FURTHER CASES AND OBSERVATIONS RELATIVE TO RHEUMATISM. By J. K. MITCHELL, M. D. ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL. [Extracted from the American Journal of the Medical Sciences, for August, 1833.] PHILADELPHIA: PRINTED BY J. R. A. SKERRETT. 1833. CASES AND OBSERVATIONS, Since making the former communication on rheumatism,* I have been able to collect a number of cases so illustrative of the truth of the new theory, and so confirmatory of the superiority of the spinal treatment, as to justify a new appeal to the attention of the profes- sion. Case I. On the 5th of October, 1831, as Dr. Parker, of Elkton, Maryland, was driving his carriage down a slight declivity, his horse fell, and he was thrown out in such a manner as to alight on the back of the neck and shoulders. He was instantly paralyzed, partially in the hands and arms, and totally in the lower extremities. On the following morning there was great pain in the hands and wrists, with swelling, heat and redness, exactly such as is observed in acute rheumatism. The pain in the hands and wrists was always abated by remedies applied to the affected part of the spine, and aggravated by pressure or rough friction there. The doctor had been subject some years before to rheumatism in the arms, side, and hip, and was able to recognise in this attack the same phenomena. While the rheumatic affection after the fall existed, it exhibited the translateable quality so characteristic of rheumatism, attacking sometimes one arm, sometimes the other, but never passing to any other part of the body. Remarks.-In this case, reported by my friend, Dr. Evans, of Elkton, with the approbation and concurrence of Dr. Parker, we have the highly respectable testimony of both, to the opinion that the injury of the spine produced the affection of the upper extremities, and that that affection was in all respects similar to rheumatism. If it is objected that the hands and wrists might have received simultaneous injury by the fall, the objection is obviated by the fact, that at any subsequent period, pressure or rough friction at the spinal seat of injury aggravated or reproduced the tumefaction, pain, and redness of the extremities. In this case then, we have an obvious spinal cause producing rheumatism in the upper extremities, a rheumatism characterized by pain, heat, redness, tumefaction and translation. Case II. Reported by Dr. Lamb, of Frankford.-On the 1st Sep- * American Journal of the Medical Sciences, Vol. VIII. p. 55. 4 tember, 1832, W. W. was attacked with acute rheumatism of the left arm and shoulder, which before the visit of Dr. L. was treated with liniments, sinapisms, &c. without relief. On the 7th Dr. L. saw the case which still presented the acute symptoms, and for which he applied, in the course of the spinous processes of the upper ver- tebrae, twelve cups, after scarification. " The relief was instantaneous and complete. The arm could be immediately extended and flexed without pain. The swelling subsided gradually, and at the end of a week, the patient w'as able to resume his usual occupation, and re- mains well to the present date." Case III. Reported by Dr. Joseph Warrington, of Philadel- phia.-" Elizabeth Turner, aged sixteen, was seized with slight pain and swelling in the right ankle. Finding the circulation active, I took blood from her arm, and, for inactive bowels, ordered a dose of rhubarb and magnesia. On the following day the blood taken indi- cated an inflammatory condition. Although the medicine had ope- rated, her case was worse. She cried with pain, and was unable to turn in bed without the most tender assistance. Both ankles looked inflamed, and were too painful to admit of the slightest touch. I or- dered fifteen cups with scarification to the lumbar spine-eighteen were applied. On the following day she was able to turn herself in bed, on the day after that she sat up, and in four days more was able to remove to the distance of six squares without inconvenience. She has since continued free from the disease." In a note appended to this case Dr. W. says that he has found " much good to follow" the use of the spinal treatment of rheumatism, but has not always succeeded in effecting a cure by it. This regret must be felt by every one who attempts the cure of rheumatism by any and every