on of adhesions between the tendon and its sheath. If the tendon
sloughs, the dead portion should be cut away, as its separation is
extremely slow and is attended with prolonged suppuration.

_Gonorrhoeal Teno-synovitis._--This is met with especially in the tendon
sheaths about the wrist and ankle. It may occur in a mild form, with
pain, impairment of movement, and oedema, and sometimes an elongated,
fluctuating swelling, the result of serous effusion into the sheath.
This condition may alternate with a gonorrhoeal affection of one of the
larger joints. It may subside under rest and soothing applications, but
is liable to relapse. In the more severe variety the skin is red, and
the swelling partakes of the characters of a phlegmon with threatening
suppuration; it may result in crippling from adhesions. Even if pus
forms in the sheath, the tendon rarely sloughs. The treatment consists
in inducing hyperaemia by Bier's method; and a vaccine may be employed
with satisfactory results.

#Tuberculous Disease of Tendon Sheaths.#--This is a comparatively common
affection, and is analogous to tuberculous disease of the synovial
membrane of joints. It may originate in the sheath, or may spread to it
from an adjacent bone.

The commonest form--hydrops--is that in which the synovial sheath is
distended with a viscous fluid, and the fibrinous material on the free
surface becomes detached and is moulded into melon-seed bodies by the
movement of the tendon. The sheath itself is thickened by the growth of
tuberculous granulation tissue. The bodies are smooth and of a
dull-white colour, and vary greatly in size and shape. There may be an
overgrowth of the fatty fringes of the synovial sheath, a condition
described as "arborescent lipoma."

The _clinical features_ vary with the tendon sheath affected. In the
common flexor sheath of the hand an hour-glass-shaped swelling is
formed, bulging above and below the transverse carpal (anterior annular)
ligament--formerly known as _compound palmar ganglion_. There is little
or no pain, but the fingers tend to be stiff and weak, and to become
flexed. On palpation, it is usually possible to displace the contents of
the sheath from one compartment to the other, and this may yield
fluctuation, and, what is more characteristic, a peculiar soft crepitant
sensation from the movement of the melon-seed bodies. In the sheath of
the peronei or other tendons about the ankle, the swelling is
sausage-shaped