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The clinical varieties are: (1) Epiphysitis with secondary herb viagra joint involvement. (2) Hydrops. (3) Arthralgias. (4) Acute, subacute, or chronic synovitis. (5) Gummatous synovitis, primary or secondary. (6) Arthritis deformans type. (7) Chondroarthritis. (8) Mixed infections. In hereditary syphilis, the viagra femenina type most common in the first year of life is that secondary to an epiphy- sitis, also called osteochondritis and pseudoparal- ysis. The process usually starts in the epiphysis of viagra femenina long bones, most viagra femenina commonly at the lower end of the femur, and the upper end of the humerus, as an irregular painful thickening caused by an in- crease herb viagra in viagra femenina the number of cartilage cells. This inter- feres with its circulation and necrosis results, with herb viagra later separation of the epiphysis into joint, suppura- tion, fluctuation, and discharging sinuses. Before the epiphysis separates, the herb viagra joint effusion is serous. The limb affected usually is useless as far as power is concerned, and for this reason the condition is called "pseudoparalysis." As the condition favors the lower end of the femur and the upper end of the humerus, which are the important centers for growth of the extremities, there is often interfer- ence with the growth of the limb. This type is most commonly mistaken for tuberculous joints with sinus formation. In children between the ages of eight and fifteen years, a simple symmetrical synovial effusion or hydrops is the usual occurrence. The knees are usually affected, either one or both. The condition herb viagra is often intermittent following some systemic dis- turbance, such as sore throat, cold, etc. The swell- ing from effusion into the joint is variable in amount and is usually the only symptom. Pathologically, there are no changes except the effusion into the joint. Arthralgias, herb viagra or joint pains, are among the first manifestations of acquired syphilis and occur in the September 18, 1915] MEDICAL RECORD. 473 larger joints in the early secondary stage, before the rash appears. There are no physical findings, no limitation of motion, but vague pains viagra femenina around the joints, worse at night. In the later secondary stage, there is a condition resembling acute articular rheumatism, with high fever, multiarticular joint involvement with pain, tendei'ness, and swelling. The joints most com- monly affected are the knees, viagra femenina elbows, shoulders, and sternoclavicular. viagra femenina There are no acid sweats, and no cardiac involvement. It may resemble gonorrheal rheumatism. Subacute viagra femenina or chronic synovitis or hydroarthritis occurs in the viagra femenina late secondary stage, usually affecting one joint, and may be the remains of the acute type or develop gradually. The knee is usually affected. This condition is sometimes intermittent. There is but little pain, worse at night, slight limitation of motion, and a variable amount of effusion. Gummatous synovitis (Frauenthal) occurs in both herb viagra congenital and viagra femenina acquired syphilis. It is usually monoarticular and the knee is the favorite site. The process may be primary in joint or secondary to a gummatous periostitis. Those starting in bone produce the most destruction and greatest deform- ity. The condition starts as an irregular lumpy thickening of the synovia, with a variable amount of effusion into the joint. It resembles and is fre- quently mistaken for tumor albus. Gummata oc- cur around ligamentous attachments and as villi protruding from synovial membrane into joint. These may break into the joint, causing suppura- tion and later sinus formation. The joint affected presents marked deformity from effusion and gum- my masses, but limitation of motion is usually not so marked as appearances would indicate. Pains are not so marked but are worse at night. Remis- sions or almost complete cures with relapse are characteristic of this condition. The arthritis deformans type is the most com- mon form in acquired syphilis, but frequently oc- curs in viagra femenina the congenital forms. The condition is usu- ally multiarticular, except when it follows an injury to viagra femenina a joint, when the monoarticular form is the rule. Joints subjected to strain, as herb viagra in certain occupations, are the chief ones to be affected. In monoarticular forms, if syphilis exists, the synovite following an injury does not subside but becomes proliferative, and produces fibrous changes in the joint. In multi- articular forms, joints subjected to strain are af- fected, as the spine, elbows, wrists, and knees of bricklayers; spines of laborers; shoulders, viagra femenina elbows, wrists, and knees of laundresses, etc. The process may be gummatous, fibrous, or mixed, starting as an osteoperiostitis and spreading to perisynovial tis- sues, causing osteophytes, contraction of ligaments and tendons, producing limitation of motion with partial or complete ankylosis and deformity. Here again, pain is not a pronounced symptom unless there is much destruction ; it is much worse at night. Limitation of motion is not so marked as the appearance of the joints indicate. Chrondroarthritis occurs in congenital syphilis in children about fourteen. The chief feature is a recurring synovitis, with a chronic inflammation of neighboring bone, with pain and tenderness. Path- ologically, it is a rarefying osteitis with deposit of caseous material in the cancellous tissue. It ex- tends to the articular cartilage resulting in its grooving and pitting. The larger joints are favor- ite sites.