383
normallv have a paucity of ACE and a characteristic, abundant lv sozyme secretion," are nevertheless capable of being induced to increase ACE synthesis markedly.’, 11 BB’e have recently observed normal mean levels of SACE activity in the following disorders (values in nmol/min/ml +S.D, and proportion with increased values): monocytic leukaemia. 23.2±4.0 (0/2); Paget’s disease of bone, 31.2±5.8 (0/6); silicosis, 33.1 (0/1); giant lymph-node hyperplasia, 27.6 (0/1): scleroderma, 35.0±13.0(1/11); angioimmunoblastic lymphadenopathy, 25.2±3.0 (0/2). We thank Dr F. Shai and Dr M. Guttadauria for Paget’s disease and scleroderma blood-samples and C. Setton for SACE assays.
Department of Medicine,
E. SILVERSTEIN
S U.N Y. Downstate Medical Center, Brooklyn, N.Y. 11203, U.S.A.
J. FRIEDLAND
NEUROSYPHILIS YESTERDAY AND TODAY
SIR,-Questions such as "Does adequate antisyphilitic therapy prevent neurosyphilis?", discussed by Dr Luxon and her colleagues in their interesting article entitled Neurosyphilis Today (Jan. 13, p. 90) were hotly debated earlier this century and are still unanswered. In the early 1900s many hoped, like Fournier,’ that adequate early treatment of syphilis would prevent general paralysis of the insane (G.P.I.) but statistics soon showed that a proportion of patients who were well treated by the standards of the day (i.e., with mercury) still proceeded to studies even showed that treatment shortened the G.P.I.; interval between syphilis and onset of G.p.l.,2 and a few observers in the 1920s regarded "metalues" as a consequence of "modern" treatment of syphilis.3.4 Most, however, felt that it was the inadequacy of treatment for early syphilis that might be damaging. The difficulty then, as now, was to determine what was adequate treatment in this context. It was hoped in the early days of neoarsphenamine treatment that this drug would prove a better prophylactic against neurosyphilis than mercury. However, when in 1937 I studied 863 male G.P.I. patients treated in Bonhoffer’s clinic at the Charite, Berlin, between 1925 and 1935, 1 found56 that several patients had already received what was then regarded as appropriate arsenical treatment for their syphilis. Your contributors’ finding, among their much more recent patients, that most "had not received adequate antisyphilitic therapy", also applied to the G.P.I. patients of the Charite, Berlin both between 1910 and 1924 in the mercury era2 and between 1925 and 1935 (neoarsphenamine5,6). However, in both eras cases of neurosyphilis presented despite appropriate antisyphilitic therapy; and this has been confirmed for penicillin-treated patients also.7.8 Yoder8 in 1975 asked for further investigation of the adequacy of penicillin-G treatment as recommended today. Perhaps today’s "adequate" antisyphilitic therapy may, in certain cases at least, again some
prove madequate tomorrow. L C H Alcoholism O.P. St Pancras Hospital, London NW1
(Teaching)
Centre
M. M. GLATT
SIR,- The series of cases of neurosyphilis reported on by D; Luxon and her colleagues did not include an acute meningo ascular case. A recent case prompts us to emphasise this pres entation. A
22-year-old North-African
man was
admitted
15. Friedland, J,
to
hospita
Setton, C., Silverstein, E. Biochem. biophys. Res. Comm 1978, 83, 843. 1. Fournier, J.C. Zbl Nervenheilk. 1906, 29, 617. 2. Jossman. P. Mon. Psychiat.1932/33, 84, 245.
3. Gartner. Z Hyg 1921, 92, 341. Wilm anns, KKlin Wschr. 1925, 1097, 1145. 5. Glatt, M.,M M.D thesis,Universityof Berlin, 1937. Glatt, M., M. Confneurol 1938, 1, 257.
4.