method hitherto suggested; but it is far from my in- tention to propose the exclusive spinal treatment. I have, it is true, in the progress of this highly interesting investigation, complicated the inquiry as little as possible, as must always be done in struggling to introduce a novel method of management, or to establish a new pathological view, founded on the evidence of superior practical suc- cess. That having been done in a manner which seems satisfactory to the profession, at least in this country, I have of late been much less exclusive in the treatment of the more obstinate forms of the dis- ease, although I do not perceive on the whole that the success has been greater since the practice has been less simple. From various very intelligent and respectable sources, cases have been forwarded to me, strikingly illustrative of the efficacy of the new 5 practice, but as they are so much like those already given, it would scarcely add force to the conviction by their repetition. I have, in my own private practice, noted a number of facts bearing advanta- geously on the point for which I contend; but as these cases always carry less weight when cited in support of a favourite theory or prac- tice, I shall hold them in reserve for mere instruction, when, after the settlement of the doctrine and practice, I shall find leisure to execute my purpose of embodying in a work on the subject, all the facts which may have professional value. It will better illustrate the whole subject to give a condensed view of the whole of the hospital cases reported at length, at my request by my zealous and inquiring friends, the resident physicians of the Institution. Two cases in the surgical department reported by Thomas Stew- ARTSON, M. D. Case IV.-Affecting upper extremities solely; pain, redness and swelling. On 13th May the attack began. On the 15th, ten cups to upper part of spine. 16th. Four cups. 17th. Blister to same region 3 by 7 inches. 18Z7i. Convalescent. Qlst. Reported well. Case V. 21st January, 1832.-Attack of superior extremities re- moved by cups; translated to inferior ones; again relieved by cups and Dover's powder, and a cathartic. But complete cure was ef- fected by the use of sulphur internally, and the patient reported well on the 2d of February. Ten cases in the medical department reported by George W. Norris, M. D. Case VI. 15th March, 1831.-Bled, and frictions of soap lini- ment without relief. Cups to spine at both ends; partial relief. 17th. Cups again; more relief. 20Z/i. Cups. Reported on 26th as having been entirely free from pain since the 20th. Discharged. Case VII. March 30th.-Rheumatism of both knees, of eleven days duration. Ten cups applied at one time to lumbar spine en- tirely removed the disease, and after a few days he was discharged. Case VIII. October 13th, 1831.-Had been cupped eight times on the spine below the scat of disease, and once on the ribs where his pain chiefly lay. The latter alone gave him any relief. He also 6 took, without benefit, blue mass and Dover's powder. On admit- tance to the hospital, he was put exclusively on the use of cups to the proper part of the spine. Three successive applications gradually relieved and finally cured him. Discharged on the 9th November. Case IX. Of all the large joints, duration three weeks before ad- mittance, which was on the 20th December, 1832. Cupped over the spine at both extremities, without relief. 21sZ. Renewed application, with improvement in upper extremi- ties only. 22(Z. Repeat cups over lumbar region with the effect of total re- moval of pain. For a surgical affection, this patient was retained un- til 28th January, 1833, without return of rheumatism. Case X. A similar case, admitted on 23d December, 1832, imme- diately relieved by cups, one application of which cured him. For an injury of the toes, he remained until the 15th January, without re- lapse, and was then discharged. Case XI. A case of three weeks duration admitted on 30th De- cember, 1831. Pain and tumefaction in right knee and shoulder, &c. Cups relieved the pain in the shoulder, and a second application of them entirely removed it from that part. At the third cupping, which was exclusively applied to the lower part of the spinal column, the whole disease left the patient. For mere stiffness, a liniment was ordered, and