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TREATMENT OF PITUITARY MICROADENOMAS
460 the red
it produced stained the infant’s diapers and removed by laundering. Fortunately, at 9 months the child was no longer colonised, much to the relief of the parents, the laundry, and the scientist who was in charge of the aerosol project.
pigment
was not
Enteric Section, Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
J. J. FARMER, III
Laboratoire de Bacteriologie Université de Bordeaux II, Bordeaux, France
P. A. D. GRIMONT F. GRIMONT
BETTY R. DAVIS
TREATMENT OF PITUITARY MICROADENOMAS
SIR The paper by Dr Shearman and Dr Fraser (June 4, p. 1195) indicates that the treatment of pituitary microadenomas is controversial, but, in their clinic, it is cobalt irradiation followed by bromocriptine. The rationale is that the tumour is less likely to enlarge in subsequent pregnancies. Others maintain, however, that radiation therapy has been uniformly unsuccessful in endocrine-active pituitary tumours and is, in fact, contraindicated.1-3 Many neurologists and neurosurgeons feel that the treatment of choice for these tumours is surgical removal by the transsphenoidal route by microsurgical techniques and not followed by irradiation.4 Comparative surgical treatment of microadenomas carries a mortality from as low as niP to 3 - 2% .6 Radiation therapy in these patients may, in fact, be damaging because: (1) the incidence of tumour recurrence, especially with growth-hormone-secreting microadenoma even with postoperative irradiation, has been reported to be as high as 29%7,8 and the speed of recurrence of primary irradiated tumours is 1-2 years;9 (2) the endocrine-active adenomas are characteristically more radio-resistant than the endocrine-inactive variety;10.11 (3) normal pituitary tissue surrounding the tumour may be destroyed;12 (4) delayed response of hormone reduction may take as long as 1-2 years to reach its maximum;13.14 (5) a more invasive or even malignant potential may be induced in a previously benign tumour; (6) radionecrosis of the brain may follow therapeutic irradiation of the pituitary’s and malignant tumours may be induced in the tissue surrounding the irradiated zone.16 The approach to macroadenomas (i.e., tumours extending outside the pituitary fossa) is surgical, often followed by radiation therapy. This, however, is not so in microadenomas. The balance between medical and surgical treatment of endocrine-active microadenoma may become clearer when a prospective randomised trial has compared the effects of bromocriptine and transsphenoidal hypopysectomy on hormone reduction. Department of Neurology, Martinez V.A. Hospital, Martinez, California 94553, U.S.A.
RICHARD RUBENSTEIN
1. Landholt, A. M. Acta neurochir. 1973, suppl. 22. 2. Pearsons, O. H., Brodkey, J. S., et al. in Clinics Neurosurgery (edited by R. H. Wilkins), vol 21. Baltimore, 1974. 3. Jenkins, J. H. in Pituitary Tumors. New York, 1973. 4. Hardy, J. J. Neurosurg. 1971, 34, 582. 5. Ray, B. S., Patterson, R. H. ibid. p. 726. 6. Stern, W. E., Batzdorf, U. ibid. 1970, 33, 564. 7. Landholt, A. M. Acta neurochir. 1973, suppl. 22. 8. Ortiz Dezarate, J. C., Scarlotti, A., et al. J. Neurosurg. 1970, 33, 345. 9. Pearson, O. H., Brodkey, J. S., et al. in Clinics in Neurosurgery (edited by R. H. Wilkins); vol. 21. Baltimore, 1974. 10. Jenkins, J. H. Pituitary Tumors. New York, 1973. 11. Wirth, F. P., Schwartz, H. G., et al. in Clinics in Neurosurgery (edited by R. H. Wilkins); vol. 21. Baltimore, 1974. 12. Jenkins, J. H. Pituitary Tumors. New York, 1973. 13. Ortiz Dezarate, J. C., Scarlatti, A., et al. J. Neurosurg. 1970, 33, 345. 14. Pearson, O. H., Brodkey, J. S. in Clinics in Neurosurgery (edited by R. H. Wilkins); vol. 21. Baltimore, 1974. 15. Crompton, M. R., Layton, D. D. Brain, 1961, 84, 85. 16. Norwood, C. W., Kelly, D. L., et al. Surg. Neurol. 1974, 2, 161.
