AN
Inaugural Dissertation
ON THE
HYDROCEPHALUS INTERNUS,
OR
INTERNAL DROPSY OF THE BRAIN.
Submitted to the Examination of
The Rev. John Ewing, S. T. P. Provost,
THE
TRUSTEES AND MEDICAL FACULTY
OF THE
UNIVERSITY of PENNSYLVANIA.
On the 17th May 1796.
For the Degree of Doctor of Medicine.
—Si ubi vera videtur,
Dede manus, et si falsa est, accingere contra. Lucret.
BY ROBERT CHISOLM,
of CHARLESTON, S. CAROLINA.
Member of the Philadelphia Medical Society.
PHILADELPHIA:
PRINTED BY ORMROD & CONRAD, FRANKLIN'S
HEAD, 41, CHESNUT-STREET.
1796. 



TO
Alexander Chisolm, Esq;
OF CHARLESTON, S.CAROLINA.
Honored Sir,
WITH a heart overflowing with effu-
sions of gratitude, permit me to lay before you
the first fruits of my medical studies. To
you I not only owe my life, but what is more
dear to me, my education. Accept this small
tribute, as a token of affection for those nu-
merous obligations which can never be obli-
terated from the mind of your dutiful and
affectionate Son,
ROBERT CHISOLM.
TO
Alexander Baron, M.D.
OF CHARLESTON, S. CAROLINA.
Respected Sir,
PERMIT me likewise to dedicate this
Inaugural Dissertation to you, as a mark of the
esteem, which I entertain for your character
as a Scholar, a Physician, and a Man.
I have the Honor to be,
With the greatest Respect,
Your Humble Servant,
ROBERT CHISOLM. 



PREFACE.
'TIS hard, says Sir Roger L'Estrange, that
a man cannot publish a book, but he must give
the world a reason for it; when there's not one
book of twenty that will bear a reason, not
one man of an hundred that is able to give one,
nor one reason of a thousand, that was the true
reason for doing it.
This observation of our ingenious author,
will apply better, perhaps, to almost any per-
formance, than to an Inaugural Dissertation.—
For let a man puzzle his brain ever so long, he
can find but one reason for publishing a Medical
Thesis, and that is necessity which obliges him
to comply with the laws of the University, from
which he receives his diploma. As this is the
case, I have only to claim the indulgence of the
reader, for attempting to write upon a disease,
which is but little known even to the most able
physicians. 



An Inaugural Dissertation.
OF all the diseases to which the human body
is subject, no one is more alarming in its
symptoms, or more fatal in its termination, than
the HYDROCEPHALUS INTERNUS.
For the sake of method, I shall in the first place
begin with the History of this disease—Secondly,
speak of the Diagnosis—Thirdly, treat of the ex-
plication of some of the symptoms—Fourthly,
say a few words on the Prognosis—Fifthly, men-
tion the causes which bring on the complaint—
and Lastly, proceed to the method of cure.
OF THE HISTORY OF THE DISEASE.
Dr. Whytt thinks the Hydrocephalus is seve-
ral months in forming; he has divided the
symptoms of the disease into three stages:—The
first stage, he supposes, begins five or six weeks
before the fatal termination of the disorder.—
The second, he says, takes place about three
weeks, and the third a week or eight days before
the death of the patient.
Fothergill cannot agree to this division; on
the contrary, he has seen children who enjoyed
an excellent state of health, seized with this dis-
B 