with hemiplegia of rapid onset and brachiofacial distribution. His history was not contributory except for acute enteritis a week before admission. He had no history of syphilis. The patient was febrile. No meningeal signs were observed. There was a motor and sensory deficit. Cardiac auscultation was benign. Funduscopy was normal. A computerised tomographic scan on the first day was normal. C.S.F. examination revealed a normal glucose, mild lymphocytosis, slightly increased protein; the c.s.F. was negative by direct examination and acid-fast test and on culture, and blood cultures were also negative. 2 days after the patient’s admission a positive blood test for syphilis was recorded. Antisyphilitic therapy was stated and the patient
rapidly improved. Meningovascular syphilis
may thus present as a "stroke", and we believe that an emergency test for syphilis should be done in all cases of acute-onset cerebrovascular disease, especially in young patients. Department of Internal Medicine, St Pierre University Hospital,
G. DECAUX M. SZYPER
B-1000 Brussels, Belgium
LEUCOCYTE-COUNTS AND SURVIVAL IN UNRESECTABLE LUNG CANCER
SIR,-Dr Check and colleagues’ in their series-of 51 patients, found a high correlation between the leucocyte-count assessment of the patient, and subin sequent survival-time, patients with unresectable lung cancer. I have analysed tuberculin reactivity as a predictor of survival-time in similar patients2 and took the opportunity to attempt to validate Check’s findings. After exclusion of patients with operable disease and those with oat-cell tumours, to ensure comparability with Check’s series, 59 sets of patient records were available for study. Leucocyte-counts had been done at the time of initial diagnosis (Technicon ’Hemalog 8’ automated cell counter). The mean-
performed
at
the initial
SURVIVAL OF PATIENTS WITH UNRESECTABLE LUNG CANCER
RELATIVE TO LEUCOCYTE-COUNT
rz=0.009; not significant. in patients surviving less than four months The table, constructed identically to Check’s table n, shows survival-times of patients whose leucocytecounts were greater or less than 9900/µ1. There is no association between white-cell count and survival-time on this basis, nor is there any obvious correlation when the results of individual leucocyte-counts are plotted graphically against survival-time in days. Unfortunately, only 16 patients had had full differential counts; of these, 7 patients with a neutrophilia survived less than four months, and 5 for more than four months (one for nearly two years). 2 patients with a marked eosinophilia (> 15%) survived only seventeen and thirty-two days. There was no statistically significant difference in mean haemoglobin level or mean erythrocyte-sedimentation rate between patients surviving for more than four months and those surviving for less. These findings do not support those of Check et al;nonethe-
leucocyte-count was
9900/µ1.
6.
7. Dattner, B Am J. Syph. Gonorrh. vener. Dis. 1949, 33, 571. 8. Yo der, F W.
J Am med. Ass.1975, 232, 270
1. Check, I. J., DeMeester, T., Vardiman, 1317. 2. Snell, N J. C. Thorax (in the press).
J., Hunter, R. L Lancet, 1978,
ii,
normallv have a paucity of ACE and a characteristic, abundant lv sozyme secretion," are nevertheless capable of being induced to increase ACE synthesis markedly.’, 11 BB’e have recently observed normal mean levels of SACE activity in the following disorders (values in nmol/min/ml +S.D, and proportion with increased values): monocytic leukaemia. 23.2±4.0 (0/2); Paget’s disease of bone, 31.2±5.8 (0/6); silicosis, 33.1 (0/1); giant lymph-node hyperplasia, 27.6 (0/1): scleroderma, 35.0±13.0(1/11); angioimmunoblastic lymphadenopathy, 25.2±3.0 (0/2). We thank Dr F. Shai and Dr M. Guttadauria for Paget’s disease and scleroderma blood-samples and C. Setton for SACE assays.
Department of Medicine,
E. SILVERSTEIN
S U.N Y. Downstate Medical Center, Brooklyn, N.Y. 11203, U.S.A.
J. FRIEDLAND
NEUROSYPHILIS YESTERDAY AND TODAY
SIR,-Questions such as "Does adequate antisyphilitic therapy prevent neurosyphilis?", discussed by Dr Luxon and her colleagues in their interesting article entitled Neurosyphilis Today (Jan. 13, p. 90) were hotly debated earlier this century and are still unanswered. In the early 1900s many hoped, like Fournier,’ that adequate early treatment of syphilis would prevent general paralysis of the insane (G.P.I.) but statistics soon showed that a proportion of patients who were well treated by the standards of the day (i.e., with mercury) still proceeded to studies even showed that treatment shortened the G.P.I.; interval between syphilis and onset of G.p.l.,2 and a few observers in the 1920s regarded "metalues" as a consequence of "modern" treatment of syphilis.3.4 Most, however, felt that it was the inadequacy of treatment for early syphilis that might be damaging. The difficulty then, as now, was to determine what was adequate treatment in this context. It was hoped in the early days of neoarsphenamine treatment that this drug would prove a better prophylactic against neurosyphilis than mercury. However, when in 1937 I studied 863 male G.P.I. patients treated in Bonhoffer’s clinic at the Charite, Berlin, between 1925 and 1935, 1 found56 that several patients had already received what was then regarded as appropriate arsenical treatment for their syphilis. Your contributors’ finding, among their much more recent patients, that most "had not received adequate antisyphilitic therapy", also applied to the G.P.I. patients of the Charite, Berlin both between 1910 and 1924 in the mercury era2 and between 1925 and 1935 (neoarsphenamine5,6). However, in both eras cases of neurosyphilis presented despite appropriate antisyphilitic therapy; and this has been confirmed for penicillin-treated patients also.7.8 Yoder8 in 1975 asked for further investigation of the adequacy of penicillin-G treatment as recommended today. Perhaps today’s "adequate" antisyphilitic therapy may, in certain cases at least, again some
prove madequate tomorrow. L C H Alcoholism O.P. St Pancras Hospital, London NW1
(Teaching)
Centre
M. M. GLATT
SIR,- The series of cases of neurosyphilis reported on by D; Luxon and her colleagues did not include an acute meningo ascular case. A recent case prompts us to emphasise this pres entation. A
22-year-old North-African
man was
admitted
15. Friedland, J,
to
hospita
Setton, C., Silverstein, E. Biochem. biophys. Res. Comm 1978, 83, 843. 1. Fournier, J.C. Zbl Nervenheilk. 1906, 29, 617. 2. Jossman. P. Mon. Psychiat.1932/33, 84, 245.
