Reprinted from the Journal of Nervous and Mental Disease, August, 1896. 
A Case of Tumor of the Thalamus, with 
Remarks on the Mental Symptoms. 
BY 
WALTER CHANNING M. D, 
Brookline, Mass. REPORT OF A CASE OF TUMOR OF THE 
THALAMUS, WITH REMARKS ON THE 
MENTAL SYMPTOMS.* 
WALTER CHANNING, M.D., 
Brookline, Mass. 
THE patient, an unmarried female, by occupation a 
teacher, and forty-one years of age, was admitted 
to my hospital for mental diseases, November 29, 
i 895- 
Her history before admission was as follows; She was 
of a lively, energetic, nervous disposition, but not of neu- 
rotic heredity, and had been a successful teacher for 
many years. For twenty years she had had each year in 
June attacks of hay fever, followed by asthma. In the 
spring of ’95 she took a variety of remedies of a certain 
“ specialist for hay-fever,” with the apparent result of 
checking the asthma, and improving her general health. 
She has suffered from time to time from “ nervous,” 
or “ sick-headache,” and three years ago, having over- 
worked, she gave up teaching for eighteen months. 
*ln September she took up her teaching in an academy, 
and at the end of the month stated, wrote that she was 
feeling especially well and enjoying her work, but the 
last of October, she wrote to a friend that she had com- 
pleted seven, or eight weeks of the hardest class-work in 
her whole experience, and if she did not have a few days 
rest, she would “ burst,” 
At this time when visiting some friends for a few 
days she was often seen to be more excitable and exhil- 
erated than was natural to her. She made many extrav- 
agant speeches in efforts to be amusing, bought flowers, 
gave away presents, and spent money more freely than 
she could afford, or would ordinarily have done. She 
also talked about engagingin the work of rescuing fallen 
women, in an expansive kind of way. 
She also had periods of depression, when she was ner- 
vous, and seemed exhausted. She complained at these 
times of a peculiar boring headache, back of the right 
* Read at the Twenty-second Annual Meeting of the American 
Neurological Association. , 2 
WALTER CHANNING. 
eye, which had troubled her for about six weeks and was 
different from anything she had ever had. Insomnia 
was another symptom at this time. 
Her friends were impressed by her unusual actions, 
but accounted for them by overwork and the nervous- 
ness resulting from the headache and loss of sleep. 
November 4th she returned to her school, and taught 
as usual for two weeks, when she again felt the need of 
change and went away, for two days only, however, re- 
turning to her teaching again for another week, or up to 
Friday, November 22nd. The next morning she went 
to school, thinking it was Friday, though she was re- 
peatedly told that it was Saturday. She took her place 
at her desk as usual, and was much surprised and con- 
fused when her pupils did not appear. 
This was apparently the first positive indication that 
her friends observed of mental disturbance. Having 
been persuaded to make them a visit, she arrived looking 
entirely unlike herself. Her hat was on the back of her 
head, her hair dishevelled, her shawl dragging half its 
length on the ground. She went to the supper table 
without arranging her hair, or paying any attention to 
her personal appearance ; was in high spirits, very effu- 
sive in what she said, and talked in a loud and unnatural 
voice. She said she had not slept for a week, and com 
plained of her head aching. 
The night following she took quieting medicine, and 
was a little nauseated once or twice. Occasionally she 
spoke of her head aching, but said little about it. 
The following days until she was admitted to the 
hospital (Nov. 29th), she remained in bed, as she was 100 
weak to sit up, and her left leg gave way when she tried 
to stand. The left arm was also noticed to be nearly 
useless. She was very restless in bed,- continually throw- 
ing her right arm over her head, slept very little, and 
took almost no nourishment. Nausea occurred a few 
times, but not to a marked degree. Vision was supposed 
to be normal. 
Mentally she was confused, but much exhilarated, 
and talked very frequently of what she thought should 
be done to alleviate the condition of working girls, and 
rescue fallen women, and she supposed herself possessed 
of large sums of money (the contrary being the fact), 
which could be used for such a purpose. 
On admission to the hospital she -was in a mildly ex- 
alted condition, talking somewhat disconnectedly, and A CASE Ob TUMOR OF THE THALAMUS. 
3 
pleased and satisfied with everything about her. In bed 
she was restless, moving her head from side to side 
throwing her right arm over her head, and rigidly fold 
ingboth arms across her chest, with her hands clenched 
and thumbs between the first and second fingers. The 
pupils appeared normal, and reacted to light, but she 
could not follow the moving finger, The eyes were not 
more carefully examined because of her restless and con 
fused condition. The tongue, which she did not ex- 
tend beyond the lips, was dry with brownish coat in 
the middle, and whitish at the edges. Pulse 104 and 
temperature 98.4°. Physical examination of the chest 
negative. Patella reflexes slightly exaggerated and 
alike on both sides. Planter reflex moderate. Sensation 
was not carefully tested as in the early stages of the dis- 
ease, it was supposed to be acute mania with sensation 
in general perverted, and not possible to correctly esti 
mate. Asked if her head pained her, she said she had 
three kinds of headache, and often she put her hand up 
to her head as if it ached, but the pain was never severe 
and never localized. Nausea occured so seldom that it 
attracted little attention. The left arm and leg could be 
moved very little by the patient. 
