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Solutions to Chapter 8

1. Determine the output of the following code when the input is (a) –1, (b) 0, and (c) 12XY

try {
number = Integer.parseInt(
JOptionPane.showInputDialog(null, "input"));
if (number != 0) {
throw new Exception("Not Zero");
}
} catch (NumberFormatException e) {
System.out.println("Cannot convert to int");
} catch (Exception e) {
System.out.println("Error: " + e.getMessage());

a) Error: Not Zero

b) no output
c) Cannot convert to int

2. Determine the output of the following code when the input is (a) –1, (b) 0, and (c) 12XY.
This is the same question as Exercise 1, but the code here has the finally clause.

try {
number = Integer.parseInt(
JOptionPane.showInputDialog(null, "input"));
if (number != 0) {
throw new Exception("Not Zero");
}
} catch (NumberFormatException e) {
System.out.println("Cannot convert to int");
} catch (Exception e) {
System.out.println("Error: " + e.getMessage());
} finally {
System.out.println("Finally Clause Executed");
}

a) Error: Not Zero

Finally Clause Executed
b) Finally Clause Executed
c) Cannot convert to int
Finally Clause Executed

3. Why is the following code not a good use of the assertion?

public void compute(int size) {

assert size > 0;
//computation code comes here
 }

We should throw an exception because the argument is invalid instead of using an assertion.
Remember: use assertions to detect internal errors and use exceptions to notify the client
programmers of the misuse of our class.

4. Modify the following code by adding the assert statement. The value of gender is either
MALE or FEMALE if the program is running correctly.

switch (gender) {
case MALE: totalFee = tuition + parkingFee;
break;
case FEMALE: totalFee = tuition + roomAndBoard;
break;
}

We can add a control flow invariant as follows:

switch (gender) {
case MALE: totalFee = tuition + parkingFee;
break;
case FEMALE: totalFee = tuition + roomAndBoard;
break;
default: assert false:
"Value of gender " +
"is invalid. Value = " +
gender;
}

5. Modify the following method by adding the assert statement. Assume the variable factor is
a data member of the class.

public double compute(double value) {

return (value * value) / factor;
}

We can add a precondition assertion as follows:

public double compute(double value) {

assert factor != 0 :
"Serious Error – factor == 0, which will lead "
"to a division by zero";
return (value * value) / factor;
}

6. Modify the getInput method of the InputHandler class from Section 8.7 so that the
method will throw an exception when an empty string is entered for the name, room, or
password. Define a new exception class EmptyInputException.
 public void getInput( ) {
throws new EmptyInputException
name = JOptionPane.showInputDialog(null, "Enter Name:");
if (name.trim().equals(""))
throw new EmptyInputException("Name should not be empty");
room = JOptionPane.showInputDialog(null, "Enter Room No.:");
if (room.trim().equals(""))
throw new EmptyInputException("Room should not be empty");
pwd = JOptionPane.showInputDialog(null, "Enter Password:");
if (pwd.trim().equals(""))
throw new EmptyInputException("Password should not be
empty");
}

class EmptyInputException extends Exception {

private static final String DEFAULT_MESSAGE = "Empty input
string";

public EmptyInputException (String msg) {

super(msg);
}
}

7. The user module of the keyless entry system in Section 8.7 does not include any logic to
terminate the program. Modify the program so it will terminate when the values Admin,
X123, and $maTrix%TwO$ are entered for name, room, and password, respectively.

This only requires changing the validate method in Ch8EntranceMonitor, and possibly
adding some new constants.
See Ch8EntranceMonitor.java

Development Exercises
8. In the sample development, we developed the user module of the keyless entry system. For
this exercise, implement the administrative module that allows the system administrator to
add and delete Resident objects and modify information on existing Resident objects. The
module will also allow the user to open a list from a file and save the list to a file. Is it
proper to implement the administrative module by using one class? Wouldn’t it be a better
design if we used multiple classes with each class doing a single well-defined task?

The solution here splits the problem into two classes, one to handle functionality and one to
handle the interface.
See files AdminHandler.java and Ch8EntranceAdmin.java

9. Write an application that maintains the membership lists of five social clubs in a dormitory.
The five social clubs are the Computer Science Club, Biology Club, Billiard Club, No Sleep
Club, and Wine Tasting Club. Use the Dorm class to manage the membership lists.
Members of the social clubs are Resident objects of the dorm. Use a separate file to store
the membership list for each club. Your program should be able to include a menu item for
each social club. When a club is selected, open a ClubFrame frame that will allow the user
to add, delete, or modify members of the club. The program can have up to five ClubFrame
frames opened at the same time. Make sure you do not open multiple instances of
ClubFrame for the same club.

