438 ON EXCISION OF THE WRIST FOR CARIES 



parts, so far as I was able to judge of their extent ; but I omitted to examine 

 the metacarpal bone of the thumb, and, whether in consequence of this or not 

 I will not pretend to say, the operation did not prove successful ; and on the 

 29th of January, 1865, being loth to sacrifice the hand, I re-excised a second 

 time, and found carious disease again present in the ends of all the bones, 

 including the metacarpal bone of the thumb, which this time I made a point 

 of examining, reopening the radial as well as the ulnar incision. The operation, 

 however, was an extremely troublesome one, and far from being as definite 

 and satisfactor}/ as a primary excision ; and even now, although she can move 

 the thumb and fingers, and it is evident that the hand would be a thoroughly 

 useful one if it would heal, I feel by no means satisfied that it will do so. 



The lesson to be learned from such a case is the necessity of using all means 

 by which recurrence of the disease may be avoided, and not too long delaying 

 exploration of the wrist when it is suspected. 



It remains to say a few words regarding the mode in which the new joint 

 at the wrist is produced. It appears that the bones of the forearm and of the 

 metacarpus become approximated, partly by shortening of the limb and partly 

 by the growth of new osseous material from their divided ends ; and I find that, 

 as a general rule, about half an inch in length of new bone is formed, and that 

 the rest is effected by shortening. The new bone appears to be generally 

 developed in about equal proportions from the radius and ulna and from the 

 metacarpus, but sometimes in an irregular manner. Thus in two instances 

 I have observed a process grown from the ulnar side of the radius, and received 

 between two lateral portions from the metacarpus, so that a secure joint on 

 an entirely new principle was the result. 



With proper care on the part of the surgeon, perfect symmetry of the hand 

 can be always ensured ; for the radius and ulna above, and the metacarpus 

 below, being divided in parallel lines, the shrinking of the new material between 

 them draws the hand equably upwards towards the forearm. In this respect 

 the operation above recommended has a great advantage over any partial 

 procedure in case of disease apparently confined to one side of the carpus, 

 independently of the paramount consideration of its greater security of eradi- 

 cating the caries. And any scruple which I might once have felt in recom- 

 mending total excision for limited disease has been entirely removed by the 

 usefulness of the hands which have been subjected to it. 



It will no doubt appear desirable that I should allude, however briefly, 

 to the rest of the cases that have come under my care. They are five in number, 

 and include some of the best and some of the worst. Among the former is 

 to be mentioned, first, my last case, that of E. P , aged thirteen, a strumous 



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