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By P. Zuben. University of Minnesota-Morris.

For example buy 100 mg suhagra overnight delivery, erythromycin may eradicate the infection in the pregnant woman order 100 mg suhagra otc, but may not prevent congenital syphilis (Preblud and Williams order suhagra online from canada, 1985; Wendel and Gilstrap, 1990; Wendel et al. Another agent, tetracycline, may be associated with significant yellow-brown discoloration of the fetal deciduous teeth and is currently not recommended for use in the latter half of pregnancy (Genot et al. The cur- rent recommended approach to the pregnant patient with syphilis who is allergic to penicillin is to utilize penicillin desensitization, as outlined in Box 2. Penicillin is the ideal antibiotic choice for the treatment of syphilis during pregnancy (Bofill and Rust, 1996). Chlamydia trachomatis may be isolated in up to 30 percent of women of lower socioeconomic status (unpublished observations, 1990). Erythromycin base or stearate in a dose of 500 mg four times a day for 7–10 days will generally prove satisfactory for the treatment of chlamydial infections during pregnancy. Other antimicrobial agents such as amoxi- cillin (with or without clavulanic acid), clindamycin, or azithromycin (1 g single oral dose), may prove satisfactory in eradicating chlamydial infections in pregnant women who are unable to tolerate erythromycin because of its gastrointestinal side effects. Viral infections Fortunately, the majority of viral infections encountered during pregnancy do not require any specific therapy. Patients with life-threatening disseminated viral infections, such as varicella zoster or herpes infections, should be treated with acyclovir, as the benefits clearly outweigh any potential risk. Acyclovir is not recommended for the routine treatment of localized genital tract herpes simplex virus infections (Scott et al. Vaccines Fortunately, most pregnant women do not require vaccination during pregnancy. However, as with drugs and medications, occasionally a woman will be given an immunization when she does not realize she is newly pregnant. Probably the two most common immunizations given in this instance are rubella and influenza. Needless to say, the mortality to both mother and neonate from tetanus is extremely high, and active immunization to the mother will pro- vide protection to the neonate in the range of 80–95 percent or greater if the mother has received at least two doses 2 weeks before delivery (Faix, 1991; Hayden et al. There are no reports of adverse fetal effects from any of these inactivated bacterial vaccines. The dose schedule recommended for hepatitis B immune globulin and for vaccina- tion is summarized in Table 2. However, several authors have recommended its use in susceptible pregnant women if it can be given within 96 h (Enders, 1985; Faix, 1991; MacGregor et al. Enders (1985) has published the most compelling data to support this recommendation. Although pregnancy is considered contraindicated in women within 3 months of receiving the rubella vaccine, the actual risk of congenital rubella syndrome from maternal vaccination would appear to be extremely small, if it exists at all (Preblud and Williams, 1985). Measles and mumps vaccines are also considered contraindicated during pregnancy, although pooled immune globulin (0. Obviously the benefits of rabies vaccination (considering the high mortality of rabies of nearly 100 percent) far outweigh any theoretical risk to the fetus, which is actually unknown. Although influenza vaccines are not routinely recommended for all pregnant women, they may be efficacious in cer- tain pregnant women with significant medical complications. The physician is concerned with whether a specific medication is safe for the fetus, remaining cognizant that most car- diac medications are chronically used to treat life-threatening conditions, and that these therapeutics cannot be discontinued when pregnancy is first diagnosed (Little and Gilstrap, 1989). Hence, embryos/fetuses of women with cardiovascular disease are exposed to these medications during the critical period of organogenesis (i. Since heart disease may be inherited in a multifactorial or polygenic fashion, pregnant women with many forms of heart disease may give birth to a newborn with congenital heart disease, and this mal- formation may in turn be blamed by both the patient and her attorney on specific car- diac medications. Scientific studies regarding the efficacy and safety of most cardiac medications during pregnancy are not conclusive, but the life-threatening nature of cardiovascular disease mandates that treatment be provided, even during pregnancy. The few investigations that are available indicate that dose and timing adjustment may be necessary because of (1) decreased drug serum concentrations (Cmax and steady state); (2) decreased half-life; and (3) increased clearance (Table 3. Cardiovascular medications may be classified into several categories: antiarrhythmic, cardiac glycosides, anticoagulants, diuretics, antihypertensives, and antianginals. This classification may prove useful in predicting both the efficacy and the toxicity of a specific agent (Brown and Wendel, 1989). Antiarrhythmics have been classified into six classes according to their major mode of action or effect (Vaughan Williams, 1984), as shown in Tables 3. Lidocaine Commonly