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limb is supported by a suitable splint. If the steps described above are adequately taken, as a rule no septic fever, no destructive suppuration, will fol- low an accidental injury; though aseptic fever due to ab- sorption of non-decomposed secretions may often enough be observed. Tissues or bone, whose vitality was compromised by the crushing force causing the injury, will be gradually detached. This will be accompanied by a rather scanty secretion of thinnish sero-pus, and very little, if any, fever. b. Asej/tic Wounds. — The nature of many wounds and their causatiou is such as to preclude the probability of con- tamination. Most gunshot wounds and many compound fractures belong to this class. In these cases interference should be very discreet. buy generic amitriptyline It should consist of a cheap amitriptyline online thorough cleansing of the integument, ordinarily an aseptic dry dress- ing, or, in case of doubt, of superficial drainage and a moist dressing, together with reduction, support, and retention bv splint, where a fracture requires it. In the more extensive injuries of the extremities caused by crushing force, the gravity of the case hinges more upon the extent of the injury to the soft parts than to the bones. A compound fracture by direct force, for instance, amitriptyline costochondritis the blow of a hammer upon the tibia, where the crushing and lacera- tion of the soft parts is comparatively limited, is by far not amitriptyline cost in uk as dangerous as, for instance, the stripping off of the entire integument of the lower extremity, or the amitriptyline online uk crushing and purification of the large muscles, nerves, and vessels of the anterior and internal aspect of the thigh, though these latter injuries be uncomplicated by fracture. The shock, the pres- ence of average cost amitriptyline extensive thrombosis, in addition to the fact that with the large quantity of mortified tissues preservation of the aseptic state is extremely uncertain and difficult, class these injuries among the most grave and dangerous. c. Gunshot Wounds. — The fact that most fresh gunshot wounds are aseptic has been pointed out by Esmareh, and is now well established.. Reyher and Bergmann's experi- ences in the Russo-Turkish war put the fact beyond con- troversy. AVise precaution against infecting afresh gunshot wound will be richly rewarded by excellent results. In most cases cleansing and disinfection of the amitriptyline hcl generic elavil skin in the vicinity of the points of entrance and exit, together with a dry dressing, will be sufficient. If the case is complicated by fracture, a suitable splint, preferably plaster of Paris (Bergmann), should be added. If the course is free from septic fever and suppuration, this will be manifest within the first three or four days ; April 9, 18M7.1 LLOYD: ASHEV1LLE AND THE MOUNTAIXS OF NORTH CAROLINA. 899 t lie splint how much does amitriptyline cost can be left undisturbed for the length of time re- quired for the accomplishment of bony union. Flesh wounds will be healed within a fortnight or three weeks. Gunshot fractures will require a amitriptyline cost without insurance longer time for healing and consolidation, but are in no way different from ordinary compound fractures. The projectile will cause very little or no irritation in aseptic — that is, non-suppurating — gunshot wounds. Gen- erally it will become encysted. Search for the projectile in the bottom of the wound is rarely indicated. It can occur, however, that pressure of a projectile or its fragment, or a sharp spiculum of generic amitriptyline hcl bone, on a nerve trunk may necessitate search and extraction. generic drug amitriptyline This must be done under careful asepsis. It is even not necessary amitriptyline online to remove a projectile lodged under the skin. It will do no harm if left there until the channel which it cut by its passage through the tissues is obliterated, when its removal by incision can not lead to an infection of the bullet-track. In eases of injury to large vessels or the intestines, im- mediate interference can not be delayed, but should buy cheap amitriptyline be car- ried out under most rigid antiseptic precautions. Recent successes (W. T. Bull) achieved by immediate laparotomy and suture of the wounded intestines justify the procedure. Where the nature of the charge or the short distance from which the shot was delivered makes the entrance of a gun-wad probable, or where the examination of the super- jacent clothing shows a large defect, rendering the proba- bility great that shreds of soiled cloth have been carried to the bottom of the wound, dilatation, search, and extraction may be indicated. But it is better to wait in cases of doubt, as even these foreign substances may become en- cysted and harmless. Should suppuration follow, the patient will not be worse off than if a fruitless search had been made at the outset, amitriptyline online no prescription and the use of the suppurating tract as a guide will mate- rially facilitate the finding of the irritating body. [Note. — Reyher's observations* may serve as a fair sample of the radical change that has taken place in the re- sults of the treatment of gunshot fractures, Gunshot fracture of tie.' knee joint was formerly con- sidered a prima facie indication fur immediate amputation. Reyher treated eighteen fresh cases aseptically — that is, by cost of amitriptyline 25mg simply cleansing and disinfecting the skin about amitriptyline hydrochloride generic the wound, and occluding the same by an antiseptic dressing. Where the wound amitriptyline cost canada was gaping, or where there was ground to elavil generic amitriptyline sus- pecl the entrance of dirt or shreds of clothing into the bullet track, dilatation, irrigation, and extraction of the foreign body, with subsequent drainage, was practiced before the wound was sealed up. Of these eighteen eases, amitriptyline online purchase fifteen recovered with movable knee joints — s:i-:i per cent, of re-

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