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temper, and carried off in about fourteen days.
Doctor Quin has very properly declared, that the
opinions of those gentlemen are both proper,
certain circumstances being taken into conside-
ration. Whytt having observed the disease in
young children, it is easy to conceive, that the
progress would be more gradual, and the symp-
toms not be so strongly marked, as in those of a
more advanced age and stronger constitution, at
which time they fell under the notice of Fother-
gill.
Children of all ages are subject to this com-
plaint; it generally affects those between two
and nine years of age. Dr. Rush tells us, that he
has seen it in a child of six weeks old. It some-
times affects adults of a good habit of body*.
In the commencement of the disease, the pa-
tient is peevish, inactive, drowsy, and feverish,
falls away in flesh, has an acute, sometimes an
obtuse pain in the head, which extends to the
region of the eye-brows, and frequently affects
the nape of the neck and shoulders; sometimes
it is confined to one side of the head, and fre-
quently the head-ach alternates with an affec-
tion of the stomach. In this state of the disease,
the patient has an aversion to the light, grinds
his teeth, and picks his nose—On a sudden, being
terrified by dreams, he starts up in his sleep. In
addition to these symptoms, a strabismus takes
place, the pupil of the eye is dilated, the pain of
the head is so great that the screaming of the
miserable patient fills the minds of the spectators
* Vide Lond. Med. Obs. & Inq. Vol. 6, p. 58—Vol. 4th,
p. 86—Medical Communications, Vol. 1st. p. 404—Medical
Comment. Vol. 9, p. 240—Quin p. 26—Fothergill, Octavo
Edition, Vol. 2, p. 74.

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with the greatest horror. A delirium frequent-
ly occurs, and that of the most violent kind, says
Quin, particularly if the patient has arrived at
the age of puberty. The heat about the head,
the part immediately affected, is excessive. The
fever increases towards evening, when the coun-
tenance is greatly flushed. In breathing, there
is a considerable pause after every expiration.
The tongue is clean and white, sometimes it ac-
quires an apthous redness.
The eyes sometimes grow red before death, the
urine and foeces come away involuntarily, and
the poor sufferer is often carried out of the world
in convulsions,
The bowels are generally costive, stools are
procured with difficulty, and when obtained are
very offensive. A diarrhæa sometimes takes place.
Physicians greatly disagree in regard to the
state of the pulse. Whytt says, in the beginning
of the disease it is quick; Fothergill and Wat-
son, that it is no quicker than in health. Some
declare that it is slow, while Dr. Rush tells us he
has met with a case, in which no uncommon
slowness was ever percieved. Quin has seen a
locked jaw take place in a child a day before its
death, and a hemiplegia in another. Dr. Rush has
observed it to terminate in this latter way
in three persons. The same author, upon the
authority of Dr. Carson, has recorded a case, in
which a Hydrophobia was produced.
This account of the disease can only be consi-
dered as a mere outline; we want many obser-
vations, in addition to those of Whytt, Fother-
gill, Quin, Patterson and Rush, in order to form
an accurate history of the Hydrocephalus. The
symptoms enumerated in the preceding pages 

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occasionally occur, though none of them ac-
company the disorder, in an invariable manner.
In consequence of this, Quin has emphatically
called the Dropsy of the brain, "a truly protei-
form disease."
Like the bilious remitting yellow fever, it
assumes a variety of shapes. Dr. Rush, to whom
the medical world is greatly indebted, has told
us, he has not found the dilated and insensible
pupil, the delirium or strabismus to attend at all
times. The same physician has seen a case in
which the appetite was entirely unimpaired,
from the first to the last stage of the disease, and
met with another in which an uncommon acute-
ness in hearing took place.
Upon opening the head after death, the wa-
ter* is sometimes found between the cranium
and dura mater, or between the dura and pia ma-
ter, but most frequently in the ventricles of the
brain. The quantity of fluid contained in these
cavities, is sometimes so great, as almost to ex-
ceed belief.—Whytt† has found eight ounces,
Bonetus five pounds‡, § Monroe three pounds,
Lieutaud relates a case where he found thirteen
pounds, and Gustavus Hume opened the cranium
and found five quarts of limpid water. This
last was a most extraordinary case of Hydroce-
phalus. There was not the smallest portion of
brain, or least trace of the membranes, except
* Morgagni, Sauvages, Patterson, Haygarth, and others,
supposed the effused matter was serum, but this is not the case,
for it will not coagulate by heat, an experiment which has been
tried by Dr. Woodhouse.
† Whytt p. 735.
‡ Bonetus Sepulch. Anat. Lib. Sect. 2d. Ob. 45, v. 1.
§ Monroe on the Dropsy, p. 154. 

