ON EXCISION OF THE WRIST FOR CARIES 431 



some ; but to any one about to perform the operation, all the details will, I 

 believe, be found weU worthy of attention. The procedure consists, in fact, 

 of a series of operations, each one of which must be executed with scrupulous 

 care. But none of them will ]ircsent any difficulty to a surgeon who has refreshed 

 his knowledge of the anatomy of the parts, and carefully studied the various 

 successive steps of the process. The operation is, however, necessarily tedious ; 

 and no one ought to undertake it who is not prepared to bestow upon it a great 

 deal of patient attention. But, considering the importance of its object, its 

 tediousness must not be regarded as an objection, more especially as the surgeon 

 alone feels the disadvantage. For the tourniquet prevents the loss of a drop 

 of blood beyond what is in the veins of the hand at the outset, and the patient 

 sleeps tranquilly under chloroform ; and if this is given by any intelligent 

 assistant in accordance with the safe and simple principles which I first learned 

 in the Edinburgh school — and have since done my best to diffuse,^ but which, 

 I regret to say, are still too little appreciated by the profession — it is a matter 

 of entire indifference whether its administration is continued half an hour or 

 an hour and a half. Under such circumstances, anything like hurr}- is as 

 uncalled for as it would be fatal to success. 



The after-treatment also requires much care, and has undergone great 

 improvement through experience ; and, indeed, the superior results obtained 

 in the more recent cases are due even more to this cause than to the better 

 method of operating. 



The principal objects to be kept in view are, to maintain fiexibilitv of the 

 fingers by frequently moving them, and at the same time to procure firmness 

 of the wrist by keeping it securely fixed during the process of consolidation. 



To the latter indication I paid scrupulous attention from the first ; and 

 hence I have in no instance met with any approach to the flail-like condition 

 of the new joint which otherwise would certainly have occurred. Indeed, 

 my anxiety to avoid interference with the process of repair at the wrist led me 

 at first to abstain from moving the knuckles, and to restrict the exercise of 

 the fingers to their middle and distal joints. Consequently, in the earlier cases 

 the movements of the knuckles are still very limited ; experience having shown 

 that any one joint which is not freely and frequently moved is apt to become 

 permanently rigid. Another circumstance which interfered at first with my 

 obtaining the best results was a needless dread of suppuration of the opened 

 sheaths of the tendons, which made me afraid to disturb them during the first 

 week. But I was gratified to find, in case after case, that nothing of the sort 



' For an investigation of these principles see an article on Anaesthetics, b\- tlic author, in Holmes's 

 System of Surgery, vol. iii. third edition (reprinted at page i_>5 of vol. i). 



