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but the patient deteriorated continuously despite parenteralnutrition. Tentative irradiation of the abdomen with 3 x 1-5

Gray/week had to be abandoned after the fifth session because of asharp deterioration of the patient’s general condition. Thereafter,staphylococcal sepsis developed, and he died of cardiovascular’failure six months after first admission.

RESULTS

Tumour cells from all 39 T cell lymphomas wereunreactive with antibodies for B cells and macrophages. Thetumour cells were positive for one or more T cell antigens.Only one T cell lymphoma, that from the patient withjejunal tumour, reacted with HML-1 (table and figs 1 and2). This lymphoma of pleomorphic T cell type was confinedto the jejunum, growing mainly in the lamina propria andthe epithelial layer. It was associated with ulcerative jejunitisand complete villous atrophy.

DISCUSSION

The findings in the case of jejunal lymphoma suggest thatthis tumour was derived from intestinal mucosa T

lymphocytes. This conclusion is in keeping with the

primary localisation of this lymphoma in the lamina propriaof the jejunum and the spread of the HML-1 + tumour cellswithin the intestinal epithelium and the expression of CD8and CD3 in the absence of CD4, since the majority ofintraepithelial T cells also carry CD8 and CD3 on theirsurface.6 The negative reaction of all other T cell

lymphomas, including those with primary involvement oflymph nodes, skin, mediastinum, and stomach, indicatesthat the specificity of the mAb HML-1 for intestinal mucosaT cells holds true for cells that have undergone malignanttransformation.The HML-1 + T cell lymphoma is of particular interest

because it was associated with ulcerative jejunitis and coeliacdisease. Malignant lymphomas occurring in associationwith ulcerative jejunitis and coeliac disease were first

recognised in 1937. In 1978, Isaacson and Wrightll,12reported evidence that this lymphoma is of a singlehistogenetic type. These workers regarded the lymphoma asa special form of malignant histiocytosis, because it met thecriteria for a diagnosis of malignant histiocytosis andimmunological analysis seemed to confirm the histiocyticproperties of the malignant cells. In a jointimmunohistological and genotype study in 1985,13 when awide range of mAbs and a T cell receptor-specific DNAprobe were available, the T cell nature of this lymphoma wasdemonstrated.At the first meeting of the European Society for

Haematopathology (April 14, 1988) Isaacson reportedanother case of intestinal T cell lymphoma associated withcoeliac disease that was reactive with the HML-1 antibody.It therefore seems possible that all T cell lymphomas of thesmall intestine that arise in coeliac disease will react with themAb HML-1.

Might there be gastrointestinal tract T cell lymphomasthat are not associated with coeliac disease, but express theantigen specific for intestinal mucosa T cells? To answer thisquestion, a larger series of primary gastrointestinallymphomas should be studied with the HML-1 antibody.Whatever the results, it is already clear that HML-1 +primary intestinal T cell lymphomas should be included inclassification schemes as a unique entity.We thank Mr B. Young for help with preparation of the text.

H. STEIN AND OTHERS REFERENCES

1. Guy-Grand D, Griscelli C, Vassali P. The mouse gut T lymphocyte, a novel type of Tcell. Nature, origin, and traffic m mice in normal and graft-versus-host conditionsJ Exp Med 1978; 148: 1661-77

2. Selby WS, Janossy G, Bofill M, Jewell DP. Lymphocyte subpopulations in the humansmall intestine The findings in normal mucosa and in the mucosa of patients withadult coeliac disease. Clin Exp Immunol 1983; 52: 219-28.

3. Carman PS, Ernst PB, Rosenthal KL, Clark DA, Befus AD, Bienenstock J.Intraepithelial leukocytes contain a unique subpopulation of NK-like cytotoxiccells active in the defense of gut epithelium to enteric murine coronavirusJ Immunol 1986; 136: 1548-53.

4 Cerf-Bensussan N, Guy-Grand D, Lisowska-Grospierre B, Griscelli C, Bhan AK. Amonoclonal antibody specific for rat intestinal lymphocytes. J Immunol 1986, 136:76-82.

5. Gallatin M, St John TP, Siegelman M, Reichert R, Butcher EC, Weissman ILLymphocyte homing receptors. Cell 1986; 44: 673-80

6. Cerf-Bensussan N, Jarry A, Brousse N, Lisowska-Grospierre B, Guy-Grand D,Griscelli C. A monoclonal antibody (HML-1) defining a novel membrane moleculepresent on human intestinal lymphocytes. Eur J Immunol 1987; 17: 1279-85

7. Cordell J, Falini B, Erber ON, et al. Immunoenzymatic labeling of monoclonalantibodies using immune complexes of alkaline phosphatase and monoclonalanti-alkaline phosphatase (APAAP complexes). J Histochem Cytochem 1984, 32:219-29

8 Stem H, Gatter KG, Asbahr H, Mason DY. Methods in laboratory investigation. Useof freeze-dried paraffin-embedded sections for immunologic staining withmonoclonal antibodies. Lab Invest 1985; 52: 676-83.