Examination of the urine gave the following results; 
Color normal, reaction acid, specific gravity 1022, urea 
normal, uric acid in excess. The sediment which was 
moderate in amount contained a few squamous epithel- 
ial cells and many round small cells, most of which 
were apparently blood corpuscles, frequently arranged 
in clumps. 
Menstruation appeared the day after admission, was 
scant in amount and lasted several days. 
The blood count four and six days after admission 
was: reds, 4,804,000; whites, 12,400. 
The exhaltation of the patient continued for several 
days after entrance. She said she was writing a series 
of articles which would make her reputation 111 this or 
another world, and she advised the doctor to read them. 
Everything pleased her that was done for her, and she 
was very polite in expressing her gratitude. Her state 
of mind was always one of contentment and happiness. 
She had apparent hallucinations .of taste and smell, 
often speaking of the bad smell of the food given her 
and its bad taste. 
A few days later (December) she responded much 
more slowly when addressed, often would make no re- 4 
WALTER CHANN INC. 
sponse to questions, and much, of the time was semi- 
somnolent, or in a deep sleep. 
December 12th, she was lying very quietly inched in 
a semi stupor, she could not be aroused to answer ques- 
tions, but called the nurse by the name of her sister 
“ Mollie,” and could be made to look and listen, and take 
food by persistent effort. The arms were much of the 
time rigidly flexed across the chest, the left more than 
the right. With the right hand she spent much of the 
time picking at the blanket between the knees, so that 
she had literally worn it thread-bare at that point. The 
right eye was closed most of the time, though with an 
effort she could open it, and judging by the way she 
took her food could not see with that eye. 
December 16th, it was noted that for two days the 
patient’s eyes had been kept open more than before, and 
she had apparently noticed people who were in the 
room; she said, “Oh, dear!” and occasionally groaned. 
The contraction of the left arm was less marked. 
December 18th, the breathing was irregular, though 
not of the “ Cheyne-Stokes” character. The expiration 
was longer than inspiration, and at times more forcible. 
The rigidity of the arms had disappeared and there was 
no more picking at the bed clothes. The right as well 
as the left leg she did not move. 
On the 22d of December the patient was quite weak 
and her color bad. The pulse was irregular, changing 
in rate while she was lying perfectly still. One quarter 
of a minute it could beat at the rate of seventy, and the 
next quarter, perhaps, at the rate of one hundred. Dur- 
ing the day it reached one hundred and twenty, and 
every time the position changed it would become imme- 
diately accelerated. The pupils varied in size during 
the day; sometimes the left would be more dilated than 
usual, and then again would be contracted, or the same 
changes might be observed in the right eye. The jaw 
began to drop, and soon was in a condition of almost 
complete relaxation. This interferred considerably with 
breathing. The legs lay straight and motionless, and 
the feet were in quite extreme extension. 
December 25th, it was noted that the pulse and tem- 
perature had been gradually dropping, as will be seen 
by the appended chart. The dropping of the jaw as 
well as of the tongue had become more frequent and 
troublesome, interfering seriously with the breathing, 
so that there would sometimes be intervals of from six A CASE OF TUMOR OF THE THALAMUS. 
to ten seconds between respirations. The following day 
the same difficulty again occurred; the breathing would 
stop when the jaw dropped, not to begin again until it 
was lifted forward. This was done repeatedly with the 
same result, until early on the morning of the 27th, 
when the breathing suddenly ceased not to begin again. 
For the first two days after admission, the urine was 
retained; after that there was always incontinence. 
5 
CLINICAL CHART. 
CLINICAL CHART 
( .... .7. 
MONTH, j 
Dwisr, 
J )at<‘. 
Dole.. 
TEMPERATURE. 
PULSE. 
RESPIRATIONS. 
Published by CODMAN & SHURTLEFF Boston. 
. CODMAN & SHURTLEFK Boston 
There was no discharge from the bowel, the sphinster 
being entirely inactive. 
The autopsy was made by Dr. E. Wyllis Taylor of 
Boston, the head only being examined. His report was 
as follows : “ Skull rather thick, especially in the frontal 
region. Brain tense on palpation. Dura normal. Pia 
normal. No Leptomeningitis. Convolutions dry, flat, 
and somewhat smooth. At the base no evidence of men- 
ingitis. Pons appears somewhat flattened. On raising 
the temporal lobes the crura are found to be broad and 6 
flattened and ribbon-like. On palpation there is a flue 
tuant sensation, which is bilateral. 
WALTER CHANNING. 
