CLINICAL CASES 



455 



until three months ago, when he first complained of occipital headache, which 

 had persisted ever since. Soon after the headaches began he became drowsy 

 and had attacks of " vacancy," during which he would sit or stand motionless 

 for as long as half an hour. He slept well and ate well. Apart from headaches 

 he did not feel ill. He had noticed dimness of vision on occasions. He had 

 had several attacks of giddiness, in one of which he fell downstairs. He had 

 only vomited once prior to admission. He had grown fatter during the last 

 three months. 



On Examination. — The patient was found to be somewhat slow in his 

 movements. He weighed 12 st. i lb. A 

 considerable amount of subcutaneous fat was 

 noticeable (Fig. 306). 



Cranial nerves. — The pupils were equal, 

 but reaction to light and accommodation was 

 slow. The visual fields were normal to rough 

 tests. Bilateral papilloedema was present ; five 

 diopters in the right and four in the left. There 

 was no nystagmus, and the ocular muscles 

 were normal. Speech was slow, and pon- 

 derous, and the whole attitude was slow and 

 heavy ; he never smiled, and the facial 

 expression seemed lost. 



Sensation to cotton-wool and pin-pricks 

 was quite normal. The cold tube felt hot on 

 the right side of the trunk from the acromion 

 process to the midline nearly down to the 

 umbilicus. All limb reflexes were normal. 

 The gait was slow, but with no obvious defect. 

 Co-ordination, finger-nose test, was poor. 

 Rombergism was slight. The heart, lungs, 

 etc., were normal, and the blood-pressure 

 100 85. An X-ray examination made on 16th 

 October, 1931, showed that the sella turcica 

 was enlarged and erodefl, and the pineal body 

 calcified. Cushing's thermic reaction was 

 negative. The blood-sugar curve was normal. 

 The visual fields were constricted. The 

 cerebrospinal fluid showed : total protein 0-03 

 per cent. ; globulin, no excess. The Wasser- 

 mann reaction was negative. 



First Operation. — Air ventriculography was carried out on 31st October, 

 1931, under local anaesthesia. A small trephine was made in the right parietal 

 bone and a cannula passed into the ventricle ; 200 c.c. of ventricular fluid were 

 withdrawn and 140 c.c. of air introduced (Fig. 307). 



The ventricular fluid was clear and colourless, cells 1 per c.mm. There 

 were no red corpuscles. Total protein was 0-015 P er cent. There was no 

 excess of globulin, and the Wasserman reaction was negative. The patient 

 was very drowsy after the ventriculography. 



Fig. 306. — Case 4. Photo- 

 graph of Patient suffering 

 from a Pineal Tumour. 



The vacant expression in 

 this patient is well marked. 



