ON EXCISION OF THE WRIST FOR CARIES 427 



Lastly, it appeared that to have botli the incisions on the dorsal aspect 

 of the limb was b}^ no means the best arrangement ; for, while the radial incision 

 must necessarily be at the back of the hand, that on the ulnar side is advan- 

 tageousl}^ made towards the palm, where it gives the most ready access to the 

 palmar surface of the carpus, and avoids injury to the tendons of the extensor 

 carpi ulnaris and the extensor minimi digiti, while it affords a dependent opening 

 for the escape of discharges from the cavity. 



The foregoing discussion of the defects of m}^ first mode of operating will, 

 I trust, prevent other surgeons from going over the laborious ground of gradual 

 improvement over which I have travelled, while it will enable the reader to 

 appreciate the advantages of the method which I now venture to recommend. 



The operation is performed in the following manner : Chloroform having 

 been administered, a tourniquet is placed upon the limb to prevent oozing of 

 blood, which would interfere with the careful scrutiny to which the bones must 

 be subjected. Before the operation is commenced, any adhesions of the tendons 

 are thoroughly broken down by freely moving all the articulations of the hand. 

 The radial incision is then made in the situation indicated by the thick line 

 (L L) in the accompanying diagram of the anatom\- of the back of the hand 

 (Fig. 4). This incision is planned so as to avoid the radial artery, and also the 

 tendons of the extensor secundi internodii pollicis and indicator. It commences 

 above at the middle of the dorsal aspect of the radius, on a level with the stjdoid 

 process, this being as close to the angle where the tendons meet as it is safe to 

 go. Thence it is at first directed towards the inner side of the metacarpo- 

 phalangeal articulation of the thumb running parallel in this course to the 

 extensor secundi internodii ; but on reaching the line of the radial border of 

 the second metacarpal bone it is carried downwards longitudinally for half the 

 length of the bone, the radial artery being thus avoided, as it lies somewhat 

 further to the outer side of the limb. These directions will be found to serve, 

 however much the parts may be obscured by infiammator}' thickening. The 

 soft parts at the radial side of the incision are next detached from the bones 

 with the knife guided by the thumb-nail, so as to divide the tendon of the extensor 

 carpi radialis longior at its insertion into the base of the second metacarpal 

 bone, and raise it, along with that of the extensor carpi radialis brevior previously 

 cut across, and the extensor secundi internodii, while the radial artery is thrust 

 somewhat outwards. This prepares the way for the next step, which is the 

 separation of the tra]:)czium from the rest of the carpus, by means of cutting 

 forceps applied in a line with the longitudinal part of the incision — a procedure 

 which, as experience shows, does not endanger the radial artery. 1 he removal 

 of the trapezium is reserved till the rest of the carpus has been taken away, 



Ff 2 



