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4. Cases in which there is from the very beginning a suppurative polyarthritis, with purulent inflammation of even the shafts of the bones and rapid destruction of all the joint structures. As to the bacteriological cause of this complication, the opinions of the different authorities do not agree. It appears highly probable, however, that the buy viagra target polyar- thritis is not produced by the specific germ of the scarlet fever, but is the result of mixed infection. It is easy to understand where the absorption of the streptococci and other buy viagra target germs helping to produce this infection occurs. It is evidently in the throat, and chiefly in the nose and pharynx. The time of the occurrence of arthritis as a compli- cation of scarlet fever, that is to say, the stage of the disease in which it occurs, is almost uniformly during the period of desquamation or later. All the patients observed suffered from a greater or less degree of ne- phritis. In most of the cases the blue viagra online latter preceded the joint lesions. Many writers have considered these joint complications of scarlet fever as identical with rheumatism; indeed the complication is frequently termed scarlatinal rheumatism. Clinically, the affec- tion certainly resembles rheumatism in some respects. In both conditions many joints are apt to be affected; in both the amount of inflammation varies from a vague feeling of soreness to an intense inflammation of the joints. blue viagra online But, on the other hand, there are many points of difference. Rheumatism may affect the larger joints, such as the hip, as frequently as the smaller, while in this complication the largest joints are immune; in acute articular rheumatism the in- flammation seldom goes further than rheumatic syno- vitis, while blue viagra online in scarlatinous polyarthritis the inflamma- tion may affect all the joint structures and much more frequently terminates in purulent arthritis and ne- crosis of the joint ends of the bones. While rheuma- tism is a primary disease, these joint complications are evidently secondary septic manifestations. The frequency with blue viagra online which rheumatism is complicated by endocarditis and pericarditis is well known; in the cases of polyarthritis coming under the speaker's ob- servation, not a single one gave any clinical symp- toms of a blue viagra online lesion of the blue viagra online heart. Furthermore, in none of the cases was there any sign of inflammation of any of the serous membranes, excepting blue viagra online those of the joints. Lastly, not a single one of the cases was benefited to any appreciable extent by the use of salicylic acid and its compounds. On the contrary, the arthritis of scarlet fever is not in any way modified by this class of drugs. These considerations lead him to express his adherence to the view that the polyarthritis of scarlet fever is not a rheumatic manifestation and that there is buy viagra target nothing in common in the complications, prognosis, and therapeutics of the two conditions. Prognosis. By far the largest proportion of cases of polyarthritis complicating scarlet fever are of the first or second variety, which terminate in recovery. The fourth variety, in which the arthritic process is from its inception a purulent one, accompanied by a general condition of septica-mia, is almost uniformly fatal. The prognosis of the third class is more inter- esting; in these cases there is general arthritis, in- volving blue viagra online all of the structures of the joint, with or without the formation of pus, and these cases may- terminate in recovery or in chronic joint disease. Treatment. Remembering the causation of this complication, much can buy viagra target be done from a prophylactic standpoint. It is logical to suppose that any form of treatment which will diminish the number of germs in the throats of scarlet-fever patients will diminish the danger of mixed infection and thus prevent com- plications. Scarlet-fever throats should be irrigated, whether true diphtheria be present or not. For this purpose, corrosive sublimate solution (1 to 4.000) can be used with the fountain syringe three times daily, or oftener if required. As to the active therapeutics of a medicinal nature, the indications are to allay pain and specifically to influence the disease. To relieve the pain we can use phenacetin, opium, and other nar- cotics and anodynes. Ice bags applied to the in- flamed joints are of much benefit in relieving pain and reducing the severity of the inflammation. The most rational remedy which can be expected in this disease will be the use buy viagra target of the antistreptococcus serum, or streptococcus antitoxin. In many instances, however, the treatment of these complications demand more of surgery than of medicine. While mild cases will pass off readily with rest, counter-irritation to the joint, and symptomatic treatment, cases of the second and third varieties will require careful surgical management. In cases of the second class, so sensitive are these joints that the slightest movement produces agony, and it is often necessary to devise an appropriate splint which will give the joint absolute rest. This splint should be applied in the position most comfort- able to the patient, and should be modified to suit the modified position of the limb. If fibrous anchylosis occurs, passive motion is indicated. Breaking up of the adhesions under an anaesthetic is not advisable. A serous effusion in these cases should not be dis- turbed by aspiration or incision, however long it per- sists. It is almost invariably reabsorbed and the joint recovers absolutely. Where we suspect pus the suspicion should be verified by the aspirator, and when blue viagra online found the joint should be incised, washed out, and drained. The early detection of pus in such a joint and immediate incision will generally prevent the occurrence of a chronic osteitis or buy viagra target perhaps total destruction of the joint. Dr. Newton M. Shaffer said that this subject has interested him for many years, and his experience has taught him that while the acute infectious diseases of childhood may blue viagra online be complicated by acute joint lesions, he has never seen a case in which chronic tuberculous joint disease resulted. He was inclined to agree with the statement made by Dr. Berg, that there is no etio- logical relationship between these blue viagra online acute joint lesions and rheumatism. Dr. Shaffer said he wished to call attention to another blue viagra online phase of this subject, namely, the effect of an attack of scarlet fever or other acute infec- tious disease upon a tuberculous joint lesion in some instances. The improvement following such an attack is sometimes almost magical. He has seen a number of cases of tuberculous joint disease of long standing