SUICIDE PREVENTION AND THE SAMARITANS
SIR,-The study by my colleagues Barraclough, Jennings, and Moss (July 30, p. 237) is faultless as far as it goes. It conclusively demonstrates that the effect of the Samaritans is not so overwhelming as to outweigh all other influences, positive and negative, on the suicide-rate. It is expecting rather a lot that it should, since as Fox has correctly observed, "... no medical treatment of any illness, anywhere and at any time, has been shown to lower suicide rates."’ It is doubtful whether the hypothesis that "Samaritan services prevent suicide" can be reliably tested by an epidemiological approach. It has been possible, using epidemiological methods, to demonstrate that heavy smoking predisposes to lung cancer and that taking the contraceptive pill predisposes to venous thrombosis. Whereas both heavy smoking and taking the contraceptive pill can be reasonably precisely defined, there is no comparable means by which so nebulous a concept as the Samaritan services can be defined. Do all Samaritans do the same thing? Does any one volunteer do the same thing all the time? Are all branches equally effective and, within each branch, are all volunteers
equally competent? How one views the Samaritans depends upon how one conceives of the aetiology of suicide; a study by Barraclough and others2 in 1974 was preceded by the quotation "... to a degree more than is generally supposed, it originates in derangement of the brain and abdominal viscera" (Forbes Winslow, 1840). In their study of 100 suicides, Barraclough et al. concluded that 85% of those studied had been suffering from depression or alcoholism. It would not be too surprising to learn that 85% of a series of people who eventually took their own lives were seriously depressed or had a drink problem. It is however, unreasonable to assume that this was due to "derangement of the brain and abdominal viscera". It is to be hoped that the data on the social circumstances of this series of cases will eventually be published. If, as seems most unlikely, it is ultimately demonstrated that the majority of those committing suicide suffer from endogenous depression, the role of the Samaritans will be limited to that of identifying such cases and bringing them to the attention of the medical services. However, there does already exist ample evidence that isolation from human contact is an important precursor to suicidal behaviour. In his influential work Suicide in London, Sainsbury3 quotes Francis Bacon as saying, "But little do men perceive what solitude is and how far it extendeth. For a crowd is not company, and faces are but a gallery of pictures, and talk but a tinkling cymbal, where there is no love." I am well acquainted with the work of the Samaritans and am confident that their methods are based upon well-established psychodynamic principles. They have, over the years, developed new strategies for coping with a wide range of contingencies. Though inevitably they vary in quality, they have among their numbers some who are most impressive. There must surely be on record at least one of them who, beyond any reasonable doubt, has prevented one client from committing suicide. Were it possible to identify this person, the correct scientific procedure would be to answer the question, how did he do it? If what he did could be described in terms such that other volunteers could emulate him, and if their subsequent failures and successes could be compared with their previous record, we would be making good progress towards proving or disproving the case for the Samaritans. Rather than contenting ourselves with the bird’s eye view of the epidemiologist, we would do well to examine at close quarters what Samaritans actually do. M.R.C. Clinical
Psychiatry Unit, Graylingwell Hospital, Chichester, Sussex PO19 4PQ 1. Fox, R. R. Soc. Hlth. J. 1975, 95, 9. 2. Barraclough, B., Bunch, J., Nelson, B.,
JOHN BIRTCHNELL Sainsbury,
125, 355. 3. Sainsbury, P. Suicide in London. London, 1955.
P. Br. J.
Psychiat. 1974,
it produced stained the infant’s diapers and removed by laundering. Fortunately, at 9 months the child was no longer colonised, much to the relief of the parents, the laundry, and the scientist who was in charge of the aerosol project.
pigment
was not
Enteric Section, Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
J. J. FARMER, III
Laboratoire de Bacteriologie Université de Bordeaux II, Bordeaux, France
P. A. D. GRIMONT F. GRIMONT
BETTY R. DAVIS
TREATMENT OF PITUITARY MICROADENOMAS
SIR The paper by Dr Shearman and Dr Fraser (June 4, p. 1195) indicates that the treatment of pituitary microadenomas is controversial, but, in their clinic, it is cobalt irradiation followed by bromocriptine. The rationale is that the tumour is less likely to enlarge in subsequent pregnancies. Others maintain, however, that radiation therapy has been uniformly unsuccessful in endocrine-active pituitary tumours and is, in fact, contraindicated.1-3 Many neurologists and neurosurgeons feel that the treatment of choice for these tumours is surgical removal by the transsphenoidal route by microsurgical techniques and not followed by irradiation.4 Comparative surgical treatment of microadenomas carries a mortality from as low as niP to 3 - 2% .6 Radiation therapy in these patients may, in fact, be damaging because: (1) the incidence of tumour recurrence, especially with growth-hormone-secreting microadenoma even with postoperative irradiation, has been reported to be as high as 29%7,8 and the speed of recurrence of primary irradiated tumours is 1-2 years;9 (2) the endocrine-active adenomas are characteristically more radio-resistant than the endocrine-inactive variety;10.11 (3) normal pituitary tissue surrounding the tumour may be destroyed;12 (4) delayed response of hormone reduction may take as long as 1-2 years to reach its maximum;13.14 (5) a more invasive or even malignant potential may be induced in a previously benign tumour; (6) radionecrosis of the brain may follow therapeutic irradiation of the pituitary’s and malignant tumours may be induced in the tissue surrounding the irradiated zone.16 The approach to macroadenomas (i.e., tumours extending outside the pituitary fossa) is surgical, often followed by radiation therapy. This, however, is not so in microadenomas. The balance between medical and surgical treatment of endocrine-active microadenoma may become clearer when a prospective randomised trial has compared the effects of bromocriptine and transsphenoidal hypopysectomy on hormone reduction. Department of Neurology, Martinez V.A. Hospital, Martinez, California 94553, U.S.A.
