50 GILBERT HOERAX 



Manifestations of Pineal Disease 



The manifestations of pineal disease, then, may be grouped under three 

 headings, as suggested by Marburg in 1913: (1) General pressure symp- 

 toms, (2) neighborhood signs, (3) constitutional symptoms. It is just 

 possible that a fourth group should be added under which would come 

 manifestations of multiglandular disturbance with the pineal playing the 

 chief role, but for the present this last group is somewhat too vague to be 

 included. 



1. General Pressure Symptoms. Little need be said as to this cate- 

 gory since it includes all the usual and well recognized evidences of in- 

 tracranial pressure characteristic of any brain tumor. Headache, of 

 course, is very prominent and very severe because frequently due to in- 

 ternal hydrocephalus. The proximity of the pineal to the aqueduct of 

 Sylvius causes any enlargement or tumor to obstruct the exit of cere- 

 brospinal fluid with consequent backing up into the third and lateral ven- 

 tricles. The headache is sometimes localized in the occipital or suboccipltal 

 region and may be associated with tenderness in this area. Vomiting, 

 dizziness, bradycardia and generalized convulsions are other expressions 

 of increased tension which occur in many cases. Choked disks are present 

 in almost every instance, varying in degree from a slight edema with 

 obscuration of the nasal borders, to a full-blown process giving an elevation 

 of 5-6 diopters. This is usually an early finding and one which is rapidly 

 progressive owing to the quickly developing hydrocephalus. The end 

 stage of course will be a secondary optic) atrophy, possibly with only 

 a small residual elevation, and this may be the picture seen when the 

 patient first comes under observation. 



2. Neighborhood Symptoms. This term was introduced by Gushing 

 in classifying the symptoms of tumors involving the hypophysis. It refers 

 to the special evidences of pressure on structures which lie in the region of 

 a growth. As applied to the pineal, the principal structures concerned 

 arc (1) the corpora quadrigemina, (2) certain cerebral nerves, especially 

 the trochlear and oculomotor, (3) the aqueduct of Sylvius, (4) the cere- 

 bellum and (5) the cerebral peduncles, 



a. Involvement of Corpora Quadrigemina. Perhaps the most signifi- 

 cant of all the neighborhood symptomatology of pineal lesions is due to 

 pressure upon the quadrigeminate bodies. They are usually the first of 

 the nearby structures to suffer because of their very close proximity. The 

 manifestations of such pressure are to be seen in pupillary changes. These 

 are remarkable, not only for their diversity, but also for their extreme 

 variability. In the same patient it may be noted at one time that the right 

 pupil is larger than the left, while a few hour's later, or perhaps the follow- 

 ing day, the left pupil will be distinctly wider than its fellow. Permanent 