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opposite the orbits of the eyes, and near the
meatus auditorius, where something like me-
dulla remained.
OF THE DIAGNOSIS.
As it is of some consequence to distinguish this
disease, from any other resembling it, I shall say
a few words on the Diagnosis. Whytt has in-
formed us, it may be distinguished from worms,
by attending to what he has called the following
characteristic marks. In the Hydrocephalus, he
says, the feverish heat is not abated when the
pulse becomes slow and irregular, whereas, when
it beats in this manner, in children who have
worms, no fever attends. Dr. Whytt has been
very unfortunate in this particular, for so seldom
do worms produce a real disease, that it is doubt-
ed by many, whether there is such a thing as a ge-
nuine worm fever:—The disorder which is cal-
led a worm fever, is now known to be a simple
remittent, which produces death, by terminat-
ing in a dropsy of the brain.* A slow irregular
pulse, often attends in persons of a delicate make,
when afflicted with violent nervous head-ach,
but it is attended with a cool skin, whereas in
the dropsy of the brain, the feverish heat is ex-
cessive. By attending then to this one symptom,
if we may give credit to the ingenious author of
the essay on the vital and involuntary motions,
we may easily distinguish it from a nervous af-
fection of the head. In short, it appears from
the few histories of the Hydrocephalus, that we
can depend upon no symptom which can be con-
* Vide some valuable observations, on the infantile remitting
fever, by Dr. Butter. 

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sidered as characteristic.—In consequence of this,
we should like faithful centinels, be continually
upon our guard, and always suspect the approach
of the enemy.—As two thirds of the diseases
which inflict the human race, terminate in effu-
sion in some part of the body, I would whenever
there was a severe head-ach, accompanied with
an affection of the stomach, slow or irregular pulse,
always suspect a dropsy of the brain.
EXPLICATION OF SOME OF THE SYMPTOMS.
We account for the loss of appetite and vomit-
ing, from the diseased state of the brain, between
which and the stomach, there is a very great
sympathy.
The aversion to light, proceeds from an in-
creased sensibility of the Retina.
The slow and irregular pulse, is not caused as
Whytt supposed, by the water pressing upon the
brain but by the vessels of this organ being dis-
tented with blood, which impairs the sensibility
of the cardiac nerves. Now, as the action of the
heart arises from the stimulus of the blood acting
upon these nerves, it is evident, that the pulse
must be affected, according to the degree of sen-
sibility with which these organs are endowed.
The dilatation of the pupils of the eyes, is
owing to the impaired sensibility of the optic
nerves. The paralytic eyelids, strabismus, and
blindness are owing to an insensibility of the se-
veral nerves which supply these different parts.
Whytt has accounted for the difficulty of res-
piration in the following manner; respiration is
a function depending partly upon the will; he has
observed, that a considerable pause generally in-
tervenes after expiration, before a new inspira- 

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tion succeeds. As the sensibility of the brain,
which is the seat of the will, is then greatly im-
paired by the accumulation of water in the ven-
tricles, the uneasy sensation, proceeding from
the difficulty the blood finds in passing through
the lungs will be less attended to than usual.
Hence, after every expiration, a long pause in-
tervenes before inspiration succeeds, because the
will is not exerted to put the muscles of respira-
tion into action, until roused by the sense of suf-
focation, which is caused by the difficulty the
blood finds in passing into the lungs, from the
right ventricle of the heart.-We cannot give
our assent to this explication, for the difficulty of
breathing takes place, when the patient is in a
sound sleep, and as the ingenious author of the
Botanic Garden, has elegantly and justly observed,
"The will presides not in the bowers of sleep."
Perhaps a better method of accounting
for this symptom, would be from an accumula-
tion of blood, in the vessels of the lungs.
OF THE PROGNOSIS.
As in other diseases, we are governed in our
Prognosis, by the parts affected, habit of body,
violence and continuance of the symptoms, so
likewise we judge of the issue of Hydrocephalus.
If it arises from a suppression of any customary
evacuation, or if it is the offspring of another
disease, there is greater certainty of a cure be-
ing affected, than when it arises from a schirrous
gland, or from a violent injury done to the head.
In the Prognosis, it is of the greatest consequence
to attend to the habit of body, for we certainly
have a greater hope of curing a person of a good 