3. Gartner. Z Hyg 1921, 92, 341. Wilm anns, KKlin Wschr. 1925, 1097, 1145. 5. Glatt, M.,M M.D thesis,Universityof Berlin, 1937. Glatt, M., M. Confneurol 1938, 1, 257.
4.
with hemiplegia of rapid onset and brachiofacial distribution. His history was not contributory except for acute enteritis a week before admission. He had no history of syphilis. The patient was febrile. No meningeal signs were observed. There was a motor and sensory deficit. Cardiac auscultation was benign. Funduscopy was normal. A computerised tomographic scan on the first day was normal. C.S.F. examination revealed a normal glucose, mild lymphocytosis, slightly increased protein; the c.s.F. was negative by direct examination and acid-fast test and on culture, and blood cultures were also negative. 2 days after the patient’s admission a positive blood test for syphilis was recorded. Antisyphilitic therapy was stated and the patient
rapidly improved. Meningovascular syphilis
may thus present as a "stroke", and we believe that an emergency test for syphilis should be done in all cases of acute-onset cerebrovascular disease, especially in young patients. Department of Internal Medicine, St Pierre University Hospital,
G. DECAUX M. SZYPER
B-1000 Brussels, Belgium
LEUCOCYTE-COUNTS AND SURVIVAL IN UNRESECTABLE LUNG CANCER
SIR,-Dr Check and colleagues’ in their series-of 51 patients, found a high correlation between the leucocyte-count assessment of the patient, and subin sequent survival-time, patients with unresectable lung cancer. I have analysed tuberculin reactivity as a predictor of survival-time in similar patients2 and took the opportunity to attempt to validate Check’s findings. After exclusion of patients with operable disease and those with oat-cell tumours, to ensure comparability with Check’s series, 59 sets of patient records were available for study. Leucocyte-counts had been done at the time of initial diagnosis (Technicon ’Hemalog 8’ automated cell counter). The mean-
performed
at
the initial
SURVIVAL OF PATIENTS WITH UNRESECTABLE LUNG CANCER
RELATIVE TO LEUCOCYTE-COUNT
rz=0.009; not significant. in patients surviving less than four months The table, constructed identically to Check’s table n, shows survival-times of patients whose leucocytecounts were greater or less than 9900/µ1. There is no association between white-cell count and survival-time on this basis, nor is there any obvious correlation when the results of individual leucocyte-counts are plotted graphically against survival-time in days. Unfortunately, only 16 patients had had full differential counts; of these, 7 patients with a neutrophilia survived less than four months, and 5 for more than four months (one for nearly two years). 2 patients with a marked eosinophilia (> 15%) survived only seventeen and thirty-two days. There was no statistically significant difference in mean haemoglobin level or mean erythrocyte-sedimentation rate between patients surviving for more than four months and those surviving for less. These findings do not support those of Check et al;nonethe-
leucocyte-count was
9900/µ1.
6.
7. Dattner, B Am J. Syph. Gonorrh. vener. Dis. 1949, 33, 571. 8. Yo der, F W.
J Am med. Ass.1975, 232, 270
1. Check, I. J., DeMeester, T., Vardiman, 1317. 2. Snell, N J. C. Thorax (in the press).
J., Hunter, R. L Lancet, 1978,
ii,
