458 THE PINEAL ORGAN 



On Examination. — When seen on ioth March, 1932, he appeared to be 

 somewhat dull and listless. His pupils were dilated and reacted sluggishly 

 to light. There was bilateral papilloedema, there being five diopters of swelling 

 in the right eye and four in the left. Except for slight bilateral deafness, the 

 other cranial nerves appeared normal. There was a slight lateral nystagmus to 

 the right. Rombergism was marked, and the patient was quite ataxic. The 

 deep reflexes were normal, and there was no impairment to sensation. 



Lumbar puncture revealed a clear colourless cerebrospinal fluid under 

 pressure ; there were no abnormal constituents. The day following the lumbar 

 puncture the patient was incontinent three times, and there was a well-marked 

 lateral nystagmus. Also for the first time there was limitation of upward gaze 

 and a definite weakness of the right sixth cranial nerve. Both lower limbs 

 became spastic two days later. Radiographs of the skull revealed a midline 

 calcified pineal shadow. This case was looked upon as a typical pinealoma, and 

 removal was advised. 



Operation. — On 21st March, under avertin and local anaesthesia, a large 



right occipito-parietal osteoplastic flap 

 was turned down, the lateral ventricle 

 tapped, and the dura mater opened. 

 Bleeding was reduced to a minimum by 

 the application of silver clips and the 

 use of the diathermy knife. The falx 

 was exposed and the inferior longitudinal 

 sinus severed between the clips. The 

 inferior border of the falx was divided 

 to the extent of half an inch. The 

 splenium of the corpus callosum was 

 split with a curved diathermy knife and 

 a large pineal tumour exposed. Large 

 FlG „ 308.— Case 5. Actual Size vdns could be seen surroun di ng the 

 of Pineal Tumour after Removal. .... . , ° 



tumour. An incision into the tumour 



was made with the diathermy knife, and a definite capsule appeared to cover 

 the tumour. With a curved dissector the tumour was shelled out of its capsule. 

 The bleeding, which was not great, was controlled by the use of diathermy. 

 The retracted cerebral hemisphere was replaced and covered by dura mater. 

 A small piece of corrugated rubber tubing was inserted into the region of the 

 tumour and brought out through the upper part of the wound. The bone flap 

 itself was removed, as it was thought that as the capsule had been left behind it 

 would be advisable to give a course of X-ray treatment later. The patient stood 

 the operation very well. 



The following day the right ventricle was tapped and 30 c.c. of blood-stained 

 cerebrospinal fluid were withdrawn. The drainage tube was removed after 

 forty-eight hours. The fifth day following operation lumbar puncture was 

 performed — the fluid was under slight pressure and blood-stained. From this 

 day recovery was uneventful, and the patient left hospital a month after the 

 operation. 



The tumour was about the size of a plum (Fig. 308) and was quite hard in 

 consistency. Histologically the tumour was a typical pinealoma. 



