where an eight-pound hammer is used almost uninterruptedly for five hours, and is carried from above the shoulder down to the level of the waist, would seem to contradict this view, as the disease is unknown to one of the largest gold leaf manufacturers ; a careful study of the movements of the operatives in performing this work, however, shows that the strain is not upon the muscles of the forearm, but rather upon those of the shoulder and arm ; as the hammer descends simply by gravity and

more »

... rns by recoil from the elastic block, composed of alternate sheets of gold and animal membrane, to a point where the biceps and deltoid muscles complete the elevation. The exciting cause of the attack is usually the resumption of work to which the individual is thoroughly accustomed, after a shorter or longer interval, when he is out of practice, and when the parts involved in executing special movements have become less actively nourished ; though in the case of the washerwoman the clothes wringer was used for the first time, and the rope twister was doing work that was new to him. In the laborer the attack was of traumatic origin. Pathology. -The means of determining the exact lesion in this disease are necessarily to a certain extent conjectural, hut as the pain and crepitation are coincident in their onset and subsidence, as there is no impairment of motion after recovery has occurred, and, as the parts under treatment regain their normal condition in a very short time, it seems highly probable that there is no true inflammatory process at all, certainly none extending beyond the stage of congestion, and that the creaking which exists is due to insufficient lubrication, with consequent dryness, not. as luis been supposed, to exudation of lymph. Under rest and counter-irritation the congestion very soon disappears, the synovial surfaces pour out their proper fluid, and the tendons once more move smoothly aud noiselessly in their sheaths. Symptoms. -Soreness, amounting to positive pain upon motion or pressure along the course of the affected tendons, inability to use the part, and the presence of the peculiar creaking, which is communicated to the finger on palpation, are the symptoms which denote the existence of tenosynovitis. Diagnosis. -From its common seat upon the dorsum of the forearm this affection may be mistaken for fracture of the radius. The history of the case, however, showing that there has been no blow or fall, as a rule ; the quality of the crepitus, which is much softer and liner than that of fracture, and like that of cellular emphysema after fracture of the ribs, or that produced by rubbing two pieces of cloth between the fingers, and the way in which the crepitation may be elicited, -all leave little chance of error. The disease will not be mistaken for a strain of the muscle, if a careful physical examination is made. Treatment. -From what has been already said, it will be seen that the disease is at once acute, painful, and disabling. It, however, yields, as a rule, readily to treatment ; for the patient can seldom work more than a day after he is attacked, and finding that he exhausts the usual home embrocations, without relief, promptly seeks aid elsewhere ; this enables the surgeon to institute treatment before an advanced stage is reached and permanent mischief done by a deposition of plastic matter. Absolute rest of all the parts concerned is the most important element in the treatment; a palmar splint, therefore, from the elbow to the tips of the fingers is applied, when the forearm is the part affected. Counter-irritation is next indicated, and may be employed in one of two ways, If the skin is red. a band one inch broad of tincture of iodine should be painted in an oval form around the area over which creaking is felt ; while a lotion of lead water and laudanum is applied within this band. In cases where there is but slight creaking, and no redness of the skin, tincture of iodine may be painted directly over the diseased part, without the employment of any lotion. The dressing is reapplied each day until all pain, tenderness, and creaking have disappeared, which generally occurs at the end of four or five days. After this a roller bandage alone is continued until the parts have regained their tone.