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rapid and sudden that recovery cannot take place in time. Naturally, this condition one would expect to find in one with weak mus'les or in those in whom the muscles have been tired out by prolonged exertion, and who from fatigue have lost their instinctive vigilance discount viagra china and power of recovery so essential to generic viagra authentic the safety of generic viagra authentic a joint. The muscles are really as much a part of a joint as the bones and ligaments. The function of a joint is movement. Considering the way in which sprains interfere with this, the muscles which direct and execute these movements are as much concerned as the ligaments, which have only the passive mission of checking them when they become excessive. The question of diagnosis is, generally speaking, not diffi- cult, though in sprains generic viagra authentic of some of the complicated joints it is often by no means generic viagra authentic easy. Dislocations. Fractures near joints and in chil- dren the separation of the epiphyses of the bones must all be excluded. Without an anaesthetic in the severe sprains of the larger joints it is often impossible to discount viagra china make a positive diagnosis. More than once have I etherized with the idea of reducing a complicated frac- ture and have found a sprain instead. The pain of a sprain is of a peculiar sickening character. Indeed, it is so sudden and often so severe as to cause strong men to faint. Muscular sprains are, as a rule, dis- tinguished by a peculiar sensitiveness of the skin, most marked over the joints or at the point of attach- ment to the bones or tendons. Very often after the 8 3 6 discount viagra china MEDICAL RECORD. [June 13, 1896 joint has almost recovered from a sprain, and an im- perfect diagnosis or no diagnosis has been made, we can clear up the matter, with some joints at least, by carefully observing the tender points. generic viagra authentic A tender spot just back of the greater trochanter nearly always af- fords valuable information as to a hip-joint sprain. In the knee this tender spot is toward the underside of the knee cap slightly below the joint centre. With the ankle joint, while the sprain is constant, its location is not so constant, though it is usually toward the inner side of the external malleolus. The tender spots prob- ably generally mark the generic viagra authentic location of adherent bands or perhaps roughened synovial fringes, or sometimes spots where there has been extravasation of blood into the joint capsule. We now come to the question of treatment, and our results will depend on the earl iness with which we see these cases, and on the thoroughness with which we carry out certain fixed indications. These indications are just three : 1st. To limit the extravasation of blood and lymph. 2d. To promote the absorption of effusion. 3d. To promote the healing of the torn structures, and to restore the usefulness of the joint. We can best control the extravasation due to broken blood-vessels by local applications, by placing the joint in the proper position and by the use of judicious pressure and thus securing rest for the joint. One of the best local applications is cold water, but strange to say in most cases we do not usually get satisfactory results from its use. This is because we do not see our cases early enough. Unless they are seen within one or two hours after the injury, or unless later in the case inflammation sets in as a complication, cold applications do not answer as well as do hot ones. Soaking the part in very hot water in these delayed cases not only relieves the pain better, but it seems to produce a more permanent impression on the generic viagra authentic swelling. The various other local applications almost invariably owe whatever virtue they possess to the spirits they contain. We can, however, make an exception with the old time honored lotion of lead water and laudanum. Much may be done to check the bleeding from torn vessels by placing the articulation in such a position that the joint cavity is diminished. If left to itself, discount viagra china in most sprains we find the joint in a condition of discount viagra china con- siderable flexion. While this position gives the most comfort temporarily, it conduces to a generic viagra authentic continuance of the bleeding, because it enlarges the joint cavity to its full extent. We can rely on the judicious appli- cation of pressure, however, not only to limit the amount of effused material, but to relieve the pain as- well. Pressure as usually applied by bandaging does more harm than good. The bony prominences which do not need it receive the support, while the hollows and irregularities about the articulation do not get any at all. It has been my pra< tire to loosely envelop the joint with a couple of layers of absorbent lint which has been saturated with a lead-water and laudanum solution. Over this a good thick padding of cotton wool is applied, care being taken to make it thicker over the hollows and irregularities. Well-picked oakum is a good substitute for the < otton. A bandage carefully applied over sui li a dressing will make the ideal com- pression and support. Sprains of most joints, when treated with proper local applications, position, band- aging, and rest, do not require a splint. It is good rou- tine praetiee. however, to ex< lude from this discount viagra china the knee and the elbow, the two most complicated joints. It is well in these sprains to apply a felt splint if the injury is at all generic viagra authentic severe. Just how long we should e discount viagra china in- jured parts rest w ithout disturbance is discount viagra china often hard to determine. Prob 1 joints are tested too long. Rest in these cases is a necessity, and while it is the first indication in this class of injuries, as well as in all others, yet a time comes when rest can be carried too far. After the subsidence of the swelling, in most cases we can begin movement within three or font- days. Unless we have to deal with a rheumatic or gouty subject, this, as a rule, is not too early. Acute