Besides the direct action which quinine may exercise upon uncomplicated fevers, we must remember that its use may be specially called for in those septic infections which so frequently occur as complications; as familiar examples I may mention the mischief caused by the absorption of putrid matters from the throat in scarlet fever, or from the bowel in typhoid fever. It can scarcely be doubted by any experienced person that in these circumstances quinine, with more or less aid from alcohol, affords one of our best sources of hope. Here, however, it is again necessary to employ very large and repeated doses.

In Whooping-cough we have a disease which can as yet only doubtfully be reckoned as of septic origin; but after the recent observations of Binz it must be considered at least probable that this is the case, and that quinine in large doses is one of the most appropriate remedies.

In Hay-fever there appears to be still better ground for supposing that quinine may prove useful in virtue of its antiseptic powers. The observation was first made by Helmholtz, and subsequently confirmed by Binz, that the injection of a solution of quinine into the nares checked the irritative catarrhal discharge and also the spasmodic symptoms.

The Hectic fever even of some chronic diseases is probably in a certain number of instances at least partly due to septic infection. In many examples of phthisis, with lung softening, one can hardly doubt that the rhythmic recurrence of fever is at least as much due to the absorption of putrescent matter from the cavities as to the exhaustion of the nervous system. Still less can we doubt that the hectic attending very large chronic abscesses connected with carious bone partakes of the character of a true pyaemic poisoning in minute but incessantly repeated doses. In both these last-quoted examples the influence of quinine can ordinarily only be effective when it is given in considerable quantities; from twelve to twenty grains daily is by no means an excessive amount.

I freely admit, however, that in many of the examples of septic fever in chronic disease there may be reasons which abundantly outweigh the arguments for the administration of quinine. Irritability of the stomach and intestines will very often prevent one from using it, especially in large doses; but the hydrochlorate will occasionally be tolerated when the sulphate cannot be borne.

y. The employment of quinine in Inflammations is a very large subject, and one which, as yet, has only been incompletely studied. From time to time some author has strongly asserted its merits in regard to a particular inflammatory disease, such, for instance, as peritonitis, in which is was so warmly recommended by Trousseau. Other authors again have occasionally expressed in general terms the opinion that quinine was antiphlogistic; but nothing like a scientific basis for this belief existed previous to the researches already mentioned, in which the multiplication and the wandering of white blood-corpuscles was plainly observed to be checked by the action of the remedy. Henceforth it must be considered as established that quinine is naturally indicated in most inflammations, especially of the acuter sort; and that the question whether it shall be given or withheld in any particular case can only arise in consequence of accidental peculiarities in the phenomena of the disease. That objections of a most practical kind do exist, however, to its use in many cases of inflammation, no experienced practitioner can doubt; and it seems advisable to give a general glance at the character of the various obstacles to its employment which are likely to present themselves.

The primary objection which is most likely to occur is doubtless the incapacity of the stomach to bear with doses that would be sufficient to materially influence progress. In these cases, supposing the need of quinine to be urgent, we have still some chance of being able to use it. As already mentioned, the hydrochlorate will often be borne by the stomach when the sulphate will not; indeed it is probable that the latter ought to be entirely superseded by the former. If not successful, we may try injection per rectum, though for obvious reasons this is inconvenient. Finally, there is the subcutaneous method, which, however, has difficulties of its own as to which I must speak presently. Another objection is the ease with which some patients are cinchonized, making it nearly impossible to give them doses large enough to affect the inflammation. In a certain proportion of such cases it will be possible to mitigate or even prevent this effect by the simultaneous use of alcohol in large doses; this is equally true of severe double pneumonia, as Socin found it true of traumatic erysipelas.

It is also to be remarked that not merely ordinary cinchonism, but even fatal results have occasionally ensued upon the use of doses by no means enormous in comparison with the quantities which have frequently been given; this seems to depend upon an idiosyncrasy which is probably somewhat rare, and it is difficult to see how it can be perfectly guarded against. It is probably less likely to occur if the patient be simultaneously treated with alcoholic stimulants; but there might of course be objections to these.

As regards its fancied tendencies to aggravate delirium, it does not appear that in inflammatory fever quinine produces this effect, except very rarely. If the patient escapes the phenomena of ordinary cinchonism, it will be found nearly always that his nervous centres are in all respects far more tolerant of the drug than they would be in health.

It is perhaps scarcely worth while to dwell upon the still rarer inconveniences which quinine produces in a very small number of persons with peculiar tendencies, e. g., the very singular effects upon the nutrition of the skin which have been mentioned above.

To say, however, that because the difficulties now described do not seriously hinder the administration of quinine in a large majority of inflammatory cases, therefore it should nearly always be administered, would be to go much too far. For there are several other antiphlogistic remedies which, in particular instances, will respectively be found superior to quinine.