ON EXCISION OF THE WRIST FOR CARIES 429 



the connexions of the tendons with the radius are purposely left undisturbed. 

 Attention is now directed to the palmar side of the incision. The anterior 

 surface of the ulna is cleared by cutting towards the bone so as to avoid the 

 artery and nerve ; the articulation of the pisiform bone is opened, if that has 

 not been already done in making the incision, and the flexor tendons are separated 

 from the carpus, the hand being depressed to relax them. While this is being 

 done, the knife is arrested by the process of the unciform bone, which is clipped 

 through at its base with pliers. Care is taken to avoid carrying the knife 

 further down the hand than the bases of the metacarpal bones ; for this, besides 

 inflicting unnecessary injury, would involve risk of cutting the deep palmar 

 arch, the position of which is shown in Fig. 3. The anterior ligament of the 

 wrist-joint is also divided, after which the junction between the carpus and 

 metacarpus is severed with cutting-pliers, and the carpus is extracted bv seizing 

 it from the ulnar incision with a serviceable pair of sequestrum forceps, and 

 touching with the knife any ligamentous connexions that may remain undivided. 

 The hand being now forcibly everted, the articular ends of the radius and ulna 

 will protrude at the ulnar incision, and are carefully examined and treated 

 according to their condition. If they appear sound or very superficially affected, 

 the articular surfaces only are removed. The ulna is divided obliquely with 

 a small saw, so as to take away the cartilage-covered rounded part over which 

 the radius sweeps, while the base of the styloid process is retained. The ulna 

 is thus left of the same length as the radius, and this greatly promotes the sym- 

 metry and steadiness of the hand, the angular interval between the bones being 

 soon filled up by fresh ossific deposit. The end of the radius is then cleared 

 sufficiently to permit a thin slice to be sawn off parallel to the general direction 

 of the inferior articular surface. For this purpose it is scarceh' needful to 

 disturb the tendons in their grooves on the back of the bone, the be\'elled un- 

 grooved part being enough to remove, and thus the extensor secundi internodii 

 pollicis may never appear at all. This may seem a refinement ; but the freedom 

 with which the thumb and fingers can be extended, even within a day or two of 

 the operation, when this point is attended to, shows that it is important. The 

 articular facet on the ulnar side of the bone is then clipped away with bone 

 forceps applied longitudinally. If, on the other hand, the bones pro\'e to be 

 deeply carious, the pliers or gouge must be used with the greatest freedom : 

 for it is of course far better to take away too much bone than too little, and 

 my earlier cases, as well as some more recent ones to which I have not yet alluded, 

 prove that a useful hand will result in spite of very extensive excision. The 

 metacarpal bones of the fingers are next dealt with on the same jMinciple. each 

 being in its turn closely investigated, the second and third being most readily 



