Part 59

Luxation of the Hip-joint.—The great strength of the ligaments, the depth and fitness of the body and cartilaginous cavity for the reception of the head of the bone, and the great power of the muscles surrounding the articulation, render dislocation here both difficult and rare. The accident is generally produced by great and sudden force, applied either to the distal end of the femur, or to the farther extremity of the limb, as by falling from a considerable height, by the foot slipping whilst the person is supporting a heavy weight, by falls from or with a horse, &c. The luxation, in a great majority of cases, takes place upwards and backwards, the head of the bone lying on the dorsum of the ilium. The limb is shortened to the extent of from an inch and a half to two inches and a half, the toes are turned in, the thigh is slightly bent upon the pelvis, and very firmly fixed. Before swelling has occurred, and also after it has subsided, the head of the bone can be felt lying under the gluteus. The trochanter is evidently out of place, being depressed, and lying farther up and back than usual. This is strikingly observable on comparing the injured limb with the opposite. Attempts to move the limb and effect rotation produce great pain. Large swelling soon follows, along with greater stiffness and immobility. If the head of the bone is not replaced, the pain gradually subsides, and, after some months, freedom of motion is regained to a slight extent; the patient is able to walk, but with a great halt.

At first, reduction is accomplished with no great difficulty. Within a very short time after the occurrence of the injury, before the patient had recovered from the shock, whilst he still lay sick, faint, and powerless, I have succeeded in effecting reduction of the femur quite unassisted,—extending with one hand, grasping the thigh behind, and, at the same time, rotating it outwards by pressure of the forearm on the leg, counter-extension being made by the left hand on the symphysis pubis. When a few hours have intervened, assistance and apparatus are requisite. The patient is secured by a broad band,—a common sheet suits very well,—passed under the perineum. The lacque is fixed above the knee, with a knot that will not run, a towel wrung out of cold water being applied next to the skin, in order to increase the security of the hold and prevent excoriation. A well-padded broad iron ring, tightened on the limb by a screw, and provided with suitable straps for attachment of the pulleys, is very useful,—fully more convenient than the common woollen lacque. Extension may be made by one or more assistants; but this may prove ineffectual, and it is better at once to have recourse to the pulleys: these are not alarming to the patient, and, being efficient, will in the end materially diminish his suffering. The extension should be gradual, steady, and persevering; the rotation of the limb during extension should be principally outwards, effected by laying hold of the ankle, and using the leg as a lever. This motion is peculiarly successful when the bone has yielded a little to the extension, when it has changed its place, and come nearly on a line with the cotyloid cavity. In some cases, even of no long standing, auxiliary means are required,—bleeding, antimony, &c., as formerly noticed. In old cases, no attempts at reduction should be made until the patient has been brought into a relaxed state, approaching to collapse, by one or more of the auxiliary means, and by such as are best suited to the particular circumstances of the case; in such instances also the extension, rotation, &c., must be persevered in for some time,—they are not at once successful. Frequently, particularly in recent cases, reduction is accompanied and indicated by an audible and perceptible snap, occasioned by the head of the bone slipping into the cotyloid cavity; the motions are again readily performed, and the limb resumes its proper length and shape. The muscular and articulating apparatus must be kept quiet for some time afterwards; a band should be passed round the knees, and the patient strictly confined to the recumbent posture; at the same time, fomentations are to be used about the joint, to the perineum, and to the part where the lacque was applied. It is rarely necessary to have recourse to abstraction of blood from the neighbourhood of the articulation.

There is no great risk of the bone again escaping from its situation. I have but once witnessed such an accident. A female suffered luxation of the hip nearly a month previously to her admission into the Royal Infirmary, and reduction was unavoidably deferred for three days more. It was accomplished without difficulty, and the usual precautions were afterwards adopted; but next day it was discovered that luxation had again taken place. The patient had cunningly contrived to have ardent spirits brought to her, and indulged freely in these, got out of bed, and slipped down. Replacement was again effected, more easily than before; the limbs were firmly secured to each other, confinement to bed and no farther indulgence in liquor were strictly enjoined, and after thirteen or fourteen days the limb fully regained its functions.