9. Stansfeld AG, Diebold J, Noel H, Kapanci Y, Rilke F, Kelenyi G, Sundstrom C,Lennert K, van Unnik JAM, Mioduszewska O, Wright DH Updated Keilclassification for lymphomas. Lancet 1988; i 292-93.

10. Fairley HN, Mackiew FP. Clinical and biochemical syndrome in lymphadenoma andallied diseases involving mesenteric lymph glands Br Med J 1937; i 375-80.

11. Isaacson PG, Wright DH. Malignant histiocytosis of the intestine: its relationship tomalabsorption and ulcerative jejunitis Hum Pathol 1978, 9: 661-77

12. Isaacson PG, Wnght DH Intestinal lymphoma associated with malabsorption Lancet1978, i: 67-70.

13. Isaacson PG, O’Conner NTJ, Spencer J, et al Malignant histiocytosis of the intestinea T cell lymphoma Lancet 1985; i: 688-91

Reviews of Books

Medical Decision MakingHarold C. Sox, Jr, Marshal A. Blatt, Michael C. Higgins, andKeith 1. Marton. Boston, London: Butterworths. 1988. Pp 406.25.ISBN 0-409900915.

THIS was a difficult book to review: on the one hand itoffers fascinating analysis of clinical decision making; on theother it strays frequently into unnecessarily complexmathematical analysis. The latter feature is so off-puttingthat I found it almost impossible to finish a single chaptercompletely. The really annoying thing is that many of theformulae express quite simple concepts, and to un-numerateclinicians figures like this can be a real deterrent. Theauthors do say in their preface that they are also aiming atcomputer-equipped statistically minded doctors.There are many excellent aspects; it does a clinician good

to stop to question how history-taking leads to differentialdiagnosis, how test results are weighed, how treatments aredecided, and how outcome is measured. Two particularlyimportant subjects are presented in considerable depth. Thefirst is Bayes’ theorem, by which the effects of a given testresult on the probability of disease can be mathematicallycalculated. This leads not only to critical evaluation of thepower of a test (based on its sensitivity and specificity) butalso to the decision on whether to use it at all-there is no

point if the diagnosis is already highly probable and the testis of low predictive value. The second important subject isdecision making; here the authors use algorithms to showhow a clinical decision can be reached with optimum resultsto the patient. Each algorithm includes chance nodes (pointsin the decision tree where chance decides the next path), anddecision nodes (points where there are choices for theclinician). At each node probabilities of outcome are quoted

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so that very complex pathways are built up to cope withnatural history of disease, effects of intervention, costs,patients’ expectations, and so on. In fact, the authors admitthat to reach optimum decisions in some of their "bedside"examples would take at least an hour with a calculator andunlimited library facilities.The book is helpfully illustrated by line drawings and

graphs. Every chapter includes clinical examples (most ofthem pretty realistic), problems for the reader to solve(answers at the back), glossaries for unpleasant words suchas representativeness heuristic (meaning how well

something fits the usual pattern), and references. The indexis good, and the style lively throughout. Despite frequentirritation, I have to recommend this book very strongly. Weare likely to be forced to explain our decisions increasingly inan audit-conscious profession, and this inexpensive bookprovides an abrasive stimulus to do so.

Southampton General Hospital,Southampton S09 4XY RICHARD GODFREY

Esophageal Cancer

International Trends in General Thoracic Surgery, vol 4.-Norman C. Delarue, Earle W. Wilkins, Jr, and John Wong. StLouis: Mosby. 1988. Pp 456. 48. ISBN 0-801620481.

