751

showed the reaction. 50% of acid-phosphatase-positivecells may still be consistent with a diagnosis of T-A.L.L.Rare cases of common-A.L.L. and null-A.L.L. also

showed a strong acid-phosphatase reaction. The 6 cases(table 11), 3 of them with a mediastinal mass, in whichthe membrane phenotype was intermediate suggest thatthe different forms of A.L.L. may represent the prolifer-ation of cells arrested at different stages of differentia-tion and maturation from a prelymphoid precursor orstem cell to a thymus-derived cell similar to that whichproliferates in T-A.L.L.

Null-A.L.L. is a less well defined category which mayinclude both prelymphoid stem cells and leukaemias ofthe T-cell lineage. This is supported by the high inci-dence of mediastinal mass (4 of 10 A.L.L. cases) reportedby Chessells et al. and may account for the strong acid-phosphatase reaction in the only case with a mediastinalmass tested in that study. Since not all their null A.L.L.cases were tested with anti-T and anti-Ia sera it is pos-sible that some belong more correctly in the interme-diate group with an incomplete T-cell phenotype. Thisis supported by Thiel et al.11 who have shown a positiveacid-phosphatase reaction in 7 of 9 cases with an E-rosette-negative T-A.L.L. surface phenotype. The localised acid-phosphatase reaction in fetal thymocytes suggests thatthis marker is acquired early in the ontogeny of Tlymphocytes. 12

T-A.L.L. accounts for 15-25% of childhood A.L.L. andthere is increasing evidence that it has a worse prognosisthan common-A.L.L.l,3-6 As shown in this study, itsrecognition is helped by a positive acid-phosphatasereaction. The addition of this cytochemical reaction tothe battery of surface markers used to classify A.L.L.may also help to define cases which, on clinical or im-munological grounds, are closer to T-A.L.L. than to com-mon-A.L.L. The value of such a distinction will dependon whether such cases respond clinically as T-A.L.L. oras common-A.L.L.6 and may aid a more rational alloca-tion of cases in therapeutic trials. More intensive ther-apy could then be tried in T-A.L.L., without the risk oftoxicity for those with less aggressive forms of A.L.L.We thank the members of the M.R.C. Working Party on Leukaemia

in Childhood for supplying the material with which we carried out ourstudies: Prof. J. H. Hutchison (chairman); Prof. R. M. Hardisty (sec-retary) ; Dr P. Barbor; Dr N. D. Barnes; Dr J. M. Bridges; Dr J. M.Chessells; Dr P. F. Deasy; Dr P. Emerson; Dr D. I. K. Evans; DrN. E. M. Harker; Dr E. M. Innes; Dr E. Jones; Dr J. S. Lilleyman;Dr J. Mann; Dr J. Martin; Dr T. J. McElwain; Dr M. Mott; Dr M.Radford; Dr E. N. Thompson; Dr M. L. N. Willoughby.

Requests for reprints should be addressed to D. C., M.R.C. Leukae-mia Unit, Royal Postgraduate Medical School, London W12 OHS.

REFERENCES

1. Sen, L., Borella, L. New Engl. J. Med. 1975, 292, 828.2. Greaves, M. F. Prog. Hæmat. 1975, 9, 255.3. Brouet, J. C., Valensi, F., Daniel, M.-T., Flandrin, G., Preud’homme, J. L.,

Seligmann, M. Br. J. Hæmat. 1976, 33, 319.4. Catovsky, D. in Recent Advances in Hæmatology, (edited by A. V. Hoff-

brand, M. C. Brain, J. Hirsh); p. 201. Edinburgh, 1977.5. Belpomme, D., Mathé, G., Davies, A. J. S. Lancet, 1977, i, 555.6. Chessells, J. M., Hardisty, R. M., Rapson, N. T., Greaves, M. F. ibid. ii,

1307.7. Catovsky, D., Galetto, J., Okos, A., Miliani, E., Galton, D. A. G. J. clin.

Path. 1974, 27, 767.8. Stein, H., Peterson, N., Gaedicke, G., Lennert, K., Landbeck, G. Int. J.

Cancer, 1976, 17, 292.9. Greaves, M. F. et al. in Hæmatology and Blood Transfusion. Vol. xx (edited

by S. Thierfelder, H. Rodt and E. Thiel); p. 61. Berlin, 1977.10. Goldberg, A. F., Barka, T. Nature, 1962, 195, 297.11. Thiel, E., Rodt, H., Netzel, B., Huhn, D., Wundisch, G. F., Thierfelder, S.

in Abstracts of the 2nd International Symposium on Therapy of AcuteLeukæmias; p. 259. Rome, 1977.