Luxation of the hip downwards and forwards, the head of the femur lying in the thyroid foramen, is generally produced by a fall under a heavy load, the thigh being at the same time forcibly abducted. I have also seen it occasioned by a fall with a restive horse. The limb is elongated considerably, and advanced a little forwards; the trochanter major is depressed, the toes are inclined neither outwards nor inwards; the limb is immoveably fixed, and this most unequivocally marks the nature of the accident.

The limb is lengthened when the trochanter major is split off, as also when severe bruise of the glutei has been inflicted without breach of continuity in any part of the bone, and without displacement. In the first stage of morbus coxarius, too, a somewhat similar appearance and position of the limb is presented; there is lengthening, but then there is also more or less wasting of the muscles, more mobility than in the dislocation, and a marked history attached. Complicated cases occasionally occur—as when a patient who has been labouring under hip-joint disease, perhaps not in an aggravated form, falls heavily, and on being lifted up is found to be incapable of moving the joint, the limb at the same time being elongated, and having a distorted appearance. An instance of this nature impressed strongly upon me the great necessity for accurate diagnosis in the first instance, and that such was to be acquired only by taking every circumstance into consideration. A young man was engaged in cleaning a slaughter-house, standing on two blocks of wood with his legs considerably apart. One of the blocks suddenly slipped from under him, and he fell with his limbs spread. He was carried home in great pain, and next day I was asked to visit him. The limb was elongated, and the hip flattened; the joint was stiff, and attempts at motion produced great pain; but by perseverance the limb could be put in various positions, and the trochanter was not so much depressed as in luxation downwards. By cross-examination it was discovered that the patient had halted in walking for many weeks previously, had felt as if the limb was longer than the other, had pain in the groin and knee; in fact, morbus coxarius had been advancing, and the pain, immobility, and greater elongation had been occasioned by the fall, causing violent excitement of the morbid action previously in progress. Dreadful consequences must have resulted from mistake in diagnosis and practice founded upon it. I have observed, in other cases, great and rapid elongation of the limb in consequence of injury to the hip-joint previously diseased; and I have known instances in which persevering and forcible efforts were made to reduce the supposed luxation.

The reduction is in many cases difficult. In young and muscular individuals, after the lapse of some hours, when reaction has occurred, the muscles are rigidly contracted, and the head of the bone is not easily dislodged. Extension, made to a certain extent and continued, is not so useful or essential here as in other forms of luxation of this joint. Adduction, carrying the injured thigh quickly and forcibly over the other, is generally successful; and the reduction is favoured by at the same time raising up the neck of the bone, by means of a towel or wooden roller passed under the upper part of the thigh. There is also no such advantage from rotating the bone as in other luxations. It is very often necessary, even in recent cases, to adopt measures to weaken muscular exertions; and again, in cases of three weeks’ duration, I have found no difficulty.

The head of the bone, when dislodged from the foramen obturatorium, may slip past the cotyloid cavity, for it is impossible to regulate its direction; it comes to be acted upon by muscles which have been displaced, some being compressed and partially paralysed, whilst others are excited; they have been put out of their usual condition and relation, and act irregularly. The head of the bone may, from this cause, get into the sacro-ischiatic notch. This has occurred to me; but I have found no difficulty in removing it from thence, and effecting reduction satisfactorily.

Displacement into the sacro-ischiatic notch is attended with great and remarkable inversion of the toes, slight shortening of the limb, the prominence of the head of the bone felt under the gluteus maximus. It is the least common form of luxation. Reduction is attempted by extension and rotation outwards, at the same time pulling the head of the bone towards the acetabulum by means of a towel passed under the thigh.

Luxation of the head of the femur on the pubes is perhaps more frequent than any other, excepting that on the dorsum of the ilium. The limb is not much shortened, the toes are everted, the trochanter major is depressed, and nearer to the anterior superior spinous process of the ilium than usually, and the head of the bone is both seen and felt prominent in the groin. Much pain, swelling, and sometimes more or less paralysis of the limb, are occasioned by this displacement; the femoral artery and vein lie immediately interior to the head of the bone, and are compressed, and the crural nerves are stretched over it. In attempting reduction, rotation inwards should be employed during extension, accompanied with endeavours to lift the upper part of the bone towards the acetabulum.

