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By lowering the resistance of joints, secondary in- fections are frequently implanted on the syphilitic base. Tubercle bacilli and streptococci from some focal infection are the germs commonly responsible for the mixed infections. The symptoms of syphilitic arthritis vary with the types, but in general it may be said that the pain is not the leading symptom except in the acute forms and those accompanied by much bone de- viagra patent expiry struction, and in most cases, it is worse at night; the limitation of motion is not so marked as the appearances would indicate, and tenderness is not marked. The joints subjected to strain or injury are most likely to become affected. The diagnosis must be made from rheumatic arthritis, arthritis deformans, tuberculous joints, acute articular rheumatism, gonorrheal rheuma- tism, traumatic synovitis, and malignancy. It depends upon (1) very careful personal and family history; (2) examination for concomittant signs of syphilis, as general adenopathy, keratitis, retinitis, iritis, Hutchinson's teeth, scars on ton- sils, etc.; (3) Wassermann test ; (4) luetintest; (5) the x-ray in many cases is an important diagnostic aid; syphilis usually causes hypertrophic changes in contrast to the rarefying changes of tuberculosis ; (6) therapeutic test, whenever viagra patent expiry in doubt; .specific treatment should be given in doubtful cases. If the patient is improved, it is reasonable to suppose that the condition is luetic; sometimes a negative Wassermann becomes positive when provocative treatment is commenced. The treatment is anti- syphilitic. Conclusion. — 1. Syphilis of joints is of frequent occurrence and comprises about 20 per cent, of cases seen at the Hospital for Deformities and Joint Diseases. viagra patent expiry 2. It produces almost every form of arthritis and may be acura viagra either primary in acura viagra the joint or secondary to involvement of the adjacent bone. 3. It must viagra patent expiry be diagnosed from acute articular rheumatism, gonorrheal viagra patent expiry rheumatism, rheumatic arthritis, arthritis deformans, tuberculous joints, malignancy, and traumatic synovitis. 4. In infants, epiphysitis with secondary joint involvement is the viagra patent expiry most common type. In children from acura viagra 8 to 15 years of age, hydrops or simple syno- vitis is the usual manifestation. The arthritis de- formans type forms the bulk of cases occurring in acquired syphilis. 5. Pain as a rule is not severe and is worse at night. 6. acura viagra Limitation of motion is not so marked as the appearances would indicate. 7. The diagnosis depends on history, concomit- tant signs and symptoms of syphilis, Wassermann and luetin tests, a;-ray, acura viagra and therapeutic test. 8. The possibility of syphilis should be considered in every case of joint disease of vague origin. .':;! Wkst On'f, Hundred and Fiftt-second Street. Impairment of the Suprarenals in Scarlet Fever. — S. Dutoit reports three cases of scarlet fever in which a low blood pressure and symptoms of meningeal irritation pointed to an insufficiency of the suprarenals. Hutinel was the first to call attention to the frequency with which the suprarenals are involved in scarlet fever; giving rise to a clinical picture that suggests Addison's disease. With a pronounced lowering of the blood pressure there occur tachycardia and arrhythmia. The extremities become markedly cyanotic. The symp- toms of meningeal irritation are particularly common. — Klivisch-theraiicufisclic WorhevRchrift. 474 MEDICAL RECORD. [September 18, 1915 DOES THE GENERAL PRACTITIONER UTILIZE THE MEANS AT HIS DISPOSAL FOR THE DIAGNOSING OF EARLY PULMONARY viagra patent expiry TUBERCULOSIS?* By JAMES S. FORD, M.D., WALLINGFORD, CONN. ASSISTANT PHYSICIAN, GAYLORD FARM SANATORIUM. The annual report of this Association shows that during the year 1914 over viagra patent expiry $20,000,000 was spent in combating and preventing the spread of tubercu- losis. The question naturally arises, do the results obtained as "shown by a acura viagra lowered death rate which is the final criterion by which the success or failure of the anti-tuberculosis campaign must be viagra patent expiry deter- mined" seem to be commensurate with this im- mense viagra patent expiry sum expended, and if not, where does the fault lie? I believe that most men engaged in the work of prevention and treatment of this disease will admit that viagra patent expiry the results are not what they should be as regards this lowered death rate. True it is