See files ClubFrame.java, ClubKeeper.java, Dorm.java, DormAdmin.java, and

Resident.java
Exploring the Variety of Random
Documents with Different Content
 1. Intermitting, remitting, and continual fevers. Of the effects of
these fevers in inducing this disease, many cases are recorded by
Lieutaud[47].
My former pupil, Dr. Woodhouse, has furnished me with a
dissection, in which the disease was evidently the effect of the
remitting fever. That state of continual fever which has been
distinguished by the name of typhus, is often the remote cause of
this disease. The languor and weakness in all the muscles of
voluntary motion, the head-ach, the inclination to rest and sleep,
and the disposition to be disturbed, or terrified by dreams, which are
said to be the precursors of water in the brain, I believe are
frequently symptoms of a typhus fever which terminates in an
inflammation, or effusion of water in the brain. The history which is
given of the typhus state of fever in children by Dr. Butter[48], seems
to favour this opinion.
2. The rheumatism. Of this I have known two instances. Dr.
Lettsom has recorded a case from the same cause[49]. The pains in
the limbs, which are supposed to be the effect, I suspect are
frequently the cause of the disease.
3. The pulmonary consumption. Of the connection of this disease
with an internal dropsy of the brain, Dr. Percival has furnished us
with the following communication[50]: “Mr. C——'s daughter, aged
nine years, after labouring under the phthisis pulmonalis four
months, was affected with unusual pains in her head. These rapidly
increased, so as to occasion frequent screamings. The cough, which
had before been extremely violent, and was attended with stitches in
the breast, now abated, and in a few days ceased almost entirely.
The pupils of the eyes became dilated, a strabismus ensued, and in
about a week death put an end to her agonies. Whether this
affection of the head arose from the effusion of water or of blood, is
uncertain, but its influence on the state of the lungs is worthy of
notice.” Dr. Quin likewise mentions a case from Dr. Cullen's private
practice, in which an internal dropsy of the brain followed a
pulmonary consumption. Lieutaud mentions three cases of the same
kind[51], and two, in which it succeeded a catarrh[52].
4. Eruptive fevers. Dr. Odier informs us[53], that he had seen four
cases in which it had followed the small-pox, measles, and
scarlatina. Dr. Lettsom mentions a case in which it followed the
small-pox[54], and I have seen one in which it was obviously the
effects of debility induced upon the system by the measles.
5. Worms. Notwithstanding the discharge of worms gives no relief
in this disease, yet there is good reason to believe, that it has, in
some instances, been produced by them. The morbid action
continues in the brain, as in other cases of disease, after the cause
which induced it, has ceased to act upon the body.
6. From the dissections of Lieutaud, Quin, and others, it appears
further, that the internal dropsy of the brain has been observed to
succeed each of the following diseases, viz. the colic, palsy,
melancholy, dysentery, dentition, insolation, and scrophula, also the
sudden healing of old sores. I have seen two cases of it from the last
cause, and one in which it was produced by the action of the vernal
sun alone upon the system.
From the facts which have been enumerated, and from dissections
to be mentioned hereafter, it appears, that the disease in its first
stage is the effect of causes which produce a less degree of that
morbid action in the brain which constitutes phrenitis, and that its
second stage is the effect of a less degree of that effusion, which
produces serous apoplexy in adults. The former partakes of the
nature of the chronic inflammation of Dr. Cullen, and of the asthenic
inflammation of Dr. Brown. I have taken the liberty to call it
phrenicula, from its being a diminutive species or state of phrenitis.
It bears the same relation to phrenitis, when it arises from indirect
causes, which pneumonicula does to pneumony; and it is produced
nearly in the same manner as the pulmonary consumption, by
debilitating causes which act primarily on the whole system. The
peculiar size and texture of the brain seem to invite the inflammation
and effusions which follow debility, to that organ in childhood, just
as the peculiar structure and situation of the lungs invite the same
morbid phænomena to them, after the body has acquired its growth,
in youth and middle life. In the latter stage which has been
mentioned, the internal dropsy of the brain partakes of some of the
properties of apoplexy. It differs from it in being the effect of a slow,
instead of a sudden effusion of water or blood, and in being the
effect of causes which are of an acute instead of a chronic nature. In
persons advanced beyond middle life, who are affected by this
disease, it approaches to the nature of the common apoplexy, by a
speedy termination in life or death. Dr. Cullen has called it simply by
the name of “apoplexia hydrocephalica.” I have preferred for its last
stage the term of chronic apoplexy, for I believe with Dr. Quin, that
it has no connection with a hydropic diathesis of the whole system. I
am forced to adopt this opinion, from my having rarely seen it
accompanied by dropsical effusions in other parts of the body, nor a
general dropsy accompanied by an internal dropsy of the brain. No
more occurs in this disease than takes place when hydrothorax
follows an inflammation of the lungs, or when serous effusions
follow an inflammation of the joints. I do not suppose that both
inflammation and effusion always attend in this disease; on the
contrary, dissections have shown some cases of inflammation, with
little or no effusion, and some of effusion without inflammation.
Perhaps this variety may have been produced by the different stages
of the disease in which death and the inspection of the brain took
place. Neither do I suppose, that the two stages which have been
mentioned, always succeed each other in the common order of
inflammation and effusion. In every case where the full tense, slow
and intermitting pulse occurs, I believe there is inflammation; and as
this state of the pulse occurs in most cases in the beginning of the
disease, I suppose the inflammation, in most cases, to precede the
effusion of water. I have met with only one case in which the slow
and tense pulse was absent; and out of six dissections of patients
whom I have lost by this disease, the brains of four of them
exhibited marks of inflammation.
 Mr. Davis discovered signs of inflammation, after death from this
disease, to be universal. In eighteen or twenty dissections, he tells
us, he found the pia mater always distended with blood[55]. Where
signs of inflammation have not occurred, the blood-vessels had
probably relieved themselves by the effusion of serum, or the morbid
action of the blood-vessels had exceeded that grade of excitement,
in which only inflammation can take place. I have seen one case of
death from this disease, in which there was not more than a tea-
spoonful of water in the ventricles of the brain. Dr. Quin mentions a
similar case. Here death was induced by simple excess of
excitement. The water which is found in the ventricles of the brain
refuses to coagulate by heat, and is always pale in those diseases, in
which the serum of the blood, in every other part of the body, is of a
yellow colour.
In addition to these facts, in support of the internal dropsy of the
brain being the effect of inflammation, I shall mention one more,
communicated to me in a letter, dated July 17th, 1795, by my former
pupil, Dr. Coxe, while he was prosecuting his studies in London. “It
so happened (says my ingenious correspondent), that at the time of
my receiving your letter, Dr. Clark was at the hospital. I read to him
that part which relates to your success in the treatment of
hydrocephalus internus. He was much pleased with it, and
mentioned to me a fact which strongly corroborates your idea of its
being a primary inflammation of the brain. This fact was, that upon
opening, not long since, the head of a child that had died of this
disease, he found between three and four ounces of water in the
ventricles of the brain; also an inflammatory crust on the optic
nerves, as thick as he had ever observed it on the intestines in a
state of inflammation. The child lost its sight before it died. The
crust accounted in a satisfactory manner for its blindness. Perhaps
something similar may always be noticed in the dissections of such
as die of this disease, in whom the eyes are much affected.”
Having adopted the theory of this disease, which I have delivered,
I resolved upon such a change in my practice as should accord with
it. The first remedy indicated by it was
I. Blood-letting. I shall briefly mention the effects of this remedy in
a few of the first cases in which I prescribed it.