used as an amide local anesthetic, lidocaine is also effective in the treatment of ventricular and supraventricular tachycardias. Lidocaine rapidly crosses the placenta and fetal levels reach about 50 percent of maternal levels within less than an hour 54 Cardiovascular drugs during pregnancy (Rotmensch et al. Lidocaine’s half-life is twice as long in the fetus/neonate (3 h) than in the mother (1. Importantly, most information available regarding pharmacokinetics of lidocaine in pregnant and postpartum women and newborns is from studies of regional or local anesthesia (Rotmensch et al. No published data are available on lidocaine from women who received the drug for cardiac arrhythmias. However, local anesthetics given in toxic doses may result in central nervous system and cardiac side effects in both the mother and the fetus. Lidocaine is not known to be ter- atogenic at acute therapeutic levels in humans or in chronic doses in animals (Fujinaga and Mazze, 1986; Heinonen et al. Toxicity risk is mini- mal when maternal lidocaine levels are maintained at less than 4 mg/mL (Bhagwat and Engel, 1995). Amide-type local anesthetics given for paracervical block are associated with spasm of the uterine arteries, causing decreased uterine blood flow. Procainamide Another amide compound, procainamide, is used to treat ventricular tachycardia. There is little information regarding the pharmacokinetics of this drug during pregnancy. However, it has been estimated that fetal levels are approximately one-fourth the mater- nal levels (Garite and Briggs, 1987). Scientific evidence of the safety of procainamide for use during pregnancy does not address possible human teratogenicity. However, given the safety profile of a closely related drug (lidocaine), procainamide seems to not pose a great risk when used during pregnancy (Little and Gilstrap, 1989). Chronic use of this drug should be avoided, unless necessary for life-threatening conditions, because a lupus-like syndrome may occur (Rotmensch et al. Breastfeeding is not contra- indicated in mothers on procainamide (American Academy of Pediatrics, 1994). Encainide and flecainide Two other lidocaine-related antiarrhythmic medications are encainide and flecainide. Encainide was not teratogenic in rats and rabbits when given at doses up to 9 and 13 times the human dose (data from the manufacturer’s insert). Flecainide has been reported to cause teratogenic and embryotoxic effects in some species of rabbits when given in doses four times the usual adult dose. It was not, however, teratogenic in rats, mice, and other species of rabbits when given in the usual adult dose, according to its manufacturer.

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It will be found of value in gonorrhea cheap 100 mg suhagra with visa, gleet and prostatorrhea buy suhagra 100 mg low price, and also in the sexual irritability purchase suhagra cheap, and impotence of the male. Senecio has an influence on the mucous surfaces, relieving congestion and correcting catarrhal disorders. It assists digestion, stimulates the secretion of gastric fluids and overcomes the conditions which cause the food to lie heavily in the stomach. In the accumulation of frothy saliva it is useful and in a constipation accompanying uterine disorders it is especially valuable. The agent has exercised an active influence in a number of cases of capillary hemorrhage. It has been given in haematuria in spoonful doses of the fluid extract, three or four times a day, with positive results. In albuminuria, with occasional attacks of haematuria, especially if occurring during pregnancy, the agent will act promptly. In hemorrhage of the lungs, or from the stomach of a passive character, it will work well. Co-operatives—In acts in harmony with viburnum, helonias, aralia, Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 399 mitchella repens, and other agents of this character. Physiological Action—The attention of the profession was called to this palm by Goss and others, from its superior fat producing properties in animals. It was observed as soon as the berries matured that the animals which fed upon them grew very sleek and fat. Read noticed the marked healthfulness of these animals, and concluded to try the berries as a medicine. As a result he found them to improve the digestion, increase the flesh, strength and weight, and steadily relieve irritation of mucous structures, especially those of the nose and air passages. Subsequent observation has proven the remedy to be a tonic of much power in stimulating the nutrition of the nerve centers, upon and through which it operates. It relieves irritability of the entire nervous system and soothes local irritation. It stimulates digestion, greatly improves the appetite, and encourages assimilation. As stated, it influences the mucous structures of the nose, throat and bronchi in a remarkable manner, overcoming catarrh and restoring normal function. Specific Symptomatology—The direct influence of this agent is exerted upon the entire reproductive apparatus, especially upon the prostate gland of the male. It is demanded in enlarged prostate, with throbbing, aching, dull pain, discharge of prostatic fluid, at times discharge of mucus, also of a yellowish, watery fluid, with weakened sexual power, orchialgia, epididymitis and orchitis, when associated with enlarged prostate. In women, ovarian enlargement, with tenderness