434 ON EXCISION OF THE WRIST FOR CARIES 



rested — viz. all of it beyond the knuckles, leaving only enough to support the 

 hollow of the palm. The thumb must also be left free for use during the day, 

 but at night it should still be kept extended with the pad before mentioned ; 

 and if there be any defect in extension of the fingers, they may be kept bound 

 at night to a piece of thick gutta-percha applied to the back of the limb, and 

 bent upwards at an angle at the knuckles. The gentle and continuous traction 

 of the elasticity of the gutta-percha will soon correct the fault. 



With regard to the dressing, after the first twenty-four hours I have found 

 a poultice the best application for a few days, and afterwards lint soaked in 

 a solution of some stimulating agent, such as sulphite of potash, which I tried 

 some time ago, on theoretical grounds, for ^ the treatment of sores, and have 

 found preferable to the ordinary astringents, diminishing the amount and fetor 

 of the discharge, and producing a ver}/ healthy state of the granulations. It 

 may be used in the proportion of ten grains to an ounce of water. 



Even after the hand is healed some support will still be required for a con- 

 siderable period, and this may be conveniently made of bend leather, accurateh' 

 moulded to the anterior aspect of the limb, and reaching from about the middle 

 of the forearm to the level of the knuckles, which it rises to support, its ulnar 

 border being turned up for the side of the hand to rest on, while at the radial 

 side it gets a purchase on the base of the metacarpal bone of the thumb. A few 

 turns of bandage, or a laced piece of soft leather, above the wrist, will be 

 sufficient to keep it securely in position, the apparatus scarcely showing at all at 

 the back of the hand. 



This support must be worn till the patient feels the wrist exactly as strong 

 without it as with it. It is a most serious mistake to lay it aside too early. Case 

 I, in which after the lapse of a year and three-quarters the necessary condition 

 for abandoning it was at last fulfilled, is a striking instance of the advantage 

 derived from its persevering employment. Considering the very large amount 

 of bone removed in that case, I confess I hardly hoped for such perfect firmness 

 as was ultimately attained ; and I feel sure that if the rule I have given had not 

 been followed, the result would have been very different. The use of the support, 

 far from hampering the motions of the fingers, favours their usefulness. For 

 it seems to be a principle in physiology that the nerves refuse to call the muscles 

 into action unless they can do so with effect ; and so, when the wrist has not the 

 firmness mechanically necessary for the efficient action of the fingers, their move- 

 ments are feebly executed ; but when the wrist is firmty supported, the motor 

 apparatus of the hand is, so to speak, encouraged to its best efforts, and recovery 

 of the power of the limb is greatly promoted. 



One or more sinuses may remain open for a long time, just as after excision 