CASE I.
On the 15th of November, 1790, I was called to visit the daughter
of William Webb, aged four years, who was indisposed with a cough,
a pain in her bowels, a coma, great sensibility of her eyes to light,
costiveness, and a suppression of urine, a slow and irregular, but
tense pulse, dilated pupils, but no head-ach. I found, upon inquiry,
that she had received a hurt on her head by a fall, about seven
weeks before I saw her. From this information, as well as from her
symptoms, I had no doubt of the disease being the internal dropsy
of the brain. I advised the loss of five ounces of blood, which gave
her some relief. The blood was sizy. The next day she took a dose of
jalap and calomel, which operated twelve times. On the 18th she
lost four ounces more of blood, which was more sizy than that
drawn on the 15th. From this time she mended rapidly. Her coma
left her on the 20th, and her appetite returned; on the 21st she
made a large quantity of turbid dark coloured urine. On the 22d her
pulse became again a little tense, for which she took a gentle puke.
On the 23d she had a natural stool. On the 24th her pupils appeared
to be contracted to their natural size, and on the 30th I had the
pleasure of seeing her seated at a tea-table in good health. Her
pulse notwithstanding, was a little more active and tense than
natural.

CASE II.
On the 24th of the same month, I was called to visit the son of
John Cypher, in South-street, aged four years, who had been hurt
about a month before, by a wound on his forehead with a brick-bat,
the mark of which still appeared. He had been ill for near two weeks
with coma, head-ach, colic, vomiting, and frequent startings in his
sleep. His evacuations by stool and urine were suppressed; he had
discharged three worms, and had had two convulsion fits just before
I saw him. The pupil of the right eye was larger than that of the left.
His pulse was full, tense, and slow, and intermitted every fourth
stroke. The symptoms plainly indicated an internal dropsy of the
brain. I ordered him to lose four or five ounces of blood. But three
ounces of blood were drawn, which produced a small change in his
pulse. It rendered the intermission of a pulsation perceptible only
after every tenth stroke. On the 25th he lost five ounces of blood,
and took a purge of calomel and jalap. On the 26th he was better.
On the 27th the vomiting was troublesome, and his pulse was still
full and tense, but regular. I ordered him to lose four ounces of
blood. On the 28th his puking and head-ach continued; his pulse
was a little tense, but regular; and his right pupil less dilated. On the
29th his head-ach and puking ceased, and he played about the
room. On the 4th of December he grew worse; his head-ach and
puking returned, with a hard pulse, for which I ordered him to lose
five ounces of blood. On the 5th he was better, but on the 6th his
head-ach and puking returned. On the 7th I ordered his forehead to
be bathed frequently with vinegar, in which ice had been dissolved.
On the 8th he was much better. On the 9th his pulse became soft,
and he complained but little of head-ach. After appearing to be well
for near three weeks, except that he complained of a little head-ach,
on the 29th his pulse became again full and tense, for which I
ordered him to lose six ounces of blood, which for the first time
discovered a buffy coat. After this last bleeding, he discharged a
large quantity of water. From this time he recovered slowly, but his
pulse was a little fuller than natural on the 19th of January following.
He afterwards enjoyed good health.

CASES III. AND IV.

In the month of March, 1792, I attended two children of three
years of age, the one the daughter of William King, the other the
daughter of William Blake: each of whom had most of the symptoms
of the inflammatory stage of the internal dropsy of the brain. I
prescribed the loss of four ounces of blood, and a smart purge in
both cases, and in the course of a few days had the pleasure of
observing all the symptoms of the disease perfectly subdued in each
of them.