and dull aching pains, weakened sexual activity, and small, undeveloped mammary glands, are much benefited by its continued use. Therapy—It is a sedative to all irritable conditions of these organs, and is a profound nutritive tonic, operating much like phosphorus. It increases the size and secreting power of the mammary glands where they are abnormally small and inactive. It improves the tone, and overcomes Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 400 irritability of the ovaries, relieving dysmenorrhea when due to atonicity. It may be given with confidence in wasting of the testes in the early stages, and the author has retarded the development of varicocele and has developed the growth and nutrition of the testes materially by its use. To this agent is ascribed considerable power in reducing the size of hypertrophied prostate in old men, and in quickly relieving cystic and other disorders incident to this condition. It relieves irritation of the bladder to a satisfactory extent, correcting the irritable character of the urine, increases the muscular power of the patient to expel the urine and produces a sense of relief, that is in every way gratifying and satisfactory. In the treatment of impotence in young men who have been excessive in their habits, or have masturbated, it can be relied upon with positiveness. It will overcome the excitability from exhaustion and increase sexual power in those newly married who, having been anxious concerning their sexual strength or ability, have become suddenly almost entirely impotent after marriage. If the patient is instructed to abstain, for from four to six weeks, and to have confidence in his ultimate recovery, this agent in doses of from twenty to thirty drops three or four times daily, combined with a direct nerve tonic, such as avena sativa in doses of fifteen drops, or the one one-hundredth of a grain of phosphorus, will establish a cure. It will relieve any undue irritation, due to excess and exhaustion, that may be present in any part of the genito-urinary apparatus. This agent is a remedy for sexual neurasthenia or sexual perversion with nerve exhaustion, a condition often overlooked in diagnosis, but quite common, one which follows onanism more often than any other habit. Its use should be persisted in for weeks, in the treatment of this form of nerve exhaustion, and if combined with avena sativa, the phosphates, strychnia, or the tonic gold salts, and abstinence enforced, a cure will result more readily than with all the rest without it. An exceedingly important use for this remedy that I have not been able to find in the books, is its use for sterility. In simple cases where there is no organic lesion on the part of the patient, this agent has an excellent reputation for restoring the ovarian action properly and assisting in putting the patient into an excellent condition. One conscientious Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 401 reliable lady physician assures me that in five definite cases, pregnancy has followed the use of this remedy where sterility was pronounced previously, and thought to be incurable. Hale in his little work on this remedy said: “I consider saw palmetto one of the most effectual uterine remedies. This remedy was spoken highly of by Rademacher, in hemorrhages, where there was congestion of the liver or spleen. He employed the tincture of the seeds, in dysuria, where there were caruncular growths, in the female urethra. This condition has been neglected by internists, they having been taught that it was a surgical condition only. A case of chronic hematuria, with sensation of weight and tension in the Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 402 pelvis depending upon varicose conditions of the rectal veins, was quickly relieved by it. Specific Symptomatology—Felter and Lloyd say that its indications are found in dull aching pain over the spleen, which passes up to the left scapula, associated with pronounced debility and despondency, splenic pain, with no enlargement or with enlargement, when there are no evidences of malaria. General bilious conditions accompanied with stitches in the right side, with hard and tender spots, in this locality, gall stone, jaundice, hepatic pain and swelling. As it overcomes congestion within the pelvis, it is useful in certain forms of dysmenorrhea, amenorrhea, or irregular passive uterine hemorrhages. Therapy—Harvey, in the California Medical Journal, says the indications are so plain that a tyro can prescribe it with certainty. It is indicated where there is venous stasis, the true veins enlarged and clogged with blood. He says he cured one case, where the veins from the hips to the toes were as large and as hard and twisted as Manila rope. There was a troublesome chronic cough with the expectoration of large quantities of offensive matter. He had observed these colored spots in other cases, and sometimes found long continued soreness and tenderness of the joints of the feet. Carduus, in five-drop doses three or four times a day, cured all the symptoms in this case, restoring the patient to perfect health. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 403 Physiological Action—Mustard is emetic, stimulant and actively revulsive with marked anodyne properties. Its application to the skin produces intense burning, violent inflammation, and if persisted in too long, sloughing or ulceration.

