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You are told of three compartments. The parti- tions between the Nitroglycerin Iv compartments are none of them strong, and pus may pass from any one Ntg Nitroglycerin compart- October 30, 1920.] COUGHLIN: SURGICAL TREATMENT OF HAXD INFECTIONS. 669 ment to any other, for the partitions Spray Nitroglycerin fail as the bases of Order Nitroglycerin the phalanges are approached. The parti- tions are of fascia and Nitroglycerin 2 are backward extensions of the deep palmar fascia. The outer compartment lodges the thumb muscles, the inner one the flexor tendons and short muscles of the little finger, while in the middle we have the flexor tendons and lum- bricals of the middle fingers, together with vessels and nerves. Tendons and muscles must be sur- rounded with loose areolar tissue,, or they will work but stiffly, and infective material spreads readily through loose areolar tissue. The deep palmar fascia is strongest over the middle compartment, and over all compartments the deep palmar fascia thins out, becomes cribriform, and finally fails en- tirely as we proceed distally. It disappears first in the interdigital spaces, leaving the digital vessels and nerves uncovered by it as they enter the webs of the fingers. Here the superficial fat of palm and web becomes continuous with fat and areolar tissue under the deep palmar fascia. One can thus see how readily a primary superficial abscess can become a deep Nitroglycerin Tablet palmar abscess by direct extension, Nitroglycerin Spray because the fascia forming the roofs of the palmar compart- ments is so strong and unyielding, and abscess in any of the compartments may spread well up into the wrist or forearm along the tendons or into its neighboring compartment long before it points on the surface of the palm. The swelling in the palm is for the .same reason never marked until the ab- scess is well advanced. Swelling on the back of the hand is always marked, but this swelling alone should not induce one to incise the dorsum. It is nearly always Sl Nitroglycerin lymphedema, because as before mentioned the lym- Buy Cheap Nitroglycerin phatics drain toward the dorsum, but pus does some- times collect here in the perifascial lymph space, and here as elsewhere localized deep tenderness is an early and never failing sign. The tender spot should be opened as soon as found. To "squeeze out" the pus is Sublingual Nitroglycerin the most primitive surgery. How to open a palmar abscess is a real problem and whether to incise vertically or transversely is a moot question. A transverse incision will remain open better while the fingers are extended, and the fingers should always be dressed in extension, but a transverse incision in the lower Nitroglycerin Sl part of the palm exposes the digital vessels and nerves to danger, while a vertical one higher up imperils the palmar arch. The patient should be anesthetized and an Esmarch bandage applied. One cannot use an Es- niarch bandage to advantage unless the patient is anesthetized ; hence the need for a general anes- thetic and, besides, a local anesthetic in an inflamed area is not often successful. We use the ether rausch or ethyl chloride for such operations.^ Use whichever incision you prefer, but identify the structures before you cut them. Cut down Nitroglycerin Sublingual to the deep fascia and proceed with Nitroglycerin Mg caution. Divide the deep fascia and then lay down the knife. If you have opened over the spot Buy Nitroglycerin Online most Iv Nitroglycerin tender on deep pressure, go straight on with blunt dissection until the pus appears. Do not pack, but insert soft rub- ber and fasten it in the wound. Any drainage material that presses on a tendon with any force for even a few hours, may cause local death of the latter. Nitroglycerin Tablets Nitroglycerin Buy If a Nitroglycerin Cream tendon or part of one dies, it takes four to six weeks to separate and come away. Immobilize fingers, hand and wrist, keep fingers in extension, and use the hot bath or moist dressing. Every student remembers the synovial sheaths of the flexor tendons. He knows that Buy Nitroglycerin there is around each set of flexor tendons, as they lie on the phalanges, a strong fibrous tunnel through which they run and which holds them to the bones. P)Ut inside this fibrous tunnel is a synovial bursa, as it were, which surrounds each set of tendons. These synovial investments extend farther up into the palm than do the fibrous sheaths : those for the index, medius, and annularis extending up to the middle of the palm, while those for the thumb and little finger reach right up to join the bursa under

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