SYNDROMES INVOLVING THE PINEAL GLAND 51 



bilateral pupillary dilatation has frequently been noted, together with a 

 loss of reaction to light, even in the absence of any marked degree of optic 

 nerve atrophy. Conjugate and skew deviations including the Majendie- 

 Hertwig syndrome have been mentioned by Bailey and JellifTe. 



b. Involvement of Cerebral Nerves. The third, fourth and sixth are 

 the nerves most frequently disturbed, and practically every combination 

 of eye muscle paralysis has been noted. With regard to the oculomotor, 

 the superior recti seem to suffer most, while in many instances poor co- 

 ordination of the ocular movements is observed. There is also sometimes 

 ptosis of one or both upper lids. 



Trochlear paralysis is of especial significance in tumors of the pineal, 

 because this nerve is implicated more often than any other of the cranial 

 series, and is frequently the first to be affected. The reason for this is 

 easily seen from the anatomical position of the fourth nerve, curving out as 

 it does just below the inferior colliculi over the dorsal surface of the mid- 

 brain. Isolated trochlear paralysis has been described by Gowers and 

 Reinhold, while Nieclen and Remak (quoted by Duret) have each re- 

 corded a case of bilateral involvement. Neumann states that the trochlear 

 was involved in each of the five cases which he analyzed. Duret goes so 

 far as to say that paralysis of the superior oblique in tumors of the pineal 

 actually begins the "scene pathologique." 



The abducens is also involved at times along with the other eye 

 muscle nerves, but sometimes alone as recorded by Nieden. 



Facial paralysis has been described by a number of writers, including 

 Neumann, Reinhold and Feilchenfeld. Deafness either partial or com- 

 plete described by Falkson, Daly, Gowers and v. Frankl-Hochwart is no 

 doubt due to pressure upon the auditory way stations in the median geni- 

 culates. Neumann also observed difficulty in swallowing, speaking and 

 articulation. In a case recorded by Schultz, the patient could not swallow 

 except when holding the head strongly forward. 



c. Occlusion of the Aqueduct of Sylvius. It is almost inevitable for 

 epiphyseal growths to press upon the aqueduct of Sylvius, causing a 

 damming back of cerebrospinal fluid and a consequent internal hydro- 

 cephalus (Fig. 1). This condition is noted in practically all the necropsy 

 reports, and it is because of this fact, with its secondary effect upon the 

 pituitary, that one must regard all statements relating to pineal adiposity 

 with considerable hesitation. Indeed, in a recent unreported case of veri- 

 fied pineal tumor at the Peter Bent Brigham Hospital, radioscopy showed 

 marked pressure changes in the sella, with destruction of the dorsum, and 

 this finding is of course common in many cases of internal hydrocephalus. 

 Marburg's theory, therefore, of a specific adiposity, attributable to an in- 

 creased pineal secretion, will require much further evidence before its 

 acceptance is justified. Polyuria, as related to pineal tumors, is also un- 

 doubtedly a secondary pituitary manifestation. 