CASE V.
In the months of July and August, 1792, I attended a female slave
of Mrs. Oneal, of St. Croix, who had an obstinate head-ach, coma,
vomiting, and a tense, full, and slow pulse. I believed it to be the
phrenicula, or internal dropsy of the brain, in its inflammatory stage.
I bled her five times in the course of two months, and each time
with obvious relief of all the symptoms of the disease. Finding that
her head-ach, and a disposition to vomit, continued after the tension
of her pulse was nearly reduced, I gave her as much calomel as
excited a gentle salivation, which in a few weeks completed her
cure.

CASE VI.
The daughter of Robert Moffat, aged eight years, in consequence
of the suppression of a habitual discharge from sores on her head, in
the month of April, 1793, was affected by violent head-ach, puking,
great pains and weakness in her limbs, and a full, tense, and slow
pulse. I believed these symptoms to be produced by an
inflammation of the brain. I ordered her to lose six or seven ounces
of blood, and gave her two purges of jalap and calomel, which
operated very plentifully. I afterwards applied a blister to her neck.
In one week from the time of my first visit to her she appeared to be
in perfect health.

CASE VII.
 A young woman of eighteen years of age, a hired servant in the
family of Mrs. Elizabeth Smith, had been subject to a head-ach every
spring for several years. The unusually warm days which occurred in
the beginning of April, 1793, produced a return of this periodical
pain. On the eighth of the month, it was so severe as to confine her
to her bed. I was called to visit her on the ninth. I found her
comatose, and, when awake, delirious. Her pupils were unusually
dilated, and insensible to the light. She was constantly sick at her
stomach, and vomited frequently. Her bowels were obstinately
costive, and her pulse was full, tense, and so slow as seldom to
exceed, for several days, from 56 to 60 strokes in a minute. I
ordered her to lose ten ounces of blood every day, for three days
successively, and gave her, on each of those days, strong doses of
jalap and aloes. The last blood which was drawn from her was sizy.
The purges procured from three to ten discharges every day from
her bowels. On the 12th, she appeared to be much better. Her pulse
was less tense, and beat 80 strokes in a minute. On the 14th, she
had a fainting fit. On the 15th, she sat up, and called for food. The
pupils of her eyes now recovered their sensibility to light, as well as
their natural size. Her head-ach left her, and, on the 17th, she
appeared to be in good health. Her pulse, however, continued to
beat between 50 and 60 strokes in a minute, and retained a small
portion of irregular action for several days after she recovered.
I am the more disposed to pronounce the cases which have been
described to have been internal dropsy of the brain, from my having
never been deceived in a single case in which I have examined the
brains of patients whom I have suspected to have died of it.
I could add many other cases to those which have been related,
but enough, I hope, have been mentioned to establish the safety
and efficacy of the remedies that have been recommended.
I believe, with Dr. Quin, that this disease is much more frequent
than is commonly supposed. I can recollect many cases of
anomalous fever and head-ach in children, which have excited the
most distressing apprehensions of an approaching internal dropsy of
the brain, but which have yielded in a few days to bleeding, or to
purges and blisters. I think it probable, that some, or perhaps most
of these cases, might have terminated in an effusion of water in the
brain, had they been left to themselves, or not been treated with the
above remedies. I believe further, that it is often prevented by all
those physicians who treat the first stage of febrile diseases in
children with evacuations, just as the pulmonary consumption is
prevented by bleeding, and low diet, in an inflammatory catarrh.
Where blood-letting has failed of curing this disease, I am
disposed to ascribe it to its being used less copiously than the
disease required. If its relation to pneumonicula be the same in its
cure, that I have supposed it to be in its cause, then I am
persuaded, that the same excess in blood-letting is indicated in it,
above what is necessary in phrenitis, that has been practised in
pneumonicula, above what is necessary in the cure of an acute
inflammation of the lungs. The continuance, and, in some instances,
the increase of the appetite in the internal dropsy of the brain,
would seem to favour this opinion no less in this disease, than in the
inflammatory state of pulmonary consumption. The extreme danger
from the effusion of water into the ventricles of the brain, and the
certainty of death from its confinement there, is a reason likewise
why more blood should be drawn in this disease, than in diseases of
the same force in other parts of the body, where the products of
inflammation have a prompt, or certain outlet from the body. Where
the internal dropsy is obviously the effect of a fall, or of any other
cause which acts directly on the brain, there can be no doubt of the
safety of very plentiful bleeding; all practical writers upon surgery
concur in advising it. The late Dr. Pennington favoured me with an
extract from Mr. Cline's manuscript lectures upon anatomy, delivered
in London in the winter of 1792, which places the advantage of
blood-letting, in that species of inflammation which follows a local
injury of the brain, in a very strong point of light. “I know (says he)
that several practitioners object to the use of evacuations as
remedies for concussions of the brain, because of the weakness of
the pulse; but in these cases the pulse is depressed. Besides,
