"Fourthly. It is of great moment, if the bowels have been previ ously well opened, to exhibit, after the first blood-letting, an opiate of forty or fifty minims of the solution of muriate of morphia; or if the bowels have not been freely moved, to effect this indication, and take a second blood-letting, and after this to administer the opiate, which may either be given alone or conjoined with antimony." So wrote Dr. Craigie in 1840. In that year appeared also Bouillaud's " Traite Clinique cln Rhumatisme Articulaire," in which the treat ment by bleeding coup sur coup was advocated with characteristic ability and energy.
To Bouillaud, indeed, belongs the credit of having systematized this mode of treatment. The full extent of his credit in this respect is not generally recognized. Previous to his time the practice of phlebotomy was wanting in method. To take so many ounces of blood, and to repeat the operation in one, two, or more days, was all the recommendation. Bouillaud insisted that there should not be too long an interval between the different bleedings—that the second should be had recourse to before the effects of the first had fully passed off, and the third before the benefit of the second was lost. That is what he meant by his recommendation to bleed coup stir coup. It was the frequent repetition of the operation, rather than the quantity of blood taken, which formed the characteristic feature of his mode of treatment. If the pathological views which then pre vailed were correct, and if bleeding were the important therapeutic agent which it was believed to be, there can be no doubt that Bouil laud's idea was therapeutically sound. No single dose of any remedy could stop a disease like acute rheumatism. It would have to be repeated from time to time; and to get its full beneficial effect the second dose would have to be given before the first had quite ceased to act. Bouillaud's merit consists in having applied this sound therapeutic rule to the practice of phlebotomy.
About the middle of this century the practice of phlebotomy and the pathological views on which it was founded were vigorously as sailed. Facts tended to show that patients recovered more 'quickly and satisfactorily when they were not bled than when they were. This was noted in acute rheumatism as in other acute diseases. The rapid accumulation of such facts produced a marked reaction against the old mode of treatment, and within twenty years of the time that Bouillaud's book appeared, the practice of bleeding in acute rheu matism was all but abandoned. Other remedies besides bleeding
were used to allay the inflammation.
Purgatives were at one time a good deal used. Those most in vogue were the saline, chiefly the sulphates of magnesia and soda. Calomel was also thus employed, especially by Latham, and with results which gave satisfaction.
Diaphoretics, especially ipecacuanha and antimony in combination with opium, have been at all times much used. Dover's powder has enjoyed a specially high reputation. Referring to it Cullen says : -"Notwithstanding what I said in favor of venesection, I must own that I never saw a cure very quickly expedited by venesection alone, in the cure of any violent case of the disease; for the disease is liable to linger, and continue for a long time, and to pass into a chronic state. The Dover's powder gives us an opportunity of more effec tually and more safely curing the disease than by bleeding alone." Opium alone, except as a diaphoretic, was condemned by Cullen; but has had much said in its favor in more recent times by Corrigan, Trousseau, and others.
Cinchona, and its alkaloid quinine, have at different times had their claims to favorable consideration pressed. Morton was the first to use cinchona in acute rheumatism. Cullen gave the great weight of his authority against it. He regarded its employment as "abso lutely improper and manifestly hurtful" except in cases in which the acute stage had been subdued by bleeding and other measures, and in which the ailment threatened to become periodic. Haygarth, who first used it on the recommendation of Dr. Fothergill, brought for ward much testimony in its favor. George Fordyce used it early and freely. Its alkaloid quinine was at one time freely used, especially in France. A suspicion that it gave rise to cerebral symptoms and dangers prevented many from trying it, notwithstanding the strong recommendations of Briquet, Moimeret, and others.
Garrod tried to revive this treatment in a modified form. He gave the quinine along with carbonate of potassium—five grains of the former and thirty grains of the latter, every four hours "until the joint affection and febrile disturbance have completely abated." The bene fits which he claims for this plan are its greater efficacy, a diminished tendency to relapse, and a more satisfactory convalescence.