OESOPHAGEAL cancer is a worldwide disease, but itsincidence varies strikingly: in some areas it is a leading causeof death and in others it is rare. Surgeons who see only a fewcases a year tend to get poor results. This outstanding book iscommendably international. The editors are from Canada,the USA, and Hong Kong and 28 of the 52 chapters are fromcountries where English is not the native language. It iscompact, succinct, and well referenced. The controversiesare discussed openly; for example, chapter 2 airs thedifferent opinions on screening for carcinoma in patientswith achalasia. Operations are well illustrated by diagrams,and technical aspects, especially of anastomotic methods, aredescribed in detail. There is judicious use of radiographs andphotographs but black-and-white photographs rarely dojustice to operations. We are offered a plan of managementbased on facts and figures, and in which perioperative carereceives due emphasis. It is reassuring to see chapters at theend on palliative treatment of advanced carcinoma.The title of the book raises the perennial controversy

about who should be doing oesophageal surgery. Theeditors in their foreword call for the recognition of generalthoracic surgery as a fully fledged specialty, separate fromboth cardiovascular surgery and general surgery. Thedebate continues; meanwhile, this book is an authoritativeguide for those doing oesophageal surgery whatever theirtraining and place of work.

Department of Surgery,Royal Hallamshire Hospital,Sheffield ALANJOHNSON

Medical Aspects of Anorexia NervosaS. Bhanji and D. Mattingly. London, Boston: Wright. 1988. Pp140. C22 (approx). ISBN 0-72361115.

WITH so much written about "the slimmer’s disease" inglossy magazines and Sunday papers, the diagnosis ofanorexia nervosa has gone into the public domain. Parentsand teachers, who often initiate the referral, may be well

informed, or just opinionated, but the doctor’s

responsibility is to look after the whole patient and the wholeproblem. A range of physical and biochemical disorders mayresult from, or are associated with, emaciation and are tooeasily overlooked in a society where health and slimness havebecome linked in common wisdom, and a degree ofself-starvation is approved social behaviour. In this small,nicely produced, and economically priced book, a

psychiatrist and a general physician review with great claritythe important medical features of anorexia nervosa.The first three chapters cover historical background,

aetiology, and the clinical features of anorexia nervosa. Theauthors then review their own series of 155 cases seen over

twenty years. The central portion of the book consists ofnine chapters which review the published work, taking thesystems in turn. Each is well referenced, self-contained, andpleasant to read. The chapters on medical and psychiatrictreatment are clear and helpful.

It is important for the doctors to rise above the nebulousconcepts of this illness and to be aware of exactly how thesystems of the body are put at risk, how these abnormalitiescan be diagnosed, and how they can be treated. In ourpractice we go further than that. A detailed knowledge andexplanation of the medical consequences judiciously usedcan promote insight and lead to engagement in therapy. Forexample, to be able to demonstrate high levels of plasmacholesterol to a girl who insists that her low-calorie,high-fibre, no-fat diet is "healthy", or to enumerate theirreversible sequelae to bones, teeth, and possibly heart, canpromote change.

This book is inexpensive and easy to read. Generalpractitioners, physicians, and psychiatrists dealing withanorexia nervosa could use a copy.

Institute of Psychiatry,London SE5 8AF JANET TREASURE

Cardiopulmonary Critical Care ManagementClinics in Critical Care Medicine 14. Edited by R Fallat andJ M Luce. Edinburgh: Churchill Livingstone. 1988. Pp 250.28.50. ISBN 0-443085641.

THE latest addition to the Clinics in Critical Care Medicineseries reviews the pathophysiology and management offailure of oxygenation of the tissues-a process that is theend result of many forms of severe illness. Pulmonary,ventilatory, and cardiovascular failure are discussed

comprehensively, whereas impairment of oxygen utilisationis dealt with only superficially. Much of the book is devotedto the establishment of cardiovascular and respiratorymonitoring and interpretation of the results. A particularlygood chapter describes factors that introduce errors into thedisplayed values of cardiovascular indices, and methods ofeliminating the causes.

This volume has maintained the high standard set byprevious works in the series. It is heavily referenced,liberally illustrated, and adequately indexed. However, thesubject matter is dealt with in many standard texts, and littlehas been added that is new. Some of the physiology, and thedescriptions of insertion of monitoring lines, would beregarded as elementary by those already involved in criticalcare; conversely, those who seek knowledge at that level willfind the descriptions of more complex concepts difficult todigest.

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The book is appropriate for doctors who have elected totrain in intensive care medicine, and is a useful referencesource for nurses in the intensive care unit. However,doctors already trained in this area will find it lessinformative than most of the previous volumes in the series.

