432 ON EXCISION OF THE WRIST FOR CARIES 



ever occurred — a fact which must, I suppose, be attributed to the entire absence 

 of tension in the soft parts, ensured by the free removal of the bones. Thus 

 I have gradually grown more bold, and now do not scruple to ask the patient 

 to demonstrate his command over the joints of the thumb and fingers on the 

 first day, and make a point of commencing passive motion on the second day, 

 whether the inflammation has subsided or not ; and from this time forth it is 

 continued daily till it ceases to be necessary. In executing these movements 

 each finger is both flexed and extended to the full degree which is possible in 

 health, care being taken that the metacarpal bone concerned is held quite 

 steady, to avoid disturbing the wrist. 



By proceeding in this way, even though the fingers have been previous^ 

 stiff, it is easy to maintain the suppleness produced by the free movement under 

 chloroform immediately before the operation as recommended above. For an 

 adhesion only one day old yields without much force on the part of the surgeon 

 or much pain to the patient, whereas a very few days will give it such firmness 

 as will require great violence to rupture it. 



The splint which I used originally was a flat one, on which the hand lay 

 with the fingers extended. But I have found it a great improvement to have 

 the hollow of the palm supported upon an obtuse-angled piece of thick cork 

 (Fig. 5, C) attached to the splint, a convenient cement for the purpose being 

 gutta-percha fused with a hot iron. The hand thus lies semiflexed, which is 

 its natural position of repose ; and has also the advantage that the fingers are 

 midway between the extremes of flexion and extension into which it is necessarj^ 

 to bring them in the daily passive movements, while a certain range of voluntary 

 motion is also permitted, which the patient should be encouraged to exercise 

 frequently during the day. At the same time, this position is best adapted 

 for allowing the extensors of the carpus to acquire fresh attachments. Lastly, 

 the palm being applied to the sloping surface of the cork, the splint is kept from 

 slipping upwards ; while any movement in the opposite direction is prevented 

 by giving the turns of bandage which encircle the wrist a purchase upon a trans- 

 verse bar of cork (Fig. 5, D) attached to the under surface of the splint about 

 the level of the knuckles. The great essential as regards the wrist — that of 

 perfect steadiness — is thus effectually secured, the hand remaining fixed through- 

 out the day, however freely the fingers be moved. While the patient is confined 

 to bed the limb should rest upon a sloping piece of wood or 'desk, which is much 

 more steady than a cushion, the inner condyle being well padded with cotton 

 to avoid bed-sore. 



The bar of cork beneath the splint has the further advantage of allowing 

 the thumb to fall below the level of the rest of the hand into the position in 