experience shows, that evacuations are frequently attended with
very great advantages. I remember a remarkable case of a man in
this [St. Thomas's] hospital, who was under the care of Mr. Baker.
He lay in a comatose state for three weeks after an injury of the
head. During that time he was bled twenty times, that is to say, he
was bled once every day upon an average. He was bled twice a day
plentifully, but towards the conclusion he was bled more sparingly,
and only every other day; but at each bleeding, there were taken,
upon an average, about sixteen ounces of blood. In consequence of
this treatment, the man perfectly recovered his health and reason.”
Local bleeding by cups, leaches, scarifications, or arteriotomy,
should be combined with venesection, or preferred to it, where the
whole arterial system does not sympathize with the disease in the
brain.
II. A second remedy to be used in the second stage of this disease
is purges. I have constantly observed all the patients whose cases
have been related, to be relieved by plentiful and repeated
evacuations from the bowels. I was led to the use of frequent
purges, by having long observed their good effects in palsies, and
other cases of congestion in the brain, where blood-letting was
unsafe, and where it had been used without benefit. In the Leipsic
Commentaries[56], there is an account of a case of internal dropsy of
the brain, which followed the measles, being cured by no other
medicines than purges and diuretics. I can say nothing in favour of
the latter remedy, in this disease, from my own experience. The
foxglove has been used in this city by several respectable
practitioners, but, I believe, in no instance with any advantage.
III. Blisters have been uniformly recommended by all practical
writers upon this disease. I have applied them to the head, neck,
and temples, and generally with obvious relief to the pain in the
head. They should be omitted in no stage of the disease; for even in
its inflammatory stage, the discharge they occasion from the vessels
of the head, greatly overbalances their stimulating effects upon the
whole system.
 IV. Mercury was long considered as the only remedy, which gave
the least chance of a recovery from a dropsy of the brain. Out of all
the cases in which I gave it, before the year 1790, I succeeded in
but two: one of them was a child of three years old, the other was a
young woman of twenty-six years of age. I am the more convinced
that the latter case was internal dropsy of the brain, from my patient
having relapsed, and died between two or three years afterwards, of
the same disease. Since I have adopted the depleting remedies
which have been mentioned, I have declined giving mercury
altogether, except when combined with some purging medicine, and
I have given it in this form chiefly with a view of dislodging worms.
My reasons for not giving it as a sialagogue are the uncertainty of its
operation, its frequent inefficacy when it excites a salivation, and,
above all, its disposition to produce gangrene in the tender jaws of
children. Seven instances of its inducing death from that cause, in
children between three and eight years of age, and with
circumstances of uncommon distress, have occurred in Philadelphia
since the year 1795.
V. Linen cloths, wetted with cold vinegar, or water, and applied to
the forehead, contribute very much to relieve the pain in the head.
In the case of Mr. Cypher's son[57], the solution of ice in the vinegar
appeared to afford the most obvious relief of this distressing
symptom.
A puncture in the brain has been proposed by some writers to
discharge the water from its ventricles. If the theory I have delivered
be true, the operation promises nothing, even though it could always
be performed with perfect safety. In cases of local injuries, or of
inflammation from any cause, it must necessarily increase the
disease; and in cases of effusion only, the debilitated state of the
whole system forbids us to hope for any relief from such a local
remedy.
Bark, wine, and opium promise much more success in the last
stage of the disease. I can say nothing in their favour from my own
experience; but from the aid they afford to mercury in other
diseases, I conceive they might be made to accompany it with
advantage.
Considering the nature of the indirect causes which induce the
disease, and the case of a relapse, which has been mentioned, after
an interval of near three years, as well as the symptoms of slow
convalescence, manifested by the pulse, which occurred in the first
and seventh cases, I submit it to the consideration of physicians,
whether the use of moderate exercise, and the cold bath, should not
be recommended to prevent a return of the disease in every case,
where it has yielded to the power of medicine.
I have great pleasure in adding, that the theory of this disease,
which I have delivered, has been adopted by many respectable
physicians in Philadelphia, and in other parts of the United States,
and that it has led to the practice that has been recommended,
particularly to copious blood-letting; in consequence of which, death
from a dropsy of the brain is not a more frequent occurrence, than
from any other of the acute febrile diseases of our country.

Footnotes:
[46] Prælectiones, vol. I. p. 254.
[47] Historia Anatomica-Medica, vol. II.
[48] Treatise on the Infantile Remitting Fever.
[49] Medical Memoirs, vol. I. p. 174.
[50] Essays, Medical, Philosophical, and Experimental, vol. II.
p. 339, 340.
[51] Historia Anatomica-Medica, vol. II. lib. tertius. obs. 380,
394, 1121.
[52] Obs. 383, 431.
[53] Medical Journal.
[54] Medical Memoirs, vol. I. p. 171.
[55] Medical Journal, vol. VIII.
[56] Vol. xxix. p. 139.
[57] Case II.
 OBSERVATIONS
UPON