12. Stem, H., Müller-Hermelink, H. K. Br. J. Hæmat. 1977, 36, 225.

Reviews of Books

THIs book, written by a cardiac surgeon and a group of car-diologists, gives a balanced and reasoned picture of coronary-artery bypass surgery in a clear and concise manner. It con-tains sections which make the book interesting not only for thecardiologist and the surgeon but also for the general practi-tioner, who must consider referring patients for such surgery.The text is comprehensive yet does not exhaust the reader withminutiae. Adequate references are given at the end of eachchapter. A short account of the evolution of coronary-arterysurgery is followed by chapters on the clinical course of pa-tients with coronary-artery disease and the risks and benefitsof such surgery. A rational approach to the preoperative eval-uation is discussed and the indications for coronary angiogra-phy reviewed. There are chapters on operative technique andon the problems encountered by the anaesthetist. Consideringthe impact that coronary-artery bypass surgery has on medi-cine and the economic resources of the community, an impor-tant chapter for health-care planning is that on the economicsof such surgery. This book can be recommended as one of thebest up-to-date reviews on this subject.

Principles of Family MedicineROBERT E. RAKEL, M.D. Philadelphia and London: Saunders.1977.Pp.336. ;12.

THE emphasis in this book, by the professor of family prac-tice in the University of Iowa College of Medicine, is almostentirely on psychosocial aspects of practice, family dynamics,and interpersonal relationships (including the doctor-patientrelationship); it also gives details of record-keeping, includingfamily and genetic charting. Social and cultural factors areclassified and categorised in detail. It would be easy to be

flippantly critical of some of the results of such categorisation,for instance that "the number of interpersonal relationships ina family has been depicted mathematically by the formula

x=yy2

where y is the number of persons involved and x the resultingnumber of interpersonal relationships". Try it out on yourfamily and then on the largest family you know (unless theyare one and the same) and see if you feel much the wiser. Onealso questions the value of describing in detail and illustratingcommon nervous habits such as sniffing, rubbing the nose, andclearing the throat as examples of the "respiratory avoidanceresponse". If these aspects are a bit leaden, there is neverthe-less much pertinent observation in the book, particularly in thecentral chapter on the impact of illness on the family and theinfluence of the family upon illness. The main interest of thebook, however, lies in the comparison between primary care inthe U.S.A. and the U.K. There is much in common, but oneof the main differences is in the personnel of the primary-careteam. Comparing the U.S.A. with the U.K., the authorremarks that "organizational efficiency [of the primary-careteam] has not progressed this far in the United States" and "aunified system of community health services is sorely needed inthis country". Conversely, there are aspects of family practicein the U.S.A. from which U.K. doctors can learn, and we canenvy the American family practitioner the time he can allocateto each patient and to record-keeping. The end of each chapterhas excellent references with notes by the author. There arenumerous diagrams and tables in this well printed and pro-duced book. Those interested in the development of primarycare on both sides of the Atlantic, especially the psychosocialaspects, will find this book a valuable source of information onthe present state of family medicine in the U.S.A.

752

Clinical Biostatistics

ALVAN R. FEINSTEIN, M.D., Yale University School of Medicine.Saint Louis: Mosby. London: Kimpton. 1977. Pp. 468.$13.50;10.65.

Professor Feinstein is a stimulating writer with somethingto say on many aspects of medicine and a happy way of sayingit, so it is easy to forgive him for giving in to pressure to pub-lish, in book form, a series of superb essays presented to adrug-oriented readership in Clinical Pharmacology and Thera-peutics in the early 1970s. Read straight through this bookmay pall: the duplication intrudes from time to time, as in acommentary on "exorcizing the ghost of Gauss" (1971) whichnow lies beside a chapter on the meaning of "normal" pub-lished in 1974. Textbook instruction as good as this may behad elsewhere-and ir. this form it comes piecemeal-butFeinstein’s scepticism gives his descriptions a special sharp-ness. He tells us how to do a Student’s t or chi-squared test,but not before he has made it clear that the criteria which

ought to be applied before either test is done are seldom met.He chooses straightforward examples, including publishedones (the University Group Diabetes Program study isattacked from so many angles that its results lose almost allcredibility). No marks for originality, full marks for readabilityand content, but take a little bit off for all those neologisms(pathogressive, retrolective, trohoc, tolpery) which Feinsteinobviously enjoys.

Atlas of Neonatal ElectroencephalographySARAH S. WERNER, JANET E. STOCKARD, and REGINALD G. BICK-FORD. New York: Raven.Press.1977. Pp. 211.$78.