The characters of this malformation are, shortening of the affected limb, unnatural projection of the great trochanter, ascent of the head of the femur into the iliac fossa, inversion of the leg, and obliquity of the pelvis. The motions of the joint, particularly those of abduction and rotation, are constrained and imperfect; the muscles of the upper part of the thigh are retracted, or drawn towards the iliac crest; the limb is thin, wasted, and out of all proportion to the rest of the body; the tuberosity of the ischium is almost uncovered, and consequently unusually prominent; the upper part of the trunk is thrown backwards, while the lumbar portion of the spine projects forwards, being concave behind; the pubes is placed almost horizontally on the thighs; and the ball of the foot alone touches the ground when the child stands erect.

In the recumbent posture, when the weight of the trunk is taken off, and the muscles are relaxed, most of the symptoms of the luxation disappear, and the limb may be shortened or elongated at pleasure. In walking, the body is inclined towards the sound side, and the head of the dislocated bone sinks towards the cotyloid cavity by its own weight. As age advances, the limb becomes shorter, in consequence of the femur ascending higher and higher on the ilium; the obliquity of the pelvis augments; and the power of locomotion, already so much impaired, is completely destroyed.

Congenital dislocation of the hip-joint may, in general, be easily distinguished from other accidents or maladies, by the affection being observed at or soon after birth, by the obliquity of one or both thighs; by the absence of pain, swelling, and ulceration; by the head of the femur being displaced without any external violence; and by the ability of the surgeon to lengthen or shorten the limb at pleasure. In disease of the hip there is always more or less pain, with a feverish state of the system, and gradual failure of the strength; the parts about the joint are tense and swollen; the limb, at first somewhat lengthened, becomes afterwards shortened, and cannot be extended without the greatest suffering; and the motions of the ileo-femoral articulation are forever impaired.

The post-mortem appearances vary. In general the cotyloid cavity is partially obliterated, or entirely deficient, being replaced by a small, irregular, osseous prominence, devoid of cartilage and synovial membrane; the head of the femur, often flattened at its antero-internal aspect, rests in a sort of superficial fossa on the dorsal surface of the ilium; the round ligament, as was before remarked, is elongated, partially worn away, or even altogether absent; and the surrounding muscles are either atrophied, transformed into a species of yellowish fibrous tissue, or preternaturally developed. In the latter case, their action is preserved; in the former, it is very much restricted, or totally impeded.

The prognosis is always unfavourable, as the patient dies either young, or remains permanently lame and deformed.

The treatment can be only palliative; and as the weight of the trunk is the main agent in aggravating the displacement, repose is obviously indicated: but it is not necessary to confine the patient to the recumbent posture; since, in the act of sitting, there is no stress on the femur, the body resting principally on the tuberosities of the ischia. Dupuytren thought favourably of the cold bath: it should be strongly impregnated with salt, and the body immersed for three or four minutes at a time. He was also in the habit of using a well-stuffed belt, about four inches wide, for surrounding the pelvis and fixing the great trochanters; thus binding the ill-adapted parts together, keeping them at the same height, and preventing that continued motion to which they are otherwise so much exposed.]

Luxation of the Bones of the Leg.—separation of them from the end of the femur—seldom occurs. It can be the effect only of great violence and great laceration. Most frequently fracture is concomitant, perhaps with wound; and such accidents require amputation, either primarily or secondarily. Subluxation, from laceration of the internal lateral ligament, is not so unfrequent. It is most common in females, the natural conformation of their thigh-bones disposing them to bend inwards; and from falling awkwardly, particularly if carrying a weight, the ligament is apt to give way. The limb is pained, deformed, and unable to support the body, and swelling to a considerable extent soon follows. Reduction is extremely easy; and the parts are retained in site by the application of a wooden splint, to either the outer or the posterior side of the joint, the leg and foot being previously bandaged. The joint remains long weak, and never recovers entirely; a sustaining apparatus, fitted on the outside, retained by straps, and with a joint opposite to the articulation, is required to be constantly worn when the patient wishes to use the limb.