on the 4th February the man was discharged. Case XII. John Morgan, a seaman, aged forty-eight, admitted December 30th, 1831, for a rheumatism of eight months duration, af- fecting chiefly his hips, knees, and elbows. At present only the lower extremities are affected. Two cuppings to the lumbar region entirely removed the pain and tumefaction. He remained in the hos- pital on account of a cough, until the 28th January. During the in- terval a slight attack of his rheumatism was again obviated by cups. Case XIII. Case of nearly the same kind as the last, of six weeks duration, was received on the 30th January, 1832. As in other cases the relief from scarification was most speedily felt in the tipper ex- tremities. The cups were again applied on the 4th, 6th, and 11th, when the pain, &c. entirely departed. On the 15th, he was discharged. Case XIV. Chronic rheumatism, admitted on the 3d December, 1831. Affects chiefly the scalp and upper extremities, and is almost entirely confined to the left side of the frame. The only tumefaction is observed in the left leg. On the 6th, he was free from pain, but relapsed on the 7th, and again on the 29th. Because of an influenza, 7 he was detained in the hospital until the 11th of February, and then discharged cured. In every relapse the cups gave full relief. Case XV. William Cater, seaman, aged twenty-nine, admitted on the 16th February, 1832, for rheumatism, affecting the back of his neck, left shoulder, and elbow, but moving from place to place on that extremity; aggravated at night; the elbow is tumefied and very tender to the touch; ten cups to the cervical spine; pain abates dur- ing the operation, and the patient sleeps better. On the 19th, re- peat; again on 22d. Case reported well. Discharged on the 27th. Twenty cases reported by Mifflin Wistar, M. D. Case XVI. Joseph Pratt, admitted 4th October, 1832, and dis- charged on the 24th November, after several relapses. Upper extremi- ties most easily relieved. The relapses were of the lower extremities. Case XVII. Joseph L. Baker, admitted 29th November. On 3d December, free from pain. Reported well on the 11th. Same treat- ment. Case XVIII. John Charles, December 1st, 1832, admitted. Af- fection of thighs, knees, and ankles. Two cuppings to lumbar spine gave relief. Reported on 4th free from pain. Case XIX. John Wilson, 3d December admitted. Head and shoulders affected. Cups to nape of neck once. Reported on the 6th free from pain. Case XX. Affection of shoulders, elbows, and knees. Admitted on 24th October, 1832. Applied eight cups to the dorsal spine with relief of lower extremities, but not of the upper. A repetition higher up gave relief to the arms. But in this case on the 15th November, for pain in the neck a blister was made, and because of a suspicion of syphilitic taint, Syr. sarsap. with minute doses of Corros. subl. were used, and on the 19th December he was reported well. Case XXI. Admitted 7th December, 1832, for a rheumatism of all his extremities. Besides the cups, for the reasons which modified the treatment in Case V. Sarsap. and Corros. subl. were added to the local depletion. On the 15th December the case was reported as perfectly well. He was cupped for the last time on the 13th. Case XXII. Admitted November 24th, 1832. Had been in the hospital from the 24th Sept, to the 13th Nov. and was sent home at her own request before she was well. The treatment had been that usually applied to such cases exclusive of the spinal applications. On readmission she complained of violent pain in her hands, knees, and feet, all of which were swelled, red and very tender. Eight cups were applied, four to each end of the spine. 8 25th. Arms much better; legs not benefited. Five cups to lower part of the spine, and one-fourth of a grain of sulph. morph, at bed- time. 27th. No better; reapply cups. 28th. Cupping of yesterday gave relief. December IsZ.-Not so well. Empl. epispast. to lumbar region. 4th. Much better. 5th. The upper extremities are more painful to-day. Empl. vesicat. to nape of neck. 8th. Much better. 12/Zt. As before. 13th. Increase of pain in inferior extremities. Ordered cups to lumbar spine. 14th. Relieved. 30th. As at last report. January IQth.