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constitution, than one who labours under the
scrophula, the consumption or the rickets.
Evacuations of water, either by the bowels
or the kidneys, are a good sign, and Celsus is
certainly right when he says, "Si plus humoris
excernitur quam assumitur, tunc demum secundæ
valetudinis spes est*."
Perhaps there is no disease in which the pulse
varies, more than it does in this: we can there-
fore seldom rely upon it in our Prognostic.
When the dilatation of the pupils of the eyes
increases, a strabismus or delirium takes place,
subsultus tendinum, or convulsions happen, the dis-
ease is generally fatal, although cases are record-
ed, in which the patients have recovered, even
after these most alarming symptoms had taken
place.
CAUSES WHICH BRING ON THE COMPLAINT.
The causes which induce the Hydrocephalus, are,
First. An original laxity of the brain.
Secondly. Falls and blows on the head, which
produce inflammation in the brain and afterwards
an effusion of water.
Thirdly. Dr. Whytt says, a schirrous tumor
of the Pituitary gland, or of any part in the neigh-
bourhood of the brain, may occasion this dis-
order.
Fourthly, It may be caused by a suppression or
diminished secretion of water.
Fifthly, It is produced by a variety of diseases,
as intermitting, remitting, continual and erup-
* Vide Celsus, p. 53, edit, Lugduni, 1760.

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tive fevers, by the rheumatism, consumption,
dysentery, melancholy, scrophula, and perhaps
by every other complaint, in which the head is
particularly affected for any length of time*.
From the facts enumerated in the preceeding
pages, it is evident there are two species of the
Hydrocephalus. One we may consider as arising
altogether from an inflammation of the brain,
and the other as proceeding entirely from an
original laxity of this organ. The following
circumstances seem to confirm the first opinion.
First. The disease affects the robust and
healthy children, as well as the weak and deli-
cate.
Secondly. The pulse in the beginning of the
disease is full and tense.
Thirdly. Delirium, difficulty of breathing,
aversion to light, are all symptoms of inflamma-
tory diseases.
Fourthly. It affects children more than adults,
for they are more subject to inflammatory com-
plaints, as excitability abounds in infancy.
Fifthly. Upon opening the cranium after
death, the blood vessels are found turgid with
blood, and there is every appearance of inflam-
mation of the brain. Dr. Quin has related a
case directly in point. The head of a patient
was opened, who died, with every symptom of
a Hpdrocephalus, and no water was found in the
ventricles; the vessels were all turgid with blood,
and no anatomist could have injected them more
nicely. This case cannot, I acknowledge, be
* Vide the observ. of Rush, Lieutaud and Quin.
C 

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properly called a dropsy of the brain, although
every symptom of this complaint was present.
Phrenicula, an appellation which Dr. Rush has
lately given to the Hydrocephalus, and which at
a future time will perhaps be generally adopted,
would have been more proper. It should like-
wise be remembered, that a physician is govern-
ed by the symptoms and not by the name of a
disease. Prescribing for the mere name of a
disorder, has made as much havoc among man-
kind, as the yellow fever or the plague.
Sixthly. Fothergill and Warren have told us,
it is fatal in a shorter time, in vigorous and heal-
thy constitutions, than in the delicate and
weakly.
Seventhly. Is it probable, that a small quan-
tity of limpid water, free from any chemical
stimulus, should cause those alarming symptoms,
which we find in the Hydrocephalus, and is it
not a well authenticated fact, that a large quan-
tity of this fluid, may be accumulated in the
cranium without any injury to the health,
and the patient enjoy the full exercise of his in-
tellectual faculties? A remarkable case of this
kind, is recorded by Dr. Michaelis, in the me-
dical communications*.
THE METHOD OF CURE.
This must be different, as in most other dis-
eases, in the beginning, and latter stage of the
complaint.
* Vide Med. Commun. vol. I. p, 404. 