Luxation of the Patella is spoken of by some as common. Others of much experience have not met with a single instance of it. I have never seen this accident. The bone, it is said, may be displaced outwards, inwards, or upwards. The first form of luxation is the most frequent, and is caused by a severe fall, with the foot twisted outwards and the knee inwards. Displacement inwards is produced by direct violence applied to the outer part of the bone, or by the foot being turned inwards in a fall. Displacement upwards can occur only after laceration of the ligamentum patellæ, the bone being then drawn up by the unresisted action of the muscles on the fore part of the thigh. In dislocation outwards, the bone has been found “resting with its inner edge upon the outer surface of the condyle, the fore part facing obliquely forwards and inwards.” In this last form of accident, sudden, forcible, and complete flexion of the limb is said to produce immediate reduction. In dislocation outwards or inwards, the muscles are to be relaxed by raising the heel, extending the limb, flexing the thigh, and then forcing the bone to its proper site by manipulation. In the dislocation upwards with rupture, the limb is to be kept extended and raised, and the bone is brought as nearly into its place as possible by bandaging. When a peculiar laxity of the apparatus about the joint exists, whether as a cause of luxation or not, the support of a well-made knee-cap is required.

As formerly stated, Dislocation of the Ankle cannot take place inwards or outwards, without fracture of the end of the tibia or of the fibula, either above the articulation, or where they project by the sides of the astragalus for the greater security and strength of the joint. Subluxation, however, or sprain, may occur without injury of the bones: in this accident, should the parts not have spontaneously resumed their original situation, no difficulty is experienced in putting them to rights; simple manipulation is sufficient. Occasionally, the foot is luxated forwards, by force applied either to the heel or to the fore part of the leg whilst the limb is fixed. The heel is shortened, the foot elongated; indeed, the marks of the injury are so distinct, that comparison of the limbs is sufficient for diagnosis. Luxation may also take place backwards; and in this case the heel is elongated and the foot shortened. In these accidents it is not unfrequently found that one or other malleolus has given way, or that the lower end of the tibia is split. Reduction is sometimes difficult. Extension is to be made by grasping the foot and pulling whilst the limb is fixed, at the same time making pressure either backwards or forwards, as may be required. To retain the bones in their proper situations, it is always necessary, at least prudent, to apply a paste-board or leathern splint to each side of the limb, particularly when fracture of the malleoli is conjoined.

Displacement of the Bones of the Tarsus may result from great force; for example, when the foot is squeezed under a heavy weight, one or more bones may escape from their connections, and project. Reduction of such displacement is exceedingly difficult at any period, and becomes almost impossible when inflammatory action is allowed to supervene previously to attempts being made. The astragalus is sometimes pushed out of its place; though it is difficult to conceive how, to a bone so hid and so firmly connected, such force should be applied as to cause protrusion of it from its natural situation. It has been found lying on the dorsum of the foot, causing swelling, lameness, great pain, shortening and deformity of the limb; and the shape of the bone can, in such circumstances, be distinctly felt and seen through the integument. As already observed, reduction is almost impracticable, and, with the view of remedying deformity, it has been proposed to cut out the displaced bone; but as to the expediency of such practice I can give no opinion.

I have seen but one instance of displacement of this bone backwards, and most probably another will never occur to me. A heavy young man, in a state of utter intoxication, fell backwards down a stair, and in the fall his foot became entangled in the railing. The astragalus was found lying betwixt the back of the tibia and the tendo-Achillis, its upper articulating surface facing forwards, the lower in contact with the tendon. All attempts to reduce the bone proved fruitless. Violent inflammatory action followed, but was reduced by active measures; and the limb ultimately became very useful; in fact, though not till after many months, little lameness or shortening was perceptible.