THE NATURE AND CURE

OF THE

GOUT.
In treating upon the gout, I shall deliver a few preliminary
propositions.
1. The gout is a disease of the whole system. It affects the
ligaments, blood-vessels, stomach, bowels, brain, liver, lymphatics,
nerves, muscles, cartilages, bones, and skin.
2. The gout is a primary disease, only of the solids. Chalk-stones,
abscesses, dropsical effusions into cavities, and cellular membrane,
and eruptions on the skin, are all the effects of a morbid action in
the blood-vessels. The truth of this proposition has been ably proved
by Dr. Cullen in his First Lines.
3. It affects most frequently persons of a sanguineous
temperament; but sometimes it affects persons of nervous and
phlegmatic temperaments. The idle and luxurious are more subject
to it, than the labouring and temperate part of mankind. Women are
said to be less subject to it than men. I once believed, and taught
this opinion, but I now retract it. From the peculiar delicacy of the
female constitution, and from the thin covering they wear on their
feet and limbs, the gout is less apt to fall upon those parts than in
men, but they exhibit all its other symptoms, perhaps more
frequently than men, in other parts of the body. The remote causes
of gout moreover to be mentioned presently, act with equal force
upon both sexes, and more of them I believe upon women, than
upon men.
It generally attacks in those periods of life, and in those countries,
and seasons of the year, in which inflammatory diseases are most
common. It seldom affects persons before puberty, or in old age,
and yet I have heard of its appearing with all its most characteristic
symptoms in this city in a child of 6, and in a man above 80 years of
age. Men of active minds are said to be most subject to it, but I
think I have seen it as frequently in persons of slender and torpid
intellects, as in persons of an opposite character. I have heard of a
case of gout in an Indian at Pittsburg, and I have cured a fit of it in
an Indian in this city. They had both been intemperate in the use of
wine and fermented liquors.
4. It is in one respect a hereditary disease, depending upon the
propagation of a similar temperament from father to son. When a
predisposition to the gout has been derived from ancestors, less
force in exciting causes will induce it than in those habits where this
has not been the case. This predisposition sometimes passes by
children, and appears in grand-children. There are instances likewise
in which it has passed by the males, and appeared only in the
females of a family. It even appears in the descendants of families
who have been reduced to poverty, but not often where they have
been obliged to labour for a subsistence. It generally passes by
those children who are born before the gout makes its appearance in
a father. It is curious to observe how extensively the predisposition
pervades some families. An English gentleman, who had been
afflicted with the gout, married a young woman in Philadelphia many
years ago, by whom he had one daughter. His wife dying three
weeks after the birth of this child, he returned to England, where he
married a second wife, by whom he had six children, all of whom
except one died with the gout before they attained to the usual age
of matrimony in Great Britain. One of them died in her 16th year.
Finally the father and grandfather died with the same disease. The
daughter whom this afflicted gentleman left in this city, passed her
life subject to the gout, and finally died under my care in the year
1789, in the 68th year of her age. She left a family of children, two
of whom had the gout. One of them, a lady, has suffered exquisitely
from it.
5. The gout is always induced by general predisposing debility.
6. The remote causes of the gout which induce this debility, are,
indolence, great bodily labour, long protracted bodily exercise,
intemperance in eating, and in venery, acid aliments and drinks,
strong tea and coffee, public and domestic vexation, the violent, or
long continued exercise of the understanding, imagination, and
passions in study, business, or pleasure, and, lastly, the use of
ardent, and fermented liquors. The last are absolutely necessary to
produce that form of gout which appears in the ligaments and
muscles. I assert this, not only from my own observations, but from
those of Dr. Cadogan, and Dr. Darwin, who say they never saw a
case of gout in the limbs in any person who had not used spirits or
wine in a greater or less quantity. Perhaps this may be another
reason why women, who drink less of those liquors than men, are so
rarely affected with this disease in the extreme parts of their bodies.
Wines of all kinds are more disposed to produce this form of gout
than spirits. The reason of this must be resolved into the less
stimulus in the former, than in the latter liquors. Wine appears to
resemble, in its action upon the body, the moderate stimulus of
miasmata which produce a common remitting fever, or intermitting
fever, while spirits resemble that violent action induced by miasmata
which passes by the blood-vessels, ligaments, and muscles, and
invades at once the liver, bowels, and brain. There is one symptom
of the gout in the extremities which seems to be produced
exclusively by ardent spirits, and that is a burning in the palms of
the hands, and soles of the feet. This is so uniform, that I have
sometimes been able to convict my patients of intemperance in the
use of spirits, when no other mark of their having taken them in
excess, appeared in the system.
I have enumerated among the remote causes of the gout, the use
of strong tea. I infer its predisposing quality to that disease, from its
frequency at Japan, where tea is used in large quantities, and from
the gout being more common among that sex in our country who
drink the most, and the strongest tea.
7. The exciting causes of the gout are frequently a greater degree,
or a sudden application of its remote and predisposing causes. They
act upon the accumulated excitability of the system, and by
destroying its equilibrium of excitement, and regular order of
actions, produce convulsion, or irregular morbid and local
excitement. These exciting causes are either of a stimulating, or of a
sedative nature. The former are violent exercise, of body or mind,
night-watching, and even sitting up late at night, a hearty meal, a fit
of drunkenness, a few glasses of claret or a draught of cyder, where
