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FARRELL: SURGEON ON THE FIRING LINE. [New York Medical Journal. be rolled up, separated from the other flap, and re- moved. In my early operations I was struck with the fact that in cases where the flaps were accidentally buttonholed, healing was much quicker and kinder, so that now as a routine, an incision is made low down through one of the flaps where such has not already been made inadvertently. It is well anafranil 50 mg to be careful to remove all portions of denuded cartilage, as the blood supply of this structure is rather poor, and, clomipramine hydrochloride as a corollary, it folloAvs that it is not wise to denude more than the case absolutely requires. Care should also be taken not to drop anafranil buy or leave be- tween the flaps any fragments of bone or cartilage or strands of cotton used in sponging. Of the different forms of packing, if any is to be used at all. the strips of gauze bandage impregnated with bismuth subnitrate powder folded over on itself, four or six thicknesses as the size of the nose might rec[uire, as suggested by Doctor Watson, are probably the best. The strips are put into both nostrils, one over the other, carefully and gently, care being taken not to crumple up the free mem- branous flap. The packing should be light, and after it is all in, the anterior free edge of the flap is found and gently pulled upon, to make sure that it has not doubled on itself — no stitches being neces- sary. This operation is an office operation — all of my cases with very few exceptions being done either in the office or in the dispensary of the Mount Sinai Hospital, and without the aid of assistants. The pa- tient sits up in an ordinary chair with a high back, and as a rule stands it well, especially if the opera- tion is done quickly. The average case can be done within cheap anafranil ten minutes of actual operating; more diffi- cult cases might take anafranil 150 mg as long as twenty minutes. Of this series, fully anafranil 150 one half required no more than ten minutes. After the operation the patient walks home, and is advised to lie down, if he feels like doing so. He reports the following morning for the removal of the packing, and in a few days, bar- ring complications, healing is complete. SUMMARY. 1. The submucous operation, having but very slight risks, is anafranil price indicated in all cases where the re- moval of displaced or hypertrophied septal bone and cartilage will restore the proper functions of the nasal chambers and their contents : such as cases where there is actual mechanical blocking, or where there is interference with ventilation and drainage of the sinuses, or where pressure on the turbinates produces headaches and other reflex phenomena, it is indicated in cases of deafness and ear anafranil online suppura- tions, where nasopharyngeal trouble traceable to the septal deformity is contributing to such deafness or suppurations. 2. The submucous resection is not a panacea for all ailments of the nose and nasopharynx, and be- fore doing one, it is well to bear in mind its limita- tions, especially as far as reducing the deformity is concerned, clomipramine 50 mg in spite of extensive removal of bone and cartilage, for instance, in a case where the deflection occurs in such a high position that it is not safe to extend the resection so clomipramine anafranil far ; in which case it must first be determined whether the removal of that which is possible, will give a satisfactory result. 3. The operation is absolutely contraindicated in ocd anafranil all cases that show presence of atrophy, and should not be done in children except as a matter of last resort. 4. In cases of marked hypertrophy, with or with- out a deviation, it is well to clomipramine hydrochloride tablets try a Wassermann reac- tion before operating. 5. To get a good result, care must be taken to re- move every clomipramine 20mg bit of the deviation, going to the very floor of order anafranil the nares if necessary, but not so with the upper end of the triangular cartilage, where a suffi- ciently large strip must be left for support. 6. The submucous operation is an office operation, and purchase anafranil can be performed readily and safely without particular preparation of the clomipramine tablets patient. 7. Most of the regrets in the cases operated in, anafranil buy online come from not having removed enough bone, rather than from having removed too much ; more par- ticularly is this true of the bony ridges along the floor. 8. A good submucous resection might not produce the desired results because of failure to reduce a hypertrophied inferior turbinate previous to the operation. 9. In acquiring the technic of the operation, it is well to learn to rely on the anafranil for ocd sense of touch as much as, if not more than on the sense of sight. 10. Packing, if employed, should be loose and carefully applied, and when once removed need never be replaced. , 11. Persistent bleeding -ifter the removal of pack- ing usually indicates infection, and the case should be so regarded and treated. 12. Serious injury to any vital parts during opera- tion is extremely unlikely, clomipramine 50mg unless extraordinary violence is employed, and whatever disappointments do arise are usually the result of excessive timidity on the part of the surgeon.

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