-Pain has returned within twenty-four hours, for which reapplied cups. 21st Supported her hand by a splint. SQth. Reports herself well. Case XXIII. Admitted on the 23d of November, 1832. It is William White, whose attack two years before, cured by cupping, was re- ported in my first paper on rheumatism. Through the winter of 1831-2, he remained free from disease, but was attacked about the middle of November, 1832, with pain and swelling of his lower ex- tremities. Before his entrance into the hospital, a translation took place to his left hand and wrist and right shoulder. As on the former occasion, cups to the spine gave him immediate and great relief, but frequent relapses caused us to apply blisters and pustulating oint- ment to the spine, raw cotton dipped in laudanum to the limbs, and splints to the joints. In addition, a nightly dose of Dover's powder was found necessary to allay pain and procure sleep. After all these things had in a great measure failed to procure ease, cups were again resorted to, and were at length the final cause of cure, according to the report of the 16th of February, 1833, at which time the history of the case before me closes. Case XXIV. John Cave, sailor, aged fifty-two, was admitted on the 28th of December, 1832, for a painful affection extending from the hip to the ankle of the left leg, causing pain and stiffness of its joints. The case has existed for ten weeks. Ordered eight cups to lower end of spine. 29//j. As yesterday; apply cups again. 9 30 th. Rather easier; apply cups again. 31s£. Some relief, but as there is still great pain, cups were to - day applied in the course of the pain down the leg. January 3d.-Has been much easier since the 31st, but is to-day in more pain. Ordered cups again to the limb. 4th. Improved. Sth. As before. 11th. Not so well; applied cups to lumbar region. 12th. He is much belter. He felt great relief immediately after the removal of the cups. 14/A. As on the 12th. 15th. His limb is very painful to-day; eight cups to lumbar region. 16th. Again greatly relieved. 20th. Support his limb by a splint. February 2d.-Continues free from pain. 13th. Remove splints; walks with great facility. 22d. Continues well. Case XXV. Admitted on the 2d of January, 1833, and reported well on the 22d; was cupped five times, bled once, and took sulph. magnes. Case XXVI. Admitted January 15th, and reported well on the 19th. Had been afllicted/or a month before admission. Was cupped on the spine once, and took a dose of calomel, followed by Epsom salts. Case XXVII. Admitted on the 10th of February, and reported free from pain on the 13th. Acute rheumatism of three weeks dura- tion. Cups relieved his upper, but failed to impress his lower extre- mities-a repetition of them to lumbar region afforded ease. For a severe pleuritic pain in his side, of blood were taken from the arm, and a dose of sal. Epsom was given. Case XXVIII. G. W. Peirce, admitted on the 13th of February, and reported well on the 15th, had violent pain and tumefaction of the left leg of two weeks duration. He was cupped on the lumbar spine once, and suffered no other treatment. Case XXIX. Mathew Donnelly, admitted 13th of February. Had been sick for five months. On admission both ankles were inflamed. Four times cupped on lumbar region, and was free from pain on the 27th. On 2d March relapsed; cupped again on spine with relief. On 4th blistered his ankles.* Reported free from pain on 10th. * I have sometimes received cases which had resisted peripheral treatment; but which could not be entirely cured by the central method. After alleviation by the latter, the secondary seat is often appealed to with the happiest effect. 2 10 Case XXX. Admitted on the 2d of February. P. M'Coy has inflam- mation of all the large joints indicated by pain, redness and tumefac- tion. The attack has lasted for six days. Apply ten cups to the spine. 3cZ. The cupping has afforded great relief. Directed a pectoral mixture for his cough. 5th. Complains of pain in the left wrist, shoulder and hip; reapply cups; and because of a dry and encrusted tongue, order mass, hydrarg. grs. iij. to be followed by a dose of magnesia. 6th. Rather better; order neutral mixture. 7th. Continues better; cups to the spine. 10?7c. Continues to improve. 26/7c. Has no pain. Case XXXI. J. Parsonage, aged seventeen, admitted on the 23d of February, 1833, for a rheumatic affection of two months duration, is afflicted with pain and tumefaction of the left knee. Apply eight cups to lumbar spine. 