those liquors have not been habitual to the patient, a sudden
paroxysm of joy, anger, or terror, a dislocation of a bone, straining of
a joint, particularly of the ankle, undue pressure upon the foot, or
leg, from a tight shoe or boot, an irritated corn, and the usual
remote causes of fever. The latter exciting causes are sudden
inanition from bleeding, purging, vomiting, fasting, cold, a sudden
stoppage of moisture on the feet, fear, grief, excess in venery, and
the debility left upon the system by the crisis of a fever. All these
causes act more certainly when they are aided by the additional
debility induced upon the system in sleep. It is for this reason that
the gout generally makes its first attack in the night, and in a part of
the system most remote from the energy of the brain, and most
debilitated by exercise, viz. in the great toe, or in some part of the
foot. In ascribing a fit of the gout to a cause which is of a sedative
nature, the reader will not suppose that I have departed from the
simplicity and uniformity of a proposition I have elsewhere delivered,
that disease is the effect of stimulus. The abstraction of a natural
and habitual impression of any kind, by increasing the force of those
which remain, renders the production of morbid and excessive
actions in the system as much the effect of preternatural or
disproportioned stimulus, as if they were induced by causes that are
externally and evidently stimulating. It is thus in many other of the
operations of nature, opposite causes produce the same effects.
 8. The gout consists simply in morbid excitement, accompanied
with irregular action, or the absence of all action from the force of
stimulus. There is nothing specific in the morbid excitement and
actions which take place in the gout different from what occur in
fevers. It is to be lamented that a kind of metastasis of error has
taken place in pathology. The rejection of a specific acrimony as the
cause of each disease, has unfortunately been followed by a belief in
as many specific actions as there are different forms and grades of
disease, and thus perpetuated the evils of our ancient systems of
medicine. However varied morbid actions may be by their causes,
seats, and effects, they are all of the same nature, and the time will
probably come when the whole nomenclature of morbid actions will
be absorbed in the single name of disease.
I shall now briefly enumerate the symptoms of the gout, as they
appear in the ligaments, the blood-vessels, the viscera, the nervous
system, the alimentary canal, the lymphatics, the skin, and the
bones of the human body, and here we shall find that it is an
epitome of all disease.
I. The ligaments which connect the bones are the seats, of what is
called a legitimate or true gout. They are affected with pain,
swelling, and inflammation. The pain is sometimes so acute as to be
compared to the gnawing of a dog. We perceive here the sameness
of the gout with the rheumatism. Many pages, and indeed whole
essays, have been composed by writers to distinguish them, but
they are exactly the same disease while the morbid actions are
confined to this part of the body. They are, it is true, produced by
different remote causes, but this constitutes no more difference in
their nature, than is produced in a coal of fire, whether it be
inflamed by a candle, or by a spark of electricity. The morbid actions
which are induced by the usual causes of rheumatism affect, though
less frequently, the lungs, the trachea, the head, the bowels, and
even the heart, as well as the gout. Those actions, moreover, are the
means of a fluid being effused, which is changed into calcareous
matter in the joints and other parts of the body, exactly like that
which is produced by the gout. They likewise twist and dislocate the
bones in common with the gout, in a manner to be described
hereafter. The only difference between what are called gouty, and
rheumatic actions, consists in their seats, and in the degrees of their
force. The debility which predisposes to the gout, being greater, and
more extensively diffused through the body than the debility which
precedes rheumatism, the morbid actions, in the former case, pass
more readily from external to internal parts, and produce in both
more acute and more dangerous effects. A simile derived from the
difference in the degrees of action produced in the system by marsh
miasmata, made use of upon a former occasion, will serve me again
to illustrate this part of our subject. A mild remittent, and a yellow
fever, are different grades of the same disease. The former, like the
rheumatism, affects the bones chiefly with pain, while the latter, like
the gout, affects not only the bones, but the stomach, bowels, brain,
nerves, lymphatics, and all the internal parts of the body.
II. In the arterial system the gout produces fever. This fever
appears not only in the increased force or frequency of the pulse,
but in morbid affections of all the viscera. It puts on all the different
grades of fever, from the malignity of the plague, to the mildness of
a common intermittent. It has moreover its regular exacerbations
and remissions once in every four and twenty hours, and its crisis
usually on the fourteenth day, in violent cases. In moderate attacks,
it runs on from twenty to forty days in common with the typhus or
slow chronic state of fever. It is common for those persons who
consider the gout as a specific disease, when it appears in the above
forms, to say, that it is complicated with fever; but this is an error,
for there can exist but one morbid action in the blood-vessels at
once, and the same laws are imposed upon the morbid actions
excited in those parts of the body by the remote causes of the gout,
as by the common causes of fever. I have seen two instances of this
disease appearing in the form of a genuine hectic, and one in which
it appeared to yield to lunar influence, in the manner described by
Dr. Balfour. In the highly inflammatory state of the gout, the
sensibility of the blood-vessels far exceeds what is seen in the same
state of fever from more common causes. I have known an instance
in which a translation of the gouty action to the eye produced such
an exquisite degree of sensibility, that the patient was unable to bear
the feeble light which was emitted from a few coals of fire in his
room, at a time too when the coldness of the weather would have
made a large fire agreeable to him. It is from the extreme sensibility
