In Pneumonia, at any rate in the stage of dry, pungently hot skin, it will be much better to commence with aconite, even if we afterwards employ quinine. The action of aconite in rapidly throwing open the cutaneous capillaries and inducing a large transpiration and evaporation from the skin has already been described; and at any rate as a first step in treatment the use of this drug is more appropriate than that of quinine. When the action of the skin has discharged a quantity of superfluous heat from the body, and thus relieved the distress of the nervous centres (including the respiratory), it may perhaps be found that we have already arrived at the end of the active inflammation, and that resolution is about to take place. There are, however, very many cases, especially those of double pneumonia (and more particularly the double pneumonia which is only one phase of a general blood-poisoning, of renal disease, etc.), where no such simple course can be expected; the inflammatory fever will soon regain and maintain its activity, and here the employment of quinine with alcohol will very probably become our best chance. But this is not always the case; and in a good many instances where I have seen a severe pneumonia complicate an acute or subacute nephritis, the use of digitalis afforded relief of a far superior kind to any effect of quinine that I have witnessed, even in more favorable cases.

In cases of pneumonia which are markedly asthenic from the first, it has been shown by Sir Dominic Corrigan that the use of quinine throughout is most valuable; about five grains every three hours are to be given. He states, however, that in young persons with evidence of general capillary congestion, the administration of quinine should be preceded by local depletion - an assertion which is open to much doubt, for these patients are usually in a state of great depression, and while the abstraction of blood from the cutaneous vessels of the chest may very probably cause an undesirable loss of strength, it is difficult to see how it can seriously affect the vascular engorgement of the lungs.

Much more might be said respecting the varying circumstances under which quinine is more or less useful in acute inflammations, but it will be better to pass on to the next division of the present subject.

8. The use of quinine in Nervous diseases is a subject with regard to which every one seems to assume that a great deal is known; yet, when we come to test this knowledge, much of it will be found to be very vague, and a good many of the popular views are certainly incorrect.

In Neuralgia quinine is to this day considered the sheet-anchor by most practitioners, although the erroneousness of the opinion has been pointed out by many high authorities. If we exclude the cases which are partially or wholly due to a malarial influence (and which form a very small proportion of the neuralgias actually encountered in practice), it will be found that quinine has not an extensive sphere of curative action. It has some hitherto unexplained preferential influence on the neuralgias of the ophthalmic division of the fifth cranial; but upon neuralgias of other nerves it frequently - perhaps most frequently - fails to produce any decided impression. In fact, not only is this the case, but we often meet with patients in whom much harm has been done by attacking an ordinary neuralgia with repeated and increasing doses of quinine; the nervous system gets seriously upset; there is more or less marked cinchonism; and the pain, so far from being relieved, is aggravated. It is a stereotyped remark in medical works that the more exactly a nervous (or indeed any other) disease conforms to a regular type of periodic exacerbations, the more surely will quinine prove useful. As a general proposition this is untrue. It is only when the neuralgia is due to actual malaria that the rule holds; and in the case of recurrent inflammations, or of hectic, there must be either malaria or else septic poisoning at work, or else we shall find this maxim fail us.

Among the non-malarial neuralgias there are none so often typically periodic as migraine; very often the attacks occur with the strictest regularity every month or every fortnight; yet there is no disease in which quinine is less of a specific. Its failures are many times more numerous than its apparent successes.

In Epilepsy I have already said that quinine is highly effective when malaria has been a cause; and by various authors it has been asserted that it is applicable to the simple non-malarious disease. No such pretensions, however, would at present be supported by our principal authorities on nervous diseases. Epilepsy can, unhappily, be studied on an immense scale at the London hospitals and dispensaries; and no one who had had such experience would now entertain the least hope of doing good with quinine, except in cases of a special nature, and which occur but rarely. Even of these it is likely that a considerable proportion are in truth obscurely malarial in origin, though the fact escapes the practitioner's observation.

In Tetanus, also, quinine has quite sunk in the estimation of prac tical physicians and surgeons from the high place which it once seemed destined to fill. There is, no doubt, one variety of the disease in which malaria plays a part, and here quinine will certainly be useful. But of the ordinary English or European cases, traumatic or otherwise, those that recover are now supposed with much probability to owe their escape from death to purely natural causes, independent of remedies. I should be loth to express myself as hostile to all attempts to benefit patients in tetanus with quinine, but I cannot but think that, at any rate in severe cases, it would be better to lose no time in applying one of those agents which are known to have a direct action in reducing reflex irritability, with which property there is no ground for crediting quinine.