4i8 ON EXCISION OF THE WRIST FOR CARIES 



would do such violence to the tendons as must have been inflicted in that acci- 

 dent, both on the flexors through which the ends of the bones were so rudely 

 thrust and on the extensors wrenched out of their sheaths in spite of the secure 

 connexions of the annular ligament. Hence the favourable issue of this case 

 indicated that the tendons might be very freely dealt with in gaining access 

 to the carious bones without inducing stiffness of the fingers, provided the after- 

 treatment were rightly conducted. 



And in the second place, the fact that a useful hand had been retained after 

 the loss of so large a portion of the bones, suggested that the same happy result 

 might follow removal of the whole articular apparatus of the wrist ; that is to 

 say, excision of all the carpal bones, together with the ends of the radius and 

 ulna, and the bases of all the five metacarpal bones. 



If this were done, recurrence of the disease, the grand cause of disappoint- 

 ment in excision of the wrist, would, as I hoped, be avoided ; and the operation 

 would be placed on a par with excision of the elbow, which, if properly per- 

 formed, may be relied on with almost absolute security for complete extirpation 

 of the caries. I have long believed that the reason of the remarkable success 

 attained in this respect by excision of the elbow is that the surgeon (when 

 operating in the manner to which I allude) takes away in all cases, however 

 limited the disease may seem, the entire surface covered with cartilage. For 

 it is in the cartilage that caries commonly takes its origin, and even parts 

 of it which may appear sound in a carious joint seem apt to be affected in an 

 insidious, incipient degree, and if left behind may lead to recurrence of the 

 complaint. But, in excising the wrist, all that has hitherto been aimed at 

 has been to take away such portions of the bones as are found to present un- 

 healthy characters, leaving behind more or less of the articular surfaces, which, 

 from the forearm to the metacarpus, may be viewed with reference to caries 

 as forming a single complicated joint, though subdivided in health into three 

 synovial sacs. On the other hand, if the whole of the structures thus liable 

 to morbid action were cleared out, there seemed good reason to hope that success 

 in excision of the wrist for caries might become the rule instead of the exception. 



A few months later two cases of caries of the wrist presented themselves 

 for treatment, and, after some experiments upon the dead body, I resolved 

 to test the new principle upon them, and operated upon both on the i6th of 

 April, 1863. Since that time the practice of our large infirmary has afforded 

 me frequent similar opportunities, which have enabled me gradually to improve 

 both the operative procedure and subsequent management, and also to judge 

 fairly of the ultimate results. These having proved fully equal to my theoretical 

 anticipations, I now feel called upon to bring the subject under the notice of 



