ON EXCISION OF THE WRIST FOR CARIES 



425 



had induced. At the present time (March 1865), though she wears a leather 

 support as a measure of precaution, she can write a fair hand without it, and also 

 employs herself frequently with knitting or crochet-work. 



In reading the above cases it will have been observed that the later ones 

 show a superiority over the earlier, both in their rate of progress and in their 

 results. This is due principally to successive improvements which experience 

 has suggested in the mode of treatment. 



In the earher cases I made two longitudinal incisions, both on the dorsal 

 aspect of the limb, one at the radial, 

 the other at the ulnar side, sacrificing 

 in the radial incision the extensor of 

 the second joint of the thumb ; then 

 divided the extensors of the carpus 

 opposite the wrist-joint ; and having 

 detached the tendons sufficiently from 

 the radius and ulna, removed the 

 articular ends of those bones by means 

 of a small saw and cutting-forceps 

 applied transversely. Next, after 

 separating the tendons from the car- 

 pus, I sawed or clipped through the 

 metacarpal bones of the fingers, so as 

 to extract their extremities together 

 with the greater part of the carpus in a 

 single piece, dissecting out afterwards 

 any articular portions that remained. 

 This method proved far from per- 

 fect, both in the way in which the 

 bones were dealt with and in the mode of gaining access to tliem. 



As regards the bones, it was objectionable in two ways. In the first place, 

 the bones being divided transversely so as to include all the cartilage-covered 

 surfaces, a needlessly large amount was removed both from the radius and ulna 

 and from the metacarpus. In a case of disease apparently limited to the carpus, 

 the essential principle of the operation would be carried out by merely taking 

 away what is represented by the unshaded parts of the accomixmying diagram 

 (Fig. 3), taken from a faithful sketch of the bones of the right wrist, the thick 

 lines indicating the extent of the articular surfaces. Hut the original n\ethod 

 sacrificed in all cases at least as much bone as is included between the dotted 



Ff 



Fig. 3.— a a, deep palmar arch ; B. trapezium ; 



C, articular surface of the ulua, over which 



the radius moves. 



I-ISTER II 