University Department of Anaesthesia,Leicester Royal Infirmary,Leicester LE1 5WW ALAN AITKENHEAD

Treating Troubled Adolescents--A Family TherapyApproach

H. Charles Fishman. London: Hutchinson. 1988. Pp 318. 25.ISBN 0-091822793.

THE title of this book, though appropriate, may beconfused with Rutter’s Helping Troubled Children. This,however, is a text for clinicians and the titles are the onlysimilarity between these two important works.Drawing on his earlier work with Salvador Minuchin, an

authoritative figure in family therapy, Dr Fishman hasproduced a clear framework for working with the mostdifficult problems of adolescence. The theoretical basis forfamily therapy with adolescents and the techniques used aredescribed in two introductory chapters where he presents ahelpful four-dimensional model that considerscontemporary developmental pressures on the family,history, structure, and process. Delinquency, running away,violence, incest, suicide, and disability are then covered inindividual chapters with clinical cases. Detailed transcriptsof the family sessions are provided, interspersed withexplanations of the therapeutic interventions. The result isa sensitive balance of practice and theory, both moving andenlightening, where the families come alive in the poignanttherapeutic dramas.Though the family is described as the mechanism

through which one’s fundamental sense of self and

well-being are maintained and family therapy as thetreatment of choice for adolescents, there are also twoexcellent chapters that focus on the parental couple. Afurther chapter with clinical material looks at the oftenforgotten problem of the single-parent family. Broadersocial and political issues are briefly addressed in a

thoughtful epilogue, worthy of attention in its own right.Highly readable for its content, the book is made even moreattractive by its crisp presentation and literary quotationsfrom W. B. Yeats to Maya Angelou.Child and Family Department,Tavistock Clinic,London NW3 5BA JIM WATTERS

To Heal or to Harm

The Prevention of Smnatic Fixation in General Practice. Editedby Richard Grol. London: Royal College of GeneralPractitioners. 1988. Pp 160. D2.50. ISBN 8-50841283.

EVERY general practitioner has "difficult" or "heart-sink" patients. Many present with somatic symptoms thatare investigated, referred, and treated, often at great cost tothe NHS and to the doctor’s nerves, but usually to littleavail. The patient returns for more and their problems havebecome "medicalised". These patients, their syndromes,and their interactions with the medical profession have untillately been poorly understood.

Richard Grol is a clinical psychologist from the

Department of General Practice, University of Nijmegen,best known for his classic tome Family Medicine-TheMedical History of Families. Together with several generalpractitioners and psychologists he has studied in depth agroup of these patients over many years, and this book is theresult. There are, however, no statistical data at all. This lackcontributes to its readability but, some would argue, limitsits scientific value. This is the first English-language edition,the previous two being in Dutch.The book’s first third is theory but its clarity of thought,

frequent use of examples, and end-of-chapter summariesmake it very readable. It discusses how the doctor-patientrelationship can influence the process of somatic fixation.The remainder of the book deals with practical issues of howthe general practitioner can creatively cope with theseproblems. Grol emphasises the importance of formulating a"concrete plan" with the patient, avoidance of a dependentrelationship, and the detection and positive use of

psychological information. Written to help generalpractitioners deal with some of their most difficult patientsthis is essential reading for GP trainers and probably theirtrainees-and for every doctor who, like me, needs every bitof help with his "Oh no, not you again" patients.15 Wyvem Close,Dartford DA1 2HA ROGER PEPPIATT

Virology Reviews, vol 1

Soviet Medical Reviews section E. Edited by V. M. Zhdanov.New York: Harwood Academic. 1987. Pp 332.$108. ISBN3-718603144.

THE iron curtain seems to be cracking open but many ofus are ill-informed on the biomedical science of the SovietUnion. One must therefore welcome the appearance of thisbook of reviews. It was edited by the late Victor Zhdanov,Director of the Ivanovskii Institute of Moscow, who waswell known to and liked by virologists throughout the world.The reviews written by himself and colleagues cover a rangeof topics but all emphasise the work of the authors, manywith tables and figures presenting original data. Zhdanovwrites on the molecular basis of viral pathogenicity (mainlyon influenza), Bukrinskaya on entry of influenza virus intocells, Lvov and Zhdanov on influenza genes in the biosphere(ie, the relation between the influenza viruses of differentspecies), and Lvov and Kliemnko on the biology andecology of arthropod-borne viruses in the USSR. Ghendonhas reviewed studies on the variability of influenza viruses,mostly observed in human infections; many of theseinvestigations were collaborative research with UK workers.The articles have all been well translated, though there are

some type-setting errors and some poorly producedillustrations. The published work is usually well cited andthe views are reasonable. There are references to Russian

papers one might not otherwise know about, but it isunfortunate that the book seems to have been written about4 years ago and there is a lack of recent references. Thereviews on interferon were of scant interest.

This book gives us a valuable view of the ideas and work ofSoviet virologists and their science.

MRC Common Cold Unit,Harvard Hospital,Salisbury SP2 8BW DAVID TYRRELL