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STUDY of the syndromes associated with pituitary adenoma began with the description of acromegaly by Marie (1886), and many reports of the symptomatology of the tumour have since appeared (Cushing, 1912;Cairns, 1935;Henderson, 1939;Jefferson, 1940;Bakay, 1950;Younghusband, Horrax, Hurxthal, Hare, and Poppen, 1952;Nurnberger and Korey, 1953; Mogensen, 1957;Ray and Patterson, 1962;Poppen, 1963). Recently a series of 260 patients with pituitary adenoma selected for combined surgery and radiotherapy because of failing vision has been studied. Both the effect of treatment on vision (Elkington and McKissock, 1967) and the subsequent endocrine function (Elkington, Buckell, Monamy, and Jenkins, 1967) have been described elsewhere. The present communication reports the pre-operative symptomatology in these patients and suggests how early diagnosis of pituitary adenoma, necessary if the best results are to be obtained from treatment, may be made on clinical grounds. Material and MethodsThe case records of 260 patients were examined. They had been operated on by one surgeon at either the National Hospital for Nervous Diseases, Queen Square, or Atkinson Morley's Hospital, Wimbledon, between 1938 and. The nature of the tumour had been confirmed by histological examination in 246; in fourteen the clinical and operative findings alone were accepted as diagnostic. Failing vision was the sole indication for operation in almost every instance, and detailed records of both the visual acuity and the visual fields were available. The former was expressed by Snellen or Jaeger reading type, and the latter was shown in charts of visual field obtained by perimetry. Quantitation of visual function using the method described by Colby and Kearns (1962) was not attempted, a simple descriptive classification being used for the visual fields. Evidence of endocrine function was not consistently recorded, and investigation of endocrine function was infrequent. FindingsOf the total of 260 patients, 145 were males and 115 females. The youngest patient was aged 14 years and the oldest 72 years at the time of operation. The greatest incidence of symptoms necessitating treatment occurred in the fifth decade in both sexes. Details of age, sex, and tumour type are given in Tables I and II (opposite).

Lactulose is a synthetic disaccharide comprising galactose and fructose in combination as 1,4-beta-galactosido-fructose. It is prepared from lactose and supplied for clinical use as a flavoured syrup* containing approximately 50 % lactulose, together with smaller amounts of galactose and of unchanged lactose (about 7 g of each per 100 ml).The intestinal mucosa possesses no disaccharidase capable of splitting lactulose into its component monosaccharides1, and only insignificant amounts are absorbed unchanged2. On reaching the colon, however, this sugar is metabolized by bacterial enzymes into carbon dioxide and low molecular weight acids (chiefly lactic and acetic)2 3. Thus in sufficient dosage lactulose lowers the faecal pH, and produces an osmotic and fermentative diarrhoea analogous to that observed in lactase-deficient subjects following the oral administration of lactose4 5.Clinical interest in lactulose first arose when Petuelyfi induced an increase in the faecal population of Lactobacillus bifidus by the administration of this sugar to adults and to bottle-fed infants. He postulated that this effect might prevent enteritis during broad-spectrum antibiotic therapy, and showed that lactulose could also be employed to treat chronic constipation4. Lactulose has been studied as a laxative in a double-blind controlled trial and has been found effective7. However, at present it appears to possess no significant advantages as an aperient over cheaper alternatives, and has therefore not achieved general acceptance for this purpose8.A novel and ingenious therapeutic concept was introduced by Bircher and his colleagues9, namely, the use of lactulose to control chronic portal-systemic encephalopathy. The rationale of this form of treatment was credited by

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