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This view was partly based on findings in enzymology generic suhagra 100mg on-line, in which this concept is generally valid for metabolite–antimetabolite competition as well as for activity studies of vitamins and hormones buy suhagra 100mg low price. An antimetabolite is a molecular analog of an intermediate in a physiologically relevant metabolic path- way that replaces a natural substrate discount suhagra 100mg. In doing so, it prevents the biosynthesis of phys- iologically important substances within the organism. The close structural resemblance of agonists and antagonists in these categories constitutes direct proof that they have identical binding sites. The lack of structural correlations between many neurotrans- mitters and their blocking agents, however, initiated a review of the competitive bind- ing hypothesis. It is generally accepted that there is complementarity between a ligand (either endogenous [e. Under optimal conditions, the energies liberated in binding can reach 40–50 kJ/mol, a figure equivalent to binding equilibrium constants of about 10–8–10–9, which is considered to represent a high affinity. Complementarity in the context of induced fit implies a plasticity of the receptor macromolecule in terms of an ability to undergo conformational changes and associate with ligands. For stereospecific binding, it is generally assumed that a ligand must have three unequal substituents; this is considered sufficient for great selectivity. The discrete forms of a receptor site are, of course, the result of receptor plasticity. Recognizing this capacity of the receptor to assume different molecular geometries without a significant change in function is probably essential to achieving some under- standing of the pluralistic nature of many receptors. It is physiologically and struc- turally unreasonable to assume that a given type of receptor—probably a complex, multisubunit structure that is part of an even more complex membrane framework—is absolutely identical throughout an organism. Mautner pointed out in 1967, long before the structure of any drug receptor was known in any detail, that the medicinal chemist would have to deal with an isoreceptor concept in the same matter-of-fact way that an enzymologist accepts isozymes. Despite recent advances in molecular biology, our present knowledge of receptor structure is still evolving. Consider, for example, the presence of opiate receptors in both the central nervous system and the ileum. In the first case, the receptor modulates neurotransmitter release; in the second, it may activate an enzyme such as adenylate cyclase, or trigger an action poten- tial. As we shall see later, almost all neurotransmitters show receptor multiplicity, and medicinal chemists deal with multiple adrenergic receptor subtypes and many different opiate receptors, just to name two examples. Receptor plasticity could be invoked as the underlying common trait of multiple receptors. For example, although the multiple adrenergic isoreceptors are similar, they react to the common neurotransmitter norepinephrine (2. They also show a drug specificity that varies from organ to organ and differs in various species of animals. In subsequent chapters of this book, receptor multiplicity as the rule rather than the exception will become amply evident. It is to be hoped that, in time, the comparison of isoreceptor molecular structures will provide precise criteria for their differentiation. The multiplicity of receptor or recognition sites for agonists and antagonists is well documented. One may distinguish (i) agonist binding sites, (ii) competitive antagonist binding sites (accessory sites), and (iii) noncompetitive antagonist or regulatory bind- ing sites (allosteric sites). The agonist binding site is the subject of continuous discussion throughout this book, ranging from a purely physical approach to the treatment of its biochemical character- istics, where these are known. In this discussion, it is implicit that we are dealing with discrete loci on the receptor macromolecule: specific amino acids, lipids, or nucleotides held in just the right geometric configuration by the scaffold of the rest of the molecule, as well as by its supramolecular environment such as a membrane. Competitive antagonists were originally assumed to bind to the agonist binding site and, in some way, displace and exclude the agonist as a result of their very high affin- ity but lack of intrinsic activity. The mere fact of great chemical dissimilarity between agonists and competitive antagonists in the vast field of neurotransmitters precludes identity of the two receptor sites. It is evident at a glance that a careful analysis is needed to discern correlations between agonist–antagonist pairs or even between antagonists of the same class. The most remarkable property of antagonists is their great receptor affinity, which is sometimes two to four orders of magnitude greater than that of the agonists. Therefore, accessory binding sites must exist on the receptor to accommodate these large hydrophobic groups. What is even more remarkable is that there