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We shall briefly consider the remedies which
have been recommended. These are
I. Venesection.
II. Cathartics.
III. Mercury.
IV. Blisters.
V. The application of cold to the head.
VI. Setons and Issues.
VII. Rest.
VIII. Pediluvium.
IX. Opium.
X. Sternutatories.
XI. Compression of the carotids.
XII. Digitalis.
XIII. An operation.
OF BLEEDING.
This is the first remedy to be used, and the
one chiefly to be depended upon. It acts power-
fully in producing absorption. Frequently in o-
ther diseases, when the eyes are suffused with
blood, a sudden absorption will take place imme-
diately after the use of the lancet. For proofs
that venesection has frequently cured dropsies in
other parts of the body, I refer to a variety of
facts, recorded by Monroe, Hewson, Rush, and
other authorities.
Dr. Quin tells us he would prefer local eva-
cuations, to general bleeding, by means of leech- 

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es, cupping, or scarifying, where the patient is
very young. A considerable discharge says he,
may be procured from the temples, and where
the operation can be performed with safety, the
jugular vein or perhaps the temporal artery may
be opened with advantage. This practice ac-
cording to Patterson, is eligible even in an ad-
vanced stage of the disorder.
OF CATHARTICS.
A second remedy is cathartics. I have con-
stantly observed, says Dr. Rush, all the patients,
whose cases have been related, to be relieved by
plentiful and repeated evacuations from the
bowells.
Quin likewise bears testimony, to the pro-
priety of this practice.
The only case, which Dr. Whytt ever suc-
cessfully treated, was by repeated purges of
Rhubarb, Jalap and Calomel.*
Dr. M'Bride performed some cures by cathar-
tics, and Percival prefers them even to the use
of the lancet.—Quin advises us to use Calomel,
and cautions us against adding any thing to it,
which is likely to produce a vomiting. Dr.
Rush combines Jalap with it, but I would prefer
the Calomel alone, because should a puking take
place, the slow of blood would be encreased in
the vessels of the head. It is necessary to give
the Calomel in large doses, as the bowels are
sometimes so torpid, that threeble the quantity
* Vide Whytt page 745. 

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of what we generally prescribe in other diseases
is frequently necessary. It has been administer-
ed to children in the extent of twenty grains at
a time.*
OF MERCURY.
Thirdly. This has been highly recommended.
Dr. Rush tells us, he succeeded in but two cases,
out of all those in which he gave it for many
years. Dr. Quin declares it cannot be depended
upon. Patterson coincides with those gentle-
men, and after accurately examining the subject
says, that even the liberal use of it cannot be re-
lied upon, as a sourse of relief.†
Out of ten cases which came under the care of
Dr. Warren, in which the mercurial treatment
was pursued, the event proved fatal.‡ 
On the contrary, Drs. Percival and Dobson
were so successful, as to lead many to believe,
that Mercury was a specific in this disorder.§
It is likewise certain, that a variety of cases are
recorded, which have been completely cured,
by the use of this celebrated medicine.‖ 
* Vide Sir Theod. Mayerne, quoted by Patterson, page 44.
† Vide Patterson page 47.
‡ Ibid Page 57.
§ Vide London Medical observ. and inq. p. 148. vol. 6. Man-
chester Memoirs, vol. 3. page 213.
‖ Vide a paper by Dr, Dobson, in the Lond. Medical obs
and inq. vol. 6. page 48. One by Dr. Hunter, page 52. vol. 6.
One by Dr. Campbell, in medical comment. vol. 9. page 240.
One by Dr. Eason, vol. 8. page 325. and several by Dr. Lett-
some, in the memoirs of the Lond. Med. Soc. vol. 1. page 273. 

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Dr. Percival effected a recovery, in a child
under one year of age, who received by succes-
sive frictions, four ounces, six drachms, and two
scruples of strong mercurial ointment, in the
space of about two months. At the same time,
thirty-six grains of Calomel were administered at
proper intervals.¶
OF BLISTERS.
Fourthly. All physicians speak highly of the
application of blisters*. They produce their
good effects, by keeping up a drain, and taking
off the plethora from the vessels of the brain.
We are directed by some to cover the whole
head with an epispastic, and to keep it continu-
ally running by means of the unguentum vesica-
torium. Dr. Dawson recommends blisters to be
applied behind the ears.
THE APPLICATION OF COLD TO THE HEAD.
Fifthly. The clay cap, ice, or cold water
should be constantly applied to the head, which
should be previously shaved.
Dr. Withering used this application, in the
following powerful manner; he poured six pints
of cold water upon the head, and repeated it
every four hours. In this case cold acts, by car-
rying off the heat, from the part affected.
¶ Vide the memoirs of the Manchester Society, vol. 3. page
213.
* Whytt, p. 145. Fothergill Oct. Edit. vol. 2, p. 73, and
74. Patterson, p. 31. Rush medical inqui. vol. 1. p. 225. 

