ON EXCISION OF THE WRIST FOR CARIES 435 



of the elbow-joint, without anything being wrong with the bones ; as, for 



example, in the case of Margaret W (Case 2), in which they did not finally 



close for more than a year after the operation. Or, again, the persistence of 

 sinuses may depend upon small exfoliations, and these may prove extremelv 

 slow in separating. This may be illustrated by 



Case 7, that of James M'G— — , sixteen years of age, whose right wrist 

 I excised on the 21st of November, 1863, on account of disease of spontaneous 

 origin, which had attained to much the same exaggerated degree as in Helen 



M (Case 4), and presented similar apparently hopeless appearances: the hand, 



greatly swollen and discoloured, and with numerous sinuses and a grey palmar 

 sore, hanging helpless at an angle of about sixty degrees, with the fingers stiff and 

 clawed. The radius and ulna were very freely resected, and it was necessar\' to 

 apply the gouge to the third and fourth metacarpal bones on account of extension 

 of the disease below their bases. All went on well after the operation, except 

 that a sinus remained in each line of incision, and a probe introduced into that 

 on the ulnar side passed down to bare bone of irregular surface. This made 

 me fear a return of the disease ; but, as the wrist was growing firm and the hand 

 useful, I did not interfere, and after the lapse of ten months a small exfoliation 

 escaped from the ulnar aperture. The probe, being then introduced, no longer 

 came in contact with any bone ; and now, three months later, the sinus has 

 become reduced to an almost invisible aperture, which yields only a minute 

 drop of limpid liquid, while the new joint at the wrist is all that can be desired 

 both in firmness and flexibility. 



Hence so long as swelling and discharge diminish, and the strength of the 

 hand increases, no interference is called for. But should the opposite conditions 

 present themselves, recurrence of the disease must be suspected, and the part must 

 be submitted to a thorough exploration, which should not be too long delayed, 

 since caries reappearing at a limited spot will spread in time to all the bones. 



This course I have found it necessary to adopt in more than one instance, 

 as, for example, in the following case, which was in some respects the worst 

 I have had to deal with. 



Case 8. — Mrs. C , aged twenty-five, a married woman, came to the 



infirmary for the purpose of having her right hand amputated, on account of 

 spontaneous disease of the carpus of two years' standing, attended tor eighteen 

 months with constant discharge, and for the last six months with sucli severe 

 pain as to dei^ive her to a great extent of her night's rest, while the effect 

 upon her general health was marked b\' her wasted and sallow aspect, impaired 

 ai)petite, and rapid pulse. 