which the gout imparts to the stomach, that the bark is so generally
rejected by it. I knew a British officer who had nearly died from
taking a spoonful of the infusion of that medicine, while his arterial
system was in this state of morbid excitability, from a fit of the gout.
It is remarkable that the gout is most disposed to assume a
malignant character, during the prevalence of an inflammatory
constitution of the atmosphere. This has been long ago remarked by
Dr. Huxham. Several instances of it have occurred in this city since
the year 1793.
III. The gout affects most of the viscera. In the brain it produces
head-ach, vertigo, coma, apoplexy, and palsy. In the lungs it
produces pneumonia vera, notha, asthma, hæmoptysis, pulmonary
consumption, and a short hecking cough, first described by Dr.
Sydenham. In the throat it produces inflammatory angina. In the
uterus it produces hæmorrhagia uterina. It affects the kidneys with
inflammation, strangury, diabetes, and calculi. The position of the
body for weeks or months on the back, by favouring the
compression of the kidneys by the bowels, is the principal reason
why those parts suffer so much in gouty people. The strangury
appears to be produced by the same kind of engorgement or
choking of the vessels of the kidneys, which takes place in the small-
pox and yellow fever. Four cases of it are described in the 3d volume
of the Physical and Literary Essays of Edinburgh, by Dr. David Clerk.
I have seen one instance of death in an old man from this cause.
The catheter brought no water from his bladder. The late Mr. John
Penn, formerly governor of Pennsylvania, I have been informed by
one of his physicians, died from a similar affection in his kidneys
from gout. The catheter was as ineffectual in giving him relief, as it
was in the case of my patient. The neck of the bladder sometimes
becomes the seat of the gout. It discovers itself by spasm, and a
suppression of urine in some cases, and occasionally by a habitual
discharge of mucus through the urethra. This disease has been
called, by Lieutaud, “a catarrh of the bladder.” Dr. Stoll describes it,
and calls it “hæmorrhoids of the bladder.” But of all the viscera, the
liver suffers most from the gout. It produces in it inflammation,
suppuration, melena, schirrus, gall-stones, jaundice, and a habitual
increased secretion and excretion of bile. These affections of the
liver appear most frequently in southern countries, and in female
habits. They are substitutes for a gout in the ligaments, and in the
extremities of the body. They appear likewise in drunkards from
ardent spirits. It would seem that certain stimuli act specifically upon
the liver, probably for the wise purpose of discharging such parts of
the blood from the body, as are vitiated by the rapidity of its
circulation. I shall, in another place[58], take notice of the action of
marsh miasmata upon the livers of men and beasts. It has been
observed that hogs that live near brewhouses, and feed upon the
fermented grains of barley, always discover enlarged or diseased
livers. But a determination of the blood to the liver, and an increased
action of its vessels, are produced by other causes than marsh
miasmata, and fermented and distilled liquors. They appear in the
fever which accompanies madness and the malignant sore-throat,
also in contusions of the brain, and in the excited state of the blood-
vessels which is produced by anger and exercise. I have found an
attention to these facts useful in prescribing for diseases of the liver,
inasmuch as they have led me from considering them as idiopathic
affections, but as the effects only of morbid actions excited in other
parts of the body.
IV. The gout sometimes affects the arterial and nervous systems
jointly, producing in the brain, coma, vertigo, apoplexy, palsy, loss of
memory, and madness, and in the nerves, hysteria, hypochondriasis,
and syncope. It is common to say the gout counterfeits all these
diseases. But this is an inaccurate mode of speaking. All those
diseases have but one cause, and they are exactly the same,
however different the stimulus may be, from which they are derived.
Sometimes the gout affects the brain and nerves exclusively, without
producing the least morbid action in the blood-vessels. I once
attended a gentleman from Barbadoes who suffered, from this
affection of his brain and nerves, the most intolerable depression of
spirits. It yielded to large doses of wine, but his relief was perfect,
and more durable, when a pain was excited by nature or art, in his
hands or feet.
The muscles are sometimes affected by the gout with spasm, with
general and partial convulsions, and lastly with great pain. Dr. Stoll
describes a case of opisthotonos from it. The angina pectoris, or a
sudden inability to breathe after climbing a hill, or a pair of stairs,
and after a long walk, is sometimes a symptom of the gout. There is
a pain which suddenly pervades the head, breast, and limbs, which
resembles an electric shock. I have known two instances of it in
gouty patients, and have taken the liberty of calling it the “aura
arthritica.” But the pain which affects the muscles is often of a more
permanent nature. It is felt with most severity in the calves of the
legs. Sometimes it affects the muscles of the head, breast, and
limbs, exciting in them large and distressing swellings. But further;
the gout in some cases seizes upon the tendons, and twists them in
such a manner as to dislocate bones in the hands and feet. It even
affects the cartilages. Of this I once saw an instance in colonel
Adams, of the state of Maryland. The external parts of both his ears
were so much inflamed in a fit of the gout, that he was unable to lie
on either of his sides.
V. The gout affects the alimentary canal, from the stomach to its
termination in the rectum. Flatulency, sickness, acidity, indigestion,
pain, or vomiting, usually usher in a fit of the disease. The sick
head-ach, also dyspepsia, with all its train of distressing evils, are
frequently the effects of gout concentrated in the stomach. I have
seen a case in which the gout, by retreating to this viscus, produced
the same burning sensation which is felt in the yellow fever. The
patient who was the subject of this symptom died two days
afterwards with a black vomiting. It was Mr. Patterson, formerly
collector of the port of Philadelphia, under the British government. I
was not surprised at these two uncommon symptoms in the gout,