24/7t. No better; reapply cups. 95th. Easier, but is still in much pain. Cups to be again applied to the spine. 9.7th. Free from pain. r March 1st-Complains of pain in both shoulders; apply eight cups between them over spine. 2c?. Experienced the usual relief from cupping. 8/7c. Continues well. Case XXXII. Wm. Woodruff', aged twenty-seven, was admitted on the 7th of January, for rheumatism of the shoulders and knees, which are swelled and painful. Was cupped on the spine; cupped again on the 8th; blistered over the cervical spine on the 10th; and on the 16th, for returning pain, again cupped. By these means re- lief of the upper extremities was experienced, but it was found ne- cessary to cup for the lower pain on the 18th. Reported much easier on the 19th. On the 30th the report states, that "owing to the un- favourable weather he has had several returns of pain, which were relieved by cups; but as there existed some reasons to suppose a syphilitic origin, compound syr. sarsap. was ordered." February 19th.-Complains of pain in the shoulders. Apply six cups to corresponding part of the spine. 15th. Has again experienced relief. 96th. Free from pain. Case XXXIII. John Robinson was admitted on the 16th of Janu- ary, 1833, for violent pain in his right shoulder, caused by a sprain 11 in attempting to lift a heavy weight some weeks before. In this case, evidently disconnected with the central nervous masses, cups were repeatedly applied to the cervical and upper part of the dorsal spine with very little if any benefit, although great pains were taken at the same time to keep the joint at rest. After convincing ourselves of the futility of the practice, we used the scarificator and cups over the joint itself with immediate advantage, and in a few days the patient could use his arm without inconvenience. Case XXXIV. Solomon Summers, seaman, aged twenty-seven, was admitted on the 25th of February, 1833, for rheumatism of the shoulders, elbows, and knees; all of which were tumefied and very painful. The attack had endured for two months. Eight cups to lum- bar spine. 26Z7z. The same as yesterday. Ten cups to upper part of spine. %7th. His upper extremities are much easier. 28/7t. As his knees are very painful, cup the lower part of spine. March 1st-Feels much better since last cupping. 3tZ. Complains of some pain in both shoulders. Cups to upper part of spine. 4th. Much better. 8/7t. Continues well. Case XXXV.-R. M'Donald, a female, admitted on the 16th of February, for a painful affection of the head, to which she has been subject at intervals for several years. This attack was brought on apparently by exposure to cold, and is accompanied by violent pain in the lower jaw. Apply six cups to the head. \7th. Greatly relieved; repeat cups to the head. 19/71. Continues better. March 6th.-The treatment has been continued according to the degree of pain, and the patient may be considered well. In reviewing the thirty-five cases now presented to the readers of the Journal, several general truths seem worthy of particular notice. Among these not the least important is the bearing on the question of pathological seat. The first case, in conjunction with the cases of rheumatism produced by carious spine, reported in my first paper on this subject, leaves no doubt in my mind that a condition of parts exactly the same as in rheumatism, may and does exist as an effect of irritation of the great nervous masses at the centre. It remains to be proved by the opponents of this system, by equally conclusive facts, that a genuine translateable rheumatism is ever found to be indepen- 12 dent of such a cause, or that the disease properly called rheumatism is ever a primary affection of the limbs or joints. The extraordinary facility with which most of the recited cases were cured by exclusive spinal treatment, goes far to establish concurrently the same truth. For when a true inflammation of a joint has a purely local character, as in Case XXXIII. the spinal treatment is altogether useless, while the more direct application of the same means meets with prompt success. If inflammation alone of the tissues ordinarily attacked by rheumatism constituted that disease, inflammation from a sprain or blow affecting the same parts