are some compounds that are antag- onistic in more than one system. In one of these, the antagonist binding site is considered to be topically close to the agonist site and may even partially overlap it. The antagonist will therefore interfere with agonist access to the receptor, even though it need not necessarily occupy both the agonist and the accessory sites. On the other hand, the antagonist may functionally deny agonist accessibility by altering the receptor affinity. Allosteric sites are at a distance from the agonist site and may even be on a different receptor protomer in the receptor–effector complex. Their occupation by allosteric inhibitors results in a conformational change that is propagated to the agonist site and changes its affinity. There is thus a mutual exclusion between the agonist and an allosteric antagonist. Moreover, classical pharmacological models cannot distinguish between com- petitive and allosteric inhibition. Just as in enzymology, some may activate whereas others deactivate one or another state of a receptor. As part of this transition, a number of molecular-level conceptual models of receptors have been put forth over the years. The two-state receptor model and the mobile receptor model are two examples of such models. Although these models have limited direct utility for the medicinal chemist involved in drug design, they are extremely instructive for a number of reasons. These models emphasize the fact that many receptors are not just simple macromole- cules, which interact with a drug in a “hand-in-glove” fashion. On the contrary, some receptors are extremely dynamic, existing as a family of low-energy conformers exist- ing in equilibrium with each other. Finally, some receptors are not only dynamic in terms of their shape, but also mobile, drifting in the membrane like an iceberg in the ocean. This model postulates that, regardless of the presence or absence of a ligand, the receptor exists in two distinct states, the R (relaxed, active, or “on”) and T (tense, inactive, or “off”) states, which are in equilibrium with each other. Some members of a receptor population are in the R state, even in the absence of any agonist.

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The medicinal properties must be extracted from the fresh herb order 100 mg suhagra amex, as the volatile character of anemonin permits of the rapid dissipation of these properties on drying order cheap suhagra. Physiological Action—The agent has a direct influence upon the brain and spinal cord generic suhagra 100 mg otc. In toxic doses it produces mental hebetude, dilated pupils, coma, and in extreme cases, convulsions. It increases, in proper doses, the cerebral functions and imparts tone to the sympathetic system. In toxic doses it is a heart depressant; it lowers arterial tension, reduces the pulse rate and temperature. It exercises an influence upon the heart similar to that of cactus, increasing its power, improving the strength and rate of the pulse and slowing the rapid and feeble pulse of nervous prostration. The influence of full doses of pulsatilla, taken into the stomach and Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 29 intestinal canal, is that of an irritant. In the mouth it acts like aconite or xanthoxylum, producing tingling, burning and subsequent numbness. It produces a sensation of rawness, and is followed by acid eructations and unpleasant taste. It produces tightness and constriction of the chest, with congestion, chilliness and great weakness. The agent is seldom given in sufficient doses to produce the physiological effects. In studying its medicinal influence on the circulation, pulsatilla is said to act in much the same manner as aconite during fevers, where there are high nervous manifestations. Where catarrhal disorders are present, subacute in character with congestion and a free discharge of thick bland, yellow or yellowish green mucous, it seems to act directly, except in chronic catarrhal conditions. This remedy will act satisfactorily only when the precise indications for which it should be prescribed, are present. Specific Symptomatology—Homeopathic physicians declare fearfulness as an indication, anticipation and dread of calamity, fear of trouble or death; in male patients suffering from sexual excesses, with spermatorrhea, threatened impotency, prostatorrhea, with fear of approaching imbecility. We find it indicated in amenorrhea, with mental perturbation, great apprehension of trouble. The remedy is especially efficacious when existing disorders of the reproductive organs are a cause of extreme anxiety. In addition to the well known indication, I might say that it is of value in disorders of the reproductive organs which depend upon defective innervation, and which are usually accompanied with manifestations of hysteria or melancholia, or which depend upon sexual derangements and menstrual disorders which are accompanied with loss of strength, chilliness, more or less headache, and gastric derangements, such as nausea, eructation of sour water and other nervous manifestations. Its best influence is exercised in women of blond temperament, particularly of lax muscular fiber, and of mild and yielding disposition, and smaller doses with these patients will produce better results than larger doses with other patients. Some writers claim that it may be given during the progress of inflammation of the mucous membranes, prescribed in much the same manner as aconite would be prescribed, or as cactus is given. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 30 It acts best in the catarrhal stage of inflammation rather than in the initial stage, and in this it differs somewhat from aconite. Therapy—Its influence is especially directed to that portion of the sympathetic nervous system influencing the reproductive organs. It increases the tone and functional power of these organs, and overcomes irregular, imperfect or deficient action. It has an apparent antispasmodic or nerve-soothing influence, which renders it valuable in hysteria and general nervous irritation with convulsive phenomena, in the absence of acute inflammation, blood determination or fever. A few physicians laud it highly in hysterical convulsions and in convulsive conditions due to uterine disorders. In general nervousness due to chronic uterine disorder, with or without hysteria, with despondency and nervous irritation, pulsatilla is an excellent remedy. In deficient, suppressed and irregular menstruation, with the above symptoms, it is of rare value. It is an excellent agent in small, frequent doses when the mental conditions above named are present during pregnancy, with a general relaxed and atonic condition. Its influence in these cases is enhanced by combination or alternation with cimicifuga. It certainly improves the general condition and conduces to a normal and easy labor. It acts better in the catarrhal stage of inflammation rather, than in the initial stage. In nervous exhaustion, with feeble pulse and deficient capillary circulation, cold extremities and a generally relaxed physical condition, it will serve an excellent purpose combined with other nerve tonics, or in conjunction with the directly indicated remedies. Strauss adds two drams to two ounces of water, and gives a teaspoonful every hour in his irritable cases, especially in low forms of Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 31 headache, light and dull; restlessness, patient rolling and tossing until worn out; a rambling mind with an occipital headache; mild ovaritis; mild neuralgia with irritation of the brain; dragging headache frequently occurring in women. Pulsatilla is a remedy for nervous headaches, especially if of the anemic variety, characterized by pallor of the countenance—the headaches of the menstrual epoch, of pregnancy, and also those of gastric origin with this specific character. It is excellent for the urinary irregularities of the pregnant condition, with ammoniacal urine, catarrh, pain, tenesmus, burning or sharp shooting pains. Its influence in this is facilitated by hydrangea, gelsemium or the benzoate or salicylate of lithium. Where there are menstrual disorders of any kind, if there be loss of strength, chilliness, headache, gastric derangements, sour stomach, and melancholia, pulsatilla is directly indicated. Leucorrheal discharges, attended with pain in the loins, weariness, depression of spirits, loss of appetite and general derangement of the nervous system, are also satisfactorily relieved by pulsatilla taken internally in five-drop doses of the tincture three times a day, and continued for a few weeks. Our observers in many cases combine pulsatilla with heart remedies and nux for heart trouble, and nervous weakness, especially if there be despondency, or with the alkaline salts in acid stomach. Homeopathists advise pulsatilla in catarrh of the stomach where the patient suffers most when the food is taken, or where the most benefit is derived from taking the food cold. Huffman prescribed it for the mental symptoms in a patient suffering from chronic catarrh of the stomach. This was followed by a burning sensation Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 32 from an excess of acids. The administration of pulsatilla and echinacea before meals finally completed the cure. Another writer cured the excessive acidity of these cases with five-drop doses of passiflora, every two hours. It is used in eruptive fevers, and in those cases of measles in which the eruption produces excessive irritation of the post-nasal cavity, throat and bronchial tubes. It has been lauded in rheumatism, but any specific influence in this condition is not ascribed to it. In gonorrheal epididymitis or in gonorrheal orchitis, the agent may be given with excellent results, especially if there be gleet and stricture. It is a tonic not only to the gastro-intestinal tract, but also to the respiratory and renal organs. It seems to possess properties very much like those of piper methysticum, and it can be used in the same conditions, as a tonic; combined with very small doses of specific nux vomica it is very Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 33 efficient. In tuberculosis, it has repute among the natives, and especially in tuberculosis with great weakness, and tendency to hemorrhage.