AN atlas of neonatal E.E.G. produces in some electroencepha-lographers a negative feeling and in others quite the reverse.Whichever the reaction, one definite shortcoming of this atlasis its cost. The other main problem is that the reader is not toldhow representative of the complete E.E.G. the sections illus-trated are. It is as important to see the phenomena under discus-sion as it is to know, for example, whether they occurred onevery page of the recording. To convey the impression of aa dynamic process such as neonatal E.E.G. activity, more nu-merical information or analysis must be given than is availablein this atlas. Electroencephalographers are often obsessed byvisual information and want clinical colleagues to see thephenomena that they have observed, but clinicians are moreconcerned with the significance of the findings-how often aparticular phenomenon will be seen in the normal population,whether it suggests brain damage, and, if it does, of whatseverity. To a large extent this atlas fails in this respect. Thereare many elegant illustrations with high quality polygraphicrecordings (E.E.G., E.O.G., E.C.G., E.M.G.) so necessary in neo-natal work. The changes produced by sleeping and waking areshown, as are the features of the tracings of premature infants.There are samples of E.E.G. from pathological conditions. Thepitfalls of recording techniques are emphasised by the inclu-sion of many tracings showing artefacts quite different in typefrom those seen in older children or adults. The comprehensiveglossary of terminology is useful. Unfortunately, a clear indi-cation of the range of normal E.E.G. findings and the overlapbetween various ages and behavioural states (the latter notvery clearly described) is not given. Thus, there is a pagelabelled "28 weeks", one labelled "29 weeks" and so on, im-plying precise maturational changes, whereas there is really awide variation and it would be more helpful to know the limitsof normality. There are valuable charts, for example, of nor-mal patterns in prematurity based on the literature even

though they give an impression rather than precise informa-tion. There is much of value in this atlas but it cannot be

wholeheartedly recommended.

ArthroscopyRICHARD L. O’CONNOR. Philadelphia: Lippincott. Oxford: Black-well. 1977. Pp. 173. £28.

Dr O’Connor has written another beautiful and detailedmonograph on arthroscopy, which is based upon his personalexperiences with the technique. However, his presentation ofdetail, which includes many short case-histories, becomestedious and distracting and there is a tendency throughout thisbook to overelaborate. The introductory chapter on the mech-anics and optics of this method is very helpful, whereas the de-scription of operating technique could be more lucid. Theaccount of arthroscopic anatomy is given in great detail andsuperbly illustrated, but again what is a moderately simplesubject has been overembellished, so that compared with a lesscostly book, such as that by Jackson and Dandy, O’Connor’smonograph is more for the arthropscopic connoisseur than forthe beginner. This book is useful in highlighting pathologybeyond the meniscus and articular cartilage, which can be seenat arthroscopy. The assessment of synovids and of the post-operative knee is emphasised. Treatment of the septic knee viathe arthroscope is a useful topic and the assessment of liga-ment injuries and intra-articular avulsion fractures is one ofO’Connor’s valuable additions to the arthroscopic repertoire.It is strange, however, that a book on arthroscopy is confinedto the knee joint. The review of meniscus function and dys-function, including the effect of meniscectomy, is excellent. Onemay admire the diagnostic opportunities provided by arthros-copy, but one can only marvel at the instrumental contortionswhich allow simple meniscus surgery to be carried out throughthis instrument.

Restructuring the Health Service

ToM HELLER. London: Croom Helm. 1978. Pp. 112. 5.9$.

A TOPICAL title after the Conservative spokesman’s avowalto abolish the area tier, but little more. This book is basedupon something of a misnomer. The two power groups,according to the author, are the medical profession and the ad-ministration, and their conflict has distorted the structure. Itis not so much the administrators but the lay politicians andcommunity health councils who wish to control the destiny ofthe service. The failure to recognise that administration re-sponds, for good or ill, to directions from the national or localgovernors of the service, mars the usefulness of this book fromthe outset. Administrators and doctors alike are criticised for

contributing to the present distortions of the service, which isthen analysed under the headings of geographical inequalities,lower standards of care for chronic conditions, fragmented ser-vices, decision-making far removed, and the inadequacy ofpreventive services. The answers suggested are for more com-munity oriented services responsive to community health coun-cils and patients’ committees, and for curbed professionalpower "toward the people for whom the service is intended".The book contains much sensible thinking but this is obscuredby inadequately considered ideas.

New Editions

Textbook of Work Physiology-2nd ed. By Per-Olof Astrand and

Kaare Rodahl. Berkshire: McGraw-Hill. 1977. Pp. 681. 14.65.’

Strabismus-A Programmed Text. 2nd ed. By R. D. Reinecke andD. Miller. New York: Appleton-Century-Crofts. London: PrenticeHall. 1977. Pp. 319..lIO.50.The Reorganised National Health SeT’liice--2nd ed. By Ruth Levitt.

London: Croom-Helm. 1977. Pp. 254. /;7.9$.Clinical Pediatric Oncology-2nd ed. Edited by Wataru W. Sutow,

Teresa J. Vietti and Donald J. Fernbach. St Louis: Mosby. London:Henry Kimpton. 1977. Pp. 751. /;3S.05,$44.50.

Accidents and Emergencies-2nd ed. By R. H. Hardy. Oxford:Oxford University Press. 1978. Pp. 108. /;2.SO.