should have the same translateable cha- racter, which is so characteristic of true rheumatic inflammation, and should also be capable of passing not only to similar parts, but to the viscera, as not unfrequently happens in rheumatic cases. The great value of the opiate practice in rheumatism, is no small auxiliary to the arguments in favour of the central origin, because it is only by lessening nervous irritation that such a medicine can prove useful. It follows as a corollary that the best possible practice in these cases consists in spinal depletion and counter-stimulation com- bined with the judicious use of opiates. That such a practice has not been more generally followed in the public duty at the hospital, arose from a desire to obtain the more conclusive evidence of the truth afforded by the avoidance of obscuring complication. That be- ing now attained, the practitioner will no longer feel justified in leaving out of his system of cure, any one of the useful auxiliaries called for by the varying contingencies of his cases. Another general fact is that rheumatism attacks those parts only whose nerves come out at or near to the part of the medulla spinalis which is in an irritated state. This was the fact in the carious cases, and in the case of Dr. Parker, of Elkton. Although all the nerves in descending along the spinal canal, must have been subjected to diseased influence, only those which took their departure from that part of the spine were influential in producing rheumatism, which consequently appeared at their sentient extremity exclusively.* The same point is sustained strongly by the effect of the remedial mea- sures, which were scarcely ever of any use when applied to remote parts of the spine, and were generally promptly beneficial, when directed to the origin of the nerves of the part inflamed. * In my letter to Dr. Evans, March 14th, 1832, making inquiry respecting Dr. Parker's case, I find the following:-" Was there, (I should suppose not,) any rheumatic pain of the legs during the present illness?" Answer-" Has not had any rheumatism in the legs since the injury." 13 As far as we could ascertain, the remedial effect of the spinal treat- ment was most potent when applied exactly over the place of exit from the spine, of the nerves which supplied the inflamed part. It is also remarkable that the affection of the upper extremities was almost al- ways the most easily remedied. This may be ascribed with proba- bility to the greater effect of the cups on those parts of the spine which lie least imbedded in cellular tissue and muscular fibre. In conclusion, I may be permitted to advert to the close connexion between common rheumatism and certain diseases of mucous and fibrous tissues in the eyes, nose, mouth, alimentary canal, bladder and urethra. In many cases diarrhoea and dysentery are found to al- ternate with rheumatism of the extremities, and particularly of the lower limbs. Wherever such cases happen, they are found to yield more readily to spinal treatment than to any other mode of cure, thus affording another proof of the spinal origin of such cases. On the whole it seems to me that the evidence for the pathology contended for, is much more conclusive in the present instance, than that on which the profession is accustomed to rest for much of its ac- credited science. As far as I can comprehend the objectors, their main difficulty lies in abandoning an unquestioned opinion, founded on prescriptive learning, and the more obvious phenomena of the dis- ease. But even they will find it impossible to explain away the facts brought forward in favour of the new doctrine, unless they can show that in original inflammations of the periphery, the most judicious treatment consists in applications to the centre, a position fully over- thrown by every abortive attempt to remedy sprains or bruises of the limbs by medicaments to the spine. Another objection lies in the ab- sence of tenderness of such parts of the spine as are here presumed to be under irritation. If, however, that irritation transmits pain to a remote part, we ought not to expect to find it tender on pressure, but we ought to look for aggravation of the peripheral disease, an event actually produced in Dr. Parker's case. In a very few persons the spine was found tender on pressure, but