procedure will not deal with neuronal damage

2. Dandy, W. E. Bull. Johns Hopk. Hosp. 1921, 32, 67.3. Putnam, T. J. New Engl. J. Med. 1934, 210, 1373.4. Scarff, J. E. Amer. J. Dis. Child. 1942, 63, 297.

already done; and, even though the hydrodynamicresult may be satisfactory, there may be physical ormental defects that make the cure considerably lessthan complete. It can be said, however, that withinfants, older children, and adults it is usuallyimpossible to select favourable cases without specialinvestigations, or even trial operations ; and theyshould all have the benefit of these investigations.Even though they carry risks, the alternative of doingnothing is almost always worse.

Annotations

THE DENTIST’S EARNINGS

FOR the second time since the National HealthService began less than- a year ago, the Minister of Healthhas found it necessary to reduce the fees of dentists. Thefirst cut-one of 50% on gross earnings beyond £4800

per annum-was introduced on Feb. 11 ; and thereafterit was still possible to gain, without reduction, a netincome some 25% in excess of the Spens Committee’s 2recommendations,

" in consideration," says the Ministryof Health, " of the long hours which dentists were workingin what was then believed to be a temporary rush."Any resentment that was felt against this first cut centredmostly on its imposition without prior negotiation.Against the new cut, which is explained on p. 929, theprofessional bodies have voiced the further objectionsthat it is based on earnings in a period of abnormallyhigh demand and on figures relating to only half thedentists in the service ; already, they say, two-thirdsof the profession in the service are earning only -what theSpens Committee recommended, or less. The Ministry,for its part, claims that the new terms satisfy the Spensrecommendations.The alteration of fees twice within a single year reflects

the difficulty of fixing a fair reward when payment isdecided by each item of service. Three factors have to beassessed : the average time taken by each operation thehours per week at the chairside ; and the average ratioof professional expenses. In January the Minister set upa working party, under the chairmanship of Mr. W.Penman, to study timings ; and the refusal of the dentalorganisations to discuss any change until the workingparty has- reported accounts for the absence of negotia-tions over the new scales. As to chairside hours, the SpensCommittee held that if these much exceeded 33 perweek, efficiency would be impaired. The original scaleswere based on the assumption of this number of hours,though by its first cut the Ministry did nothing to

discourage a somewhat greater number. With regard toexpenses, the Ministry has accepted 52% as the

appropriate proportion.Perhaps the most difficult of these three factors to

assess is the timing of each operation. In the payment ofthe general dental practitioner, as in the payment. of hismedical colleague, no allowance is made for special skillor special care ; indeed in the case of the dentist a

premium is placed on hasty and unconscientious work.Wherever payment for professional services is calculatedby the average time for each item, anomalies will befound. With dentistry these anomalies could be endedif all were engaged at centres on either a full-time or asessional basis. The dental organisations are believed tooppose such an arrangement ; but it is hard to see how,in its absence, dental earnings can be fairly equated toother expenses in the National Health Service while

doing justice to the careful worker. Meanwhiledissension is likely to continue.

1. Lancet, 1948, ii, 938.2. Ibid, 1948, i, 802.