1050 cancer at operation. Life-table analysis of the follow-up of these patients resulted in 5 and 10 year survival rates identical to those of the age and sex adjusted so-called normal population-in other words, the diagnosis of early gastric cancer and immediate operation are equivalent to cure.This frequency (1such case out of every 200 gastroscopies on average is ascribable to endoscopic biopsy and could not be achieved by macroscopic evaluation, by X-ray or by endoscopy alone. Similar reports have come from Japanzbut the success of endoscopy in early gastric cancer may not be so well recognised in Europe. 3-6 Clark thinks that endoscopy may be popular because it is easier to do this investigation than to think about the problem. By the same token it is easier to order an X-ray than to analyse the clinical situation. If a clinician thinks logically and requires morphological evidence he will prefer endoscopy to a barium meal because the result will be more decisive; endoscopy is also less time-consuming than a double-contrast X-ray and is free of radiation. The financial gain from endoscopy which Clark thinks to be a major motive is exaggerated. The vast majority of endoscopic examinations are done in hospitals where the gastroenterologist earns the same whether he asks for X-ray studies or does the gastroscopy himself. This is certainly true in Austria. On the Continent of Europe the barium meal has in large measure been replaced by gastroscopy but without endangering the specialty of radiology whose practitioners have shifted to more modern techniques such as ultrasound, computerised tomography, and nuclear magnetic resonance.
Gastroenterolgy Unit, 1st Medical Department,
1 Hentschel E, Schütze K, Dufek W, et al. Early gastric cancer. Five and ten year survival of 69 patients. XIIth International Congress of Gastroenterology (Lisbon, 1984), abstr 725 Hayashida T, Kidokoro T End results of early gastric cancer collected from 22 institutions. Stomach Intest (Tokyo) 1969, 4: 1077. Miller G, Froelicher P Das Magenfruhkarzinom m Europa. Z Gastroenterol 1978; 16: rates
Department of Medical Protozoology, London School of Hygiene and Tropical Medicine, London WC1E 7HT
P. G. SARGEAUNT T. F. H. G. JACKSON
Sargeaunt PG, Jackson TFHG, Simjee A. Biochemical homogeneity of Entamoeba histolytica isolates, especially those from liver abscess. Lancet 1982, i: 1386 Sargeaunt PG, Oates JK, Maclennan I, Oriel JD, Goldmeier D. Entamoeba histolytica in male homosexuals Br J Ven Dis 1983; 59: 193-95
CSF ANGIOTENSIN-CONVERTING ENZYME IN NEUROSARCOIDOSIS
SIR,-Dr Chan Seem and colleagues (Feb 23, p 456) report serial of cerebrospinal fluid (CSF) angiotensin-converting
Hanusch-Krankenhaus, 1140 Vienna, Austria
characterisation of 147 isolates among which were no less than 38 amoebic liver abscess cases. Male homosexuals have an approximate 11% prevalence of infection with Entamoeba histolytica.2Continuing research shows that 205 of 1487 subjects so far tested had E histolytica infections, of which every single isolate expressed a non-pathogenic zymodeme. In the two March 30 articles you discuss amoebae were cultured from 50 of 257 (not 24 of 303) healthy subjects. Also 1 of 33 (not 7) subjects with non-pathogenic zymodemes had a "strongly positive" serological response. Fig 4 clearly shows an equal distribution of males and females with pathogenic zymodemes and not that "pathogenic organisms were relatively more common in men than women".
678-83 4. Gentsch HH, Groitl
H, Giedl J Results of surgical treatment of early gastric cancer in 113 patients. World J Surg 1981; 5: 103-06. 5. Schlag P, Meister H, Merkle P, et al. Prognostische Aspekte des Magenfrühkarzinoms. Dtsch Med Wschr 1979; 104: 659-62 6 Roesch W. Contribution of gastroscopy to early diagnosis and treatment of gastric carcinoma. J Cancer Res Clin Oncol 1979, 93: 1-5.
enzyme (ACE) concentrations in neurosarcoidosis. Raised CSF ACE levels were reported by Schweisfurth et all though serial samples were not analysed. At a conference last September we too reported high CSF ACE levels in active neurosarcoidosis.2 The highest ACE level (by the enzyme method 3) was 18 kU/1, the concomitant serum ACE level being 16 kU/1. After steroid treatment the CSF ACE concentration fell to 5 kU/l but did not return to normal. The disease progressed to death in three years. The persistently raised CSF ACE may reflect poor response to treatment.
A novel assay principle, based on 1211-labelled "351 A" (an inhibitor of ACE4), permits measurement of low CSF ACE levels. In seven patients serial measurements of CSF ACE have reflected the clinical picture. CSF ACE levels were significantly higher in active neurosarcoidosis (see figure) than in extraneural sarcoidosis
COMMUNITY CARE FOR THE MENTALLY ILL
SIR,-It is laudable that The Lancet (March 30, p 731) should on community care, but your enthusiastic editorial seems to have overlooked the major lesson of community care in the countries mentioned. Mental hospitals are closed before community facilities are established. The steps of the Grand Central railway station in New York are no replacement for a caring mental hospital. A recent assessmentof the Italian experience is also very discouraging. Community facilities should be created first, after adequate pilot studies, and a shift from hospital to community should be gradual. Your editorial is enthusiastic about the value of multidisciplinary teams-the talking shops of inactivity. We should re-establish faith in the cooperation between independent, well-trained professionals with rigidly defined roles and responsibilities.
J. G. HOWELLS
Jones K, Poletti A. Understanding the Italian experience. Br J Psychiatry 1985; 146: 342-47.
SIR,-We thank you for highlighting the amoebic isoenzyme research in your editorial of March 30. The
preliminary Durban work you mention was preceded by major research entailing enzyme
Serial CSF ACE
analysis in seven patients with neurosarcoidosis.