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OF SETONS AND ISSUES.
Sixthly. As Setons and Issues in the neck or
neighbouring parts have been of service in the
epilepsy and apoplexy, Dr. Quin reasoning
from analogy, supposes they may be tried as pre-
ventative of the Hydrocephalus, especially if
it arises from an hereditary predisposition.-
Patterson supposes, that in a lingering or chro-
nic case, there may be room for their applica-
tion, and that they may be introduced as pro-
phylactics, with strong expectations of advan-
tage*.
A perpetual issue, says Monroe, may be kept
running at the bregma, or at the lower part of
the occiput†.
OF REST.
Seventhly. The patient should be kept as quiet
as possible, in a dark room, free from the stimu-
lus of light.
PEDILUVIUM.
Eightly. Pediluvium has been tried in one or
two instances.
Quin mentions this remedy as an antiphlogistic,
adapted to the first stage of the disease‡, while
* Vide Patterson, p. 302.
† Monroe ou the dropsy, p. 168. 
‡ Quin, p. 78.

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Patterson supposes, it ought not to be omitted at
any time §. Dr. Hunter has related a case,
which the vapour bath effectually cured ‖.
OPIUM.
Ninthly. Can Opium be administered with ad-
vantage? Patterson thinks favourably of this
remedy. It has been used by Percival, who
says, that opiates are necessary in large and re-
peated doses, when the pains are very acute.
Dr. Dawson also tried this medicine, in the form
of Theriaca Andromachi.
As the Hydrocephalus bears some relation to
an inflammation of the brain, and as according
to the most celebrated writers* opium is impro-
per in the Phrenitis, I would administer it with
the greatest caution.
STERNUTATORIES.
Tenthly. Are Sternutatories ever proper? I
should suppose the shock given to the head in
the act of sneezing, could in no manner lessen
the accumulation of blood, in the vessels of the
brain, or produce an absorption of water from
the ventricles. Besides, as the least motion of
the head, must be detrimental to the patient,
I should not be disposed to make the experi-
ment.
§ Patterson, p. 51.
‖ Medical Comment. vol. 8. p. 107.
* Vide Sydenham, Pringle and Cullen. 

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COMPRESSION OF THE CAROTIDS.
11thly. This has been proposed by Patterson,
in order to obviate a morbid accession of blood
to the vessels of the head. We have no objec-
tion to a trial of this practice, Fiat Experi-
mentum.
DIGITALIS.
12thly. Quin was not fortunate in his trial
of the digitalis. Withering gave it to some
of his patients, and Patterson is altogether silent
on the subject.
AN OPERATION.
13thly. Can a puncture be made in the brain
with safety? When the disease arises from in-
flammation, the operation promises nothing.
In chronic cases it has been tried, but the pa-
tients have Uniformly died.—Le Catt and Re-
met* evacuated the water of several Hydroce-
phalic patients, at different times, but death fol-
lowed in every instance. Dr. Monroe† advises
us, if ever the operation is attempted, to make the
opening with a lancet, and at a part where
* Vide Le Catt Philos. Trans. for 1751, and Med. Commen,
Vol. 6, p. 422.
† Monroe on the Dropsy, p. 161. 
F 

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there is no danger of wounding any large artery
or venal sinus of the head.
If ever the Hydrocephalus proceeds from an
original laxity of the brain, we must place our
chief dependance upon that class of medicines,
which are used in diseases proceeding from de-
bility.
ERRATUM.
In page 8th, fourth Line from bottom,—
for water, read urine.