RICHARD RUBENSTEIN
1. Landholt, A. M. Acta neurochir. 1973, suppl. 22. 2. Pearsons, O. H., Brodkey, J. S., et al. in Clinics Neurosurgery (edited by R. H. Wilkins), vol 21. Baltimore, 1974. 3. Jenkins, J. H. in Pituitary Tumors. New York, 1973. 4. Hardy, J. J. Neurosurg. 1971, 34, 582. 5. Ray, B. S., Patterson, R. H. ibid. p. 726. 6. Stern, W. E., Batzdorf, U. ibid. 1970, 33, 564. 7. Landholt, A. M. Acta neurochir. 1973, suppl. 22. 8. Ortiz Dezarate, J. C., Scarlotti, A., et al. J. Neurosurg. 1970, 33, 345. 9. Pearson, O. H., Brodkey, J. S., et al. in Clinics in Neurosurgery (edited by R. H. Wilkins); vol. 21. Baltimore, 1974. 10. Jenkins, J. H. Pituitary Tumors. New York, 1973. 11. Wirth, F. P., Schwartz, H. G., et al. in Clinics in Neurosurgery (edited by R. H. Wilkins); vol. 21. Baltimore, 1974. 12. Jenkins, J. H. Pituitary Tumors. New York, 1973. 13. Ortiz Dezarate, J. C., Scarlatti, A., et al. J. Neurosurg. 1970, 33, 345. 14. Pearson, O. H., Brodkey, J. S. in Clinics in Neurosurgery (edited by R. H. Wilkins); vol. 21. Baltimore, 1974. 15. Crompton, M. R., Layton, D. D. Brain, 1961, 84, 85. 16. Norwood, C. W., Kelly, D. L., et al. Surg. Neurol. 1974, 2, 161.
SUICIDE PREVENTION AND THE SAMARITANS
SIR,-The study by my colleagues Barraclough, Jennings, and Moss (July 30, p. 237) is faultless as far as it goes. It conclusively demonstrates that the effect of the Samaritans is not so overwhelming as to outweigh all other influences, positive and negative, on the suicide-rate. It is expecting rather a lot that it should, since as Fox has correctly observed, "... no medical treatment of any illness, anywhere and at any time, has been shown to lower suicide rates."’ It is doubtful whether the hypothesis that "Samaritan services prevent suicide" can be reliably tested by an epidemiological approach. It has been possible, using epidemiological methods, to demonstrate that heavy smoking predisposes to lung cancer and that taking the contraceptive pill predisposes to venous thrombosis. Whereas both heavy smoking and taking the contraceptive pill can be reasonably precisely defined, there is no comparable means by which so nebulous a concept as the Samaritan services can be defined. Do all Samaritans do the same thing? Does any one volunteer do the same thing all the time? Are all branches equally effective and, within each branch, are all volunteers
equally competent? How one views the Samaritans depends upon how one conceives of the aetiology of suicide; a study by Barraclough and others2 in 1974 was preceded by the quotation "... to a degree more than is generally supposed, it originates in derangement of the brain and abdominal viscera" (Forbes Winslow, 1840). In their study of 100 suicides, Barraclough et al. concluded that 85% of those studied had been suffering from depression or alcoholism. It would not be too surprising to learn that 85% of a series of people who eventually took their own lives were seriously depressed or had a drink problem. It is however, unreasonable to assume that this was due to "derangement of the brain and abdominal viscera". It is to be hoped that the data on the social circumstances of this series of cases will eventually be published. If, as seems most unlikely, it is ultimately demonstrated that the majority of those committing suicide suffer from endogenous depression, the role of the Samaritans will be limited to that of identifying such cases and bringing them to the attention of the medical services. However, there does already exist ample evidence that isolation from human contact is an important precursor to suicidal behaviour. In his influential work Suicide in London, Sainsbury3 quotes Francis Bacon as saying, "But little do men perceive what solitude is and how far it extendeth. For a crowd is not company, and faces are but a gallery of pictures, and talk but a tinkling cymbal, where there is no love." I am well acquainted with the work of the Samaritans and am confident that their methods are based upon well-established psychodynamic principles. They have, over the years, developed new strategies for coping with a wide range of contingencies. Though inevitably they vary in quality, they have among their numbers some who are most impressive. There must surely be on record at least one of them who, beyond any reasonable doubt, has prevented one client from committing suicide. Were it possible to identify this person, the correct scientific procedure would be to answer the question, how did he do it? If what he did could be described in terms such that other volunteers could emulate him, and if their subsequent failures and successes could be compared with their previous record, we would be making good progress towards proving or disproving the case for the Samaritans. Rather than contenting ourselves with the bird’s eye view of the epidemiologist, we would do well to examine at close quarters what Samaritans actually do. M.R.C. Clinical
Psychiatry Unit, Graylingwell Hospital, Chichester, Sussex PO19 4PQ 1. Fox, R. R. Soc. Hlth. J. 1975, 95, 9. 2. Barraclough, B., Bunch, J., Nelson, B.,
JOHN BIRTCHNELL Sainsbury,
125, 355. 3. Sainsbury, P. Suicide in London. London, 1955.
P. Br. J.
Psychiat. 1974,