430 ON EXCISION OF THE WRIST FOR CARIES 



reached from the radial incision, the fourth and fifth from the ulnar side. If 

 they seem sound, the articular surfaces only are clipped off, the little facets 

 bv which they articulate with one another being removed by the longitudinal 

 application of the pliers, as is indicated in Fig. 3. On the other hand, we have 

 had in Case 4 an illustration of what may be required when the disease proves 

 extensive ; for it may be remembered that in that case it was necessary not 

 merely to take away the whole base of the metacarpal bone of the middle finger, 

 but to drill its entire shaft into a hollow tube, and yet a sound and most useful 

 hand was retained. 



The trapezium is next seized with a strong efficient pair of forceps, and 

 dissected out so as to avoid cutting the tendon of the flexor carpi radialis, which 

 is firmly bound into the groove on its palmar aspect, the knife being also kept 

 close to the bone elsewhere to preserve the radial artery. The thumb being 

 then pushed up longitudinally by an assistant, the articular end of its metacarpal 

 bone is cleared and removed. This may seem a superfluity, as this bone articu- 

 lates with the trapezium by a separate joint. But besides the possibility of 

 its being affected through its immediate vicinity to the other articulations, 

 the symmetry of the hand is promoted by reducing it to the same level as the 

 other metacarpal bones. Lastly, the articular surface of the pisiform bone 

 is clipped off, the rest of the bone being left, if sound, as it gives insertion to 

 the flexor carpi ulnaris, and affords attachment to the anterior annular ligament, 

 and may serve other useful purposes in the palm. But if there is any suspicion 

 of its unsoundness, it must be dissected out completely. The same applies 

 to the process of the unciform. It may be observed that the extensors of the 

 carpus are the only tendons divided ; for the flexor carpi radialis is connected 

 with the second metacarpal bone below its base, and so escapes. But if it should 

 be cut, there is no doubt that, like the extensors, it would acquire new and 

 secure attachments. The tourniquet being now removed, it will probably 

 be found that either no vessel at all requires ligature, or merely one or two 

 superficial branches. The radial incision is stitched closely throughout, and 

 also the ends of the ulnar incision, as it is desirable that union should take place 

 there, and more especially over the end of the ulna ; but the middle of this 

 incision must be kept open by pieces of lint introduced lightly into the wound 

 to give support to the extensor tendons, and to ensure a wide opening into the 

 cavity, which may serve for the free exit of the pus which must necessarily 

 be formed there. The limb is placed upon a suitable splint, and dressed with 

 some porous material, arranged so as to avoid pressure upon the lines of incision, 

 in order that it may absorb without obstructing the discharge. 



To the general reader the above description will, I fear, have proved weari- 



