426 ON EXCISION OF THE WRIST FOR CARIES 



lines of the same diagram, and it will be readily understood that the greater 

 loss both of length and breadth of the bones must have interfered seriously with 

 the process of consolidation, and impaired the ultimate strength of the hand. 

 This point may be further illustrated by comparing the sketches in Figs, i and 2, 

 of which the former exhibits the parts removed according to the first method 

 in Case 2, and the latter the portions excised on an improved plan in Case 5, 

 which was very similar as regards the extent of the disease. 



But a greater objection to the original procedure lay in the fact that, the 

 bones being divided in the dark, there was serious risk of leaving behind some 

 portions of the disease ; for it is, of course, impossible to know beforehand the 

 precise extent of the caries, and when the bones have been confused by operative 

 interference, it is somewhat difficult to judge accurately of their condition. 



In order to attain completely the twofold object of taking away all the 

 disease, and leaving behind all bone that may be relied upon as sound, it is 

 desirable that both the radius and ulna and the metacarpal bones should be 

 presented untouched for examination ; and in my later cases this condition 

 has been fulfilled in a thoroughly satisfactory manner by removing the carpus 

 in the first instance, when the free space so afforded permitted me to deal 

 methodically and surely with the other bones. 



The soft parts, too, were by no means in the best possible condition after 

 the original operation. In exposing the ends of the bones, and especially the 

 radius, for the application of the saw or pliers, the tendons were separated 

 from their sheaths to an extent which the preliminary removal of the carpus 

 renders quite unnecessary. They consequently acquired a disposition to con- 

 tract adhesions to neighbouring parts, which occasioned a great deal of needless 

 trouble in the after-treatment. 



Again, the division of the extensors of the carpus opposite to the wrist- 

 joint gave less power of raising the hand than was afterwards obtained by cutting 

 them long at their insertions into the metacarpus, and so imitating as nearly 

 as possible the natural arrangement. This point seemed deserving of con- 

 sideration when the progress of some of the cases had proved that those 

 muscles will regain command over the hand. The idea was first acted on in 



Case 3, that of William C , and the result in him and in all that have 



followed him has shown that it is well worthy of attention. 



I also found that by properly planning the radial incision it was quite 

 unnecessary to sacrifice the extensor secundi internodii pollicis, and in the more 

 recent cases the second joint of the thumb has commonly been moved with 

 perfect freedom, whereas in the earlier ones the first joint only was capable of 

 any material motion. 