On opening the right ventricle there is a boggy, cyst- 
like looking mass extending back an inch behind the 
posterior border of the optic thalamus, and forward to 
the junction of the caudate nucleus with the thalamus, 
the mass apparently involving the latter in its entire 
extent. (See figure) The consistency varies in different 
places; in some the sensation to the fingers is that 
normal tissue, in others that of cyst-like masses, app 
ently multiple. 
The surface of the tumor (see figures) is for the most 
part injected, and gelatinous in appearance. The cor- 
tex is nowhere involved. The ventricles are normal in 
size and there is no increase of ventricular fluid.” 
In the report of the microscopic examination of the 
tumor made by Dr. Taylor sometime later, he states that 
“The growth consists of very numerous and rather 
small cells with round or oval nuclei. The cells are ar- 
ranged without order. In many places the tumor is 
partially and completely necrotic, doubtless in a meas- 
ure, at least, due to post-mortem changes. As was evident 
microscopically, the growth is exceedingly vascular. 
There are numerous new-formed vessels of large size, 
and many of smaller calibre, all filled with blood. Cer- 
tain of the larger vessels contain thrombi, which are 
partially organized. In places there is considerable free 
blood to be seen, probably as a result of hemorrhage in 
the substance of the tumor. The growth is to be classed 
as a vascular glioma, probably of rapid growth.” 
Remarks.—This patient entered the hospital as a case 
of mild acute mania, which would probably develop and 
grow worse. Such was the diagnosis of the experienced 
alienist who had seen her, and recommended her re- 
moval to a hospital Though mention is made in the 
above report of the left arm being nearly useless a few 
days before admission, nothing was said of this at the 
time, and I believe it to be an after-thought in looking 
back with the cause of death in mind, as the history has 
been obtained very recently. 
The fact is undoubted that there was a plain history 
of at first slight exhilaration extending over some weeks, 
gradually increasing, and finally assuming the form of 
maniacal excitement with expansive delusions. The 
patient was put early to bed because of the weakness 
and exhaustion which had resulted from weeks of mental A CASE OF TUMOR OF THE THALAMUS. 
over-activity and sleeplessness, bat in bed there was 
an undue degree of motor restlessness, combined with 
the mental exhilaration, sometimes resulting in slight 
attacks of violence. The headache, which had been an 
early symptom, had almost disappeared; there was 
practically no nausea, and nothing unusual in the eye- 
sight had attracted attention. 
Such was the history up to admission to the hospital. 
During the first week there, or within three weeks of 
death, the mental symptoms wTere still prominent. The 
expansive delusions continued, and hallucinations of 
taste and smell, which made food obnoxious to her, were 
conspicuous. 
As the physical symptoms of the brain lesion devel- 
oped, the manifestation of the mental alienation grew 
gradually less and less, but as long as she had any pow- 
er of expression the same happy, exalted underlying 
mental condition was apparent, a point of considerable 
interest. Though roused with difficulty, when she was 
finally aroused, even up to within twenty-four hours of 
death, she understood, at least, partly what was said to 
her, as she showed by the movements of her eyes, and 
her willingness to try to open her mouth and swallow 
food. 
The mental symptoms produced in this case seem to 
have been quite unlike those of the usual cases of brain 
tumors recorded, in which are found depression, dull- 
ness, irritability, lethargy, stupor, or even pronounced 
dementia. It is a striking fact that up to within five 
weeks of death this patient was still actively pursuing 
her avocation of school-teaching, being at this time in a 
condition of over exhilaration, and having been so for 
weeks. Though she became confused and lost her grasp 
as to the relation of things,there was a tendency to men 
tal over activity, instead of the opposite, and even to the 
end it seemed as if the patient would have responded to 
questions had her speech mechanism been unimpaired. 
The first indication of cerebral disturbance to attract 
attention in this case, was psychical. There was the 
headache to be sure, and the possible ocular lesions, 
which might have been discovered had an ophthalmo- 
logical examination been made, but the physical changes 
were not of a degree to interfere with the patient’s ac- 
tivity, caused little or no inconvenience, and hence re- 
ceived no recognition. 
Several interesting questions arise in such a case, as WALTER CHANNING. 
for instance : Which symptoms probably first presented 
themselves, the mental or physical ? Why should there 
be so much mental disturbance in such a case? Was the 
mental trouble an accident and independent of the 
tumor? If not, how can it be satisfactorily explained? 
What diagnostic value do mental symptoms possess in 
tumor of the brain ? 
The tumor must have grown very rapidly, and it ap- 
pears to be a fact that the physical impairment was in 
inverse ratio to its size. 
The writer thinks the criticism may be fairly made 
that the physical symptoms of probable tumor of the 
brain might have been found at an earlier period had 
they been carefully looked for. They existed, but were 
not discovered. Further, no adequate eye examination 
was made, which certainly was unfortunate. Recogniz- 
ing fully the justice of these strictures, and regretting 
his lack of medical acumen, which did not put him on 
the right scent, it nevertheless is, he believes, true that 
the mental disturbance, which showed itself in this 
case, was unusual, both in kind and degree. Press of raff & CO., 
512, 514 & 516 West 41st Street, 
NEW YORK.