CLINICAL CASES 453 



flap was turned down over the right parieto-occipital region. The lateral 

 ventricle was tapped, but owing to the poor condition of the patient no further 

 exploration was carried out. The patient never really rallied, and died three 

 days later. 



At autopsy the pathologist unfortunately cut into the brain, and exposed a 

 large but somewhat fragmentary vascular pineal tumour. Microscopically 

 there was a definite mosaic arrangement of the cells, with one or two giant cells 

 surrounded by a definite layer of small cells. It was unfortunate that the 

 brain was not hardened before it was sectioned. 



Case 3. — Hilda H., aged 25, was admitted to hospital on 30th October, 

 1930, complaining of headaches, sickness, and occasional attacks of double 

 vision. The headaches were not continuous, but occurred spasmodically, 

 the patient being quite free from them for several weeks at a time. The head- 

 aches first commenced about two years previously. A month before admission 

 to hospital she became unsteady in her gait and could not see to mend her 

 clothes. She was seen as an out-patient, and was found to have bilateral papil- 

 ledema, and admission was recommended. 



On Examination. — The patient was found to be well-nourished and quite 

 cheerful and very keen to get well in order that she could go back to her work. 



There was bilateral papilledema, four diopters of swelling in the right eye, 

 and three diopters in the left. The pupils reacted sluggishly to light and 

 accommodation. The visual fields were full. There was weakness of both 

 Vlth cranial nerves. There was limitation of upward gaze, which increased 

 while under observation in hospital. An X-ray examination showed some 

 increase in the meningeal grooves in the skull, which was significant of increased 

 intracranial pressure. There was no sign of calcification of the pineal gland. 

 There was some ataxia on walking, but this on the whole was slight. There 

 was a fine lateral nystagmus to the right, and slight deafness in the right ear. 

 Rombergism was present. The deep reflexes were slightly increased on the 

 right side of the body. There were no other neurological symptoms. The 

 diagnosis of tumour of the pineal gland was made, and a supratentorial approach 

 was advised. 



Operation. — On 21st November, 1930, under intratracheal gas and oxygen 

 anaesthesia combined with local infiltration, a large occipito-parietal osteoplastic 

 flap was turned down on the right side. The dura mater was very tense, and 

 to relieve the intracranial pressure the right lateral ventricle was tapped. The 

 dura mater was incised and the cerebral hemisphere was carefully retracted ; 

 several cerebral veins required to be secured by silver clips, as they entered the 

 superior longitudinal sinus. On exposing the falx cerebri, a little more retrac- 

 tion brought the corpus callosum into view. Two silver clips were placed on 

 the inferior longitudinal sinus and the falx was divided between them. The 

 corpus callosum was then divided longitudinally, and a large tumour of the 

 pineal gland was exposed. An attempt to remove this with the diathermy knife 

 failed owing to excessive bleeding from the great vein of Galen and its tribu- 

 taries. When the bleeding was more or less under control the condition of the 

 patient was so very poor that the osteoplastic flap was replaced and the scalp 

 wound closed. A blood transfusion of 400 c.c. of citrated blood was given 

 immediately the patient returned to the ward. The condition of the patient 