these were patients who belonged to a debilitated class, in whom certain parts of the spine are almost always found too susceptible, whether they have or have not rheumatism, hysteria, or any fibrous or any uterine irritation. That tenderness so much insisted on, is but proof of an irritated con- dition of the spinal braces, the effect of weakness too highly tasked, and is totally independent of disease of the medulla spinalis. So far as this case has been discussed, the facts have been adduced solely on the side of the new doctrine, while its opponents have con- 14 tented themselves with irrational and supposititious objections, ac- cording to a system which long since driven from other sciences, finds yet, I am sorry to say, a refuge in the temple of medical dog- matism. They admit the remarkable cures, the potent practice. They do not deny that rheumatism is produced by caries and injury of the spine, but as they do not see or feel the spinal irritation in the rest of the cases, the treatment, the relief, the victory over this obstinate malady, carry no argument to them, though sustained by analogies so striking and so profitable. Tabular Abstract of Cases. Name. Date of ad- mission. Date of Cure. Duration of treatment. Remarks. W. W. - - - 1st Sept. 1 day Eliz. Turner - 14th Sept. 4 days Geo. Steiner - 13 th May 18 th May 5 do. Chas. Wilson - 21st Jan. 9th Feb. 19 do. Spinal treatment failed. W. Barnard 15th Mar. 20th Mar. 5 do. Chas. Schroeder 30th Mar. 1st Apr. 2 do. W. Bowes - - 1st Nov. 6th Nov. 5 do. Anthony Della 20th Dec. 25th Dec. 5 do. Christ. Rudolph 23d Dec. 25th Dec. 2 do. Daniel Wilson 30th Dec. 2d Jan. 3 do. John Morgan - 30th Dec. 2d Jan. 3 do. Charles Slater 3d Jan. 11th Jan. 8 do. Andrew Franklin 3d Dec. 11th Feb. 70 do. Four relapses. W. Carter - - 16th Feb. 22d Feb. 6 do. Joseph Pratt - 4th Oct. 6th Oct. 2 do. ? Several other relapses, The same 15th Oct. 17th Oct. 2 do. j discharged on 24th Nov. Total, 59 days. Jos. L. Baker - 29th Nov. 3d Dec. 4 do. John Charles - 1st Dec. 4th Dec. 3 do. John Wilson - 3d Dec. 4th Dec. 1 day J. M. Grezinger 24th Oct. 19th Dec. 56 days Salivated. James Carpenter 7th Dec. 15th Dec. 8 do. Margaret Poston 24th Nov. 30th Jan. 67 do. Blisters and splints. W. White - - Relapsed Relapsed 23d Nov. 1st Dec. 2d Jan. 27th Nov. 26th Dec. 16th Feb. 4 do. T 26 do. £ 34 do. J Total, 74 days; other treatment used. John Cave - - 28th Dec. 2d Feb. 36 do. Splints. John Henry 2d Jan. 22d Jan. 20 do. W. Goldsmith 15th Jan. 19th Jan. 4 do. Capt. P. - - 10th Feb. 13th Feb. 3 do. G. W. Peirce - 13th Feb. 15th Feb. 2 do. M. Donnelly - 13th Feb. 27th Feb. 14 do. 7 Total, 22 days. Relapsed 2d Mar. 10th Mar. 8 do. 5 P. M'Coy - - 2d Feb. 10th Feb. 8 do. J. Parsonage - 23d Feb. 2d Mar. 7 do. W. Woodruff - 7th Jan. 26th Feb. 50 do. S. Summers - 25th Feb. 3d Mar. 7 do. R. M'Donald - 16th Feb. 6th Mar. 18 do. 15 Twenty-two of these cases were cured within eight days; and of the re- maining ten cases, four were instances of frequent relapses through im- prudent exposure during convalescence. At least two were supposed to complain for the purpose of remaining in the hospital, an event which not unfrequently exhibits hospital practice in a disadvantageous light. Only four cases therefore required any other than spinal treatment. Although cupping is the most potent mode of spinal treatment, I have, in private practice, not unfrequently found that a good rube- facient, such as a sinapism, produced great relief, and sometimes ef- fected a cure. At the very commencement of an attack, it is often adequate to the entire removal of the pain, and consequent preven- tion of greater severity of symptoms. FURTHER CASES AND OBSERVATIONS RELATIVE TO " / RHEUMATISM. By J. K. MITCHELL, M. D. ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL. [Extracted from the American Journal of the Medical Sciences, for August, 1833.] PHILADELPHIA: PRINTED BY J. R. A. SKERRETT. 1833. AGENTS FOR THE AMERICAN JOURN AL of the MEDICAL SCIENCES. MAINE-Augusta, Dole SI TZet/tng/on-11 allow eZl, Glazier, MastersSI Co.-Port- land, G. Hyde SI Co., Colman, Holden & Co.-West Jefferson, F. Sheppard, P.M. N. HAMPSHIRE-Portsmouth, J. F. Shores-Concord, Marsh, Capen & Lyon- Keene, G. Tilden-Hanover, T. Mann-Dover, S. C. Stevens, E. J. 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