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the red pigment it produced stained the infant’s diapers andwas not removed by laundering. Fortunately, at 9 monthsthe child was no longer colonised, much to the relief of the par-ents, the laundry, and the scientist who was in charge of theaerosol project.Enteric Section,Center for Disease Control,Atlanta, Georgia 30333, U.S.A.

J. J. FARMER, IIIBETTY R. DAVIS

Laboratoire de BacteriologieUniversité de Bordeaux II,

Bordeaux, FranceP. A. D. GRIMONTF. GRIMONT

TREATMENT OF PITUITARY MICROADENOMAS

SIR The paper by Dr Shearman and Dr Fraser (June 4,p. 1195) indicates that the treatment of pituitary micro-adenomas is controversial, but, in their clinic, it is cobalt irra-diation followed by bromocriptine. The rationale is that thetumour is less likely to enlarge in subsequent pregnancies.Others maintain, however, that radiation therapy has been uni-formly unsuccessful in endocrine-active pituitary tumours andis, in fact, contraindicated.1-3 Many neurologists and neurosur-geons feel that the treatment of choice for these tumours is sur-

gical removal by the transsphenoidal route by microsurgicaltechniques and not followed by irradiation.4 Comparative sur-gical treatment of microadenomas carries a mortality from aslow as niP to 3 - 2% .6

Radiation therapy in these patients may, in fact, be damag-ing because: (1) the incidence of tumour recurrence, especiallywith growth-hormone-secreting microadenoma even with post-operative irradiation, has been reported to be as high as 29%7,8and the speed of recurrence of primary irradiated tumours is1-2 years;9 (2) the endocrine-active adenomas are characteris-tically more radio-resistant than the endocrine-inactive

variety;10.11 (3) normal pituitary tissue surrounding thetumour may be destroyed;12 (4) delayed response of hormonereduction may take as long as 1-2 years to reach its maxi-mum;13.14 (5) a more invasive or even malignant potential maybe induced in a previously benign tumour; (6) radionecrosis ofthe brain may follow therapeutic irradiation of the pituitary’sand malignant tumours may be induced in the tissue surround-ing the irradiated zone.16The approach to macroadenomas (i.e., tumours extending

outside the pituitary fossa) is surgical, often followed by radia-tion 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 bro-mocriptine and transsphenoidal hypopysectomy on hormonereduction.

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 con-clusively demonstrates that the effect of the Samaritans is notso overwhelming as to outweigh all other influences, positiveand negative, on the suicide-rate. It is expecting rather a lotthat it should, since as Fox has correctly observed, "... nomedical treatment of any illness, anywhere and at any time,has been shown to lower suicide rates."’ It is doubtful whetherthe hypothesis that "Samaritan services prevent suicide" canbe reliably tested by an epidemiological approach. It has beenpossible, using epidemiological methods, to demonstrate thatheavy smoking predisposes to lung cancer and that taking thecontraceptive pill predisposes to venous thrombosis. Whereasboth heavy smoking and taking the contraceptive pill can bereasonably precisely defined, there is no comparable means bywhich so nebulous a concept as the Samaritan services can bedefined. Do all Samaritans do the same thing? Does any onevolunteer do the same thing all the time? Are all branchesequally effective and, within each branch, are all volunteersequally competent?How one views the Samaritans depends upon how one con-

ceives of the aetiology of suicide; a study by Barraclough andothers2 in 1974 was preceded by the quotation "... to a degreemore than is generally supposed, it originates in derangementof the brain and abdominal viscera" (Forbes Winslow, 1840).In their study of 100 suicides, Barraclough et al. concludedthat 85% of those studied had been suffering from depressionor alcoholism. It would not be too surprising to learn that 85%of a series of people who eventually took their own lives wereseriously depressed or had a drink problem. It is however, un-reasonable to assume that this was due to "derangement of thebrain and abdominal viscera". It is to be hoped that the dataon the social circumstances of this series of cases will even-

tually be published. If, as seems most unlikely, it is ultimatelydemonstrated that the majority of those committing suicidesuffer from endogenous depression, the role of the Samaritanswill be limited to that of identifying such cases and bringingthem to the attention of the medical services. However, theredoes already exist ample evidence that isolation from humancontact is an important precursor to suicidal behaviour. In hisinfluential work Suicide in London, Sainsbury3 quotes FrancisBacon as saying, "But little do men perceive what solitude isand how far it extendeth. For a crowd is not company, andfaces are but a gallery of pictures, and talk but a tinkling cym-bal, where there is no love."

I am well acquainted with the work of the Samaritans andam confident that their methods are based upon well-estab-lished psychodynamic principles. They have, over the years,developed new strategies for coping with a wide range of con-tingencies. Though inevitably they vary in quality, they haveamong their numbers some who are most impressive. Theremust surely be on record at least one of them who, beyond anyreasonable doubt, has prevented one client from committingsuicide. Were it possible to identify this person, the correctscientific procedure would be to answer the question, how didhe do it? If what he did could be described in terms such thatother volunteers could emulate him, and if their subsequentfailures and successes could be compared with their previousrecord, we would be making good progress towards proving ordisproving the case for the Samaritans. Rather than content-ing ourselves with the bird’s eye view of the epidemiologist, wewould do well to examine at close quarters what Samaritansactually do.

M.R.C. Clinical Psychiatry Unit,Graylingwell Hospital,Chichester, Sussex PO19 4PQ JOHN BIRTCHNELL

1. Fox, R. R. Soc. Hlth. J. 1975, 95, 9.2. Barraclough, B., Bunch, J., Nelson, B., Sainsbury, P. Br. J. Psychiat. 1974,

125, 355.3. Sainsbury, P. Suicide in London. London, 1955.