By Sprain is understood subluxation or partial displacement of a joint, with stretching, and more or less laceration of the articulating apparatus—ligaments, tendons, sheaths, and bursæ, being all involved in the injury. Sometimes small portions of the processes of bone are separated, being torn away, attached to ligament or tendon. All joints, both large and small, are liable to the accident. In the proximal, or in the middle joints of the finger, for example, one or other lateral ligament is stretched or torn; the finger is twisted to a side; the joint is swelled; and this swelling, with pain, is of long continuance, perhaps increased by repeated twists, or by imprudent use of the joint. The elbow and shoulder are frequently sprained, as also the hip and knee; but the injury most frequently occurs in the wrist and ankle. It is generally occasioned by a fall, the foot or hand coming awkwardly to the ground, the muscles being at the time relaxed and unprepared; by over-exertion in lifting heavy weights; by entanglement and twisting of the limb, &c. The ankle is often sprained by what is called a false step; the fore part of the foot comes in contact with an obstacle unexpectedly, the foot is twisted under the limb, the weight of the body is thrown on the apparatus of one side of the joint, and this is in consequence immoderately and unnaturally stretched. Violent pain immediately occurs, and the patient is sick and faint. Discoloration and rapid swelling take place from extravasation of blood into the cellular tissue, into the sheaths of the tendons, and perhaps into the synovial pouches, in consequence of laceration of the bloodvessels. Effusion of serum and increased secretion of synovia afterwards occur, from incited action of the vessels. Thus the joint is deformed. Attentive examination is required to guard against mistakes; the existence or non-existence either of displacement or of fracture must be at once ascertained by determined and perfect manipulation; the parts must be pressed and moved, to such an extent as is necessary, notwithstanding the pain thereby occasioned, and notwithstanding the resistance afforded by the patient. It has been already stated that luxation of the wrist is not uncommon; that separation of the one bone of the forearm from the other, and transverse fracture or splitting of the radius, at the distal extremity, are accidents by no means rare. Great disfiguration follows simple sprain, much swelling taking place on the fore part of the limb from effusion under the fascia, and there is also much serous and bloody infiltration of the cellular tissue on the back of the hand and forearm. In the ankle, the ends of the bones must be carefully examined, and also the fibula in its whole extent, that the existence or non-existence of fracture may be ascertained, and that the surgeon may be guided to a correct mode of treatment. If the joint is not put at rest immediately, the extravasation is increased, and, in consequence, the pain and inflammatory swelling also; and parts of the joint at first not involved in the injury may thus be made to suffer. Many diseases of synovial membrane and articulating cartilages are attributable, and can be traced, to badly managed sprains; and in some constitutions, but slight injury, combined with a little bad treatment, suffices to destroy a joint. When, the case is well managed, the pain is never great, and soon abates; the swelling after a few days slackens; the discoloration becomes greater, the serum being absorbed, and the effused blood shining through the skin; the integuments appear green, blue, red, purple—these hues either being present all at the same time, or occurring successively; the discoloration often extends far from the joint. The mobility and strength of the joint are recovered gradually.

Perhaps no injury is more frequently mismanaged, by those both in and out of the profession. Every old woman thinks she can cure a sprain; most absurd and hurtful measures are resorted to; the injured parts are kept in motion; cold lotions and cold effusions are employed, and at the same time stimulating frictions: probably attempts are made, either by leeching or by puncturing, to extract the effused blood; and many similar follies are committed. The proper treatment certainly appears to consist principally in absolute rest and position. If there is any displacement it must be rectified immediately. If there is any fracture; or if there is a tendency to redisplacement after reduction; or if the patient is restless either from folly or from insensibility, as when the head has been injured by the accident, when the patient is under the influence of strong liquors, or when he labours under delirium tremens,—a splint or splints must be applied to secure immobility of the parts, at the same time without such compression as may interfere with swelling from effusion; the effusion is a salutary process, and should be encouraged, not repressed. By absolute rest and elevation of the limb, the extent of the swelling is limited, and inflammation warded off. Fomentations, properly employed, afford much relief; at first they probably encourage the serous effusion. The integuments soon become relaxed, during the regular use of fomentation, and tension and vascular action subside, as also pain. The swelling then abates, and is no longer hard; it pits on pressure, and the skin has a puckered appearance. Then gentle friction becomes advantageous, and uniform support should be afforded by the application of a flannel roller. The longer the limb is disused, the more perfect and rapid is the recovery, provided the rest of the cure be properly conducted. In general nothing more than what has been stated is required. But if the limb be moved, or stimulated in any way, early, then necessity will arise for antiphlogistic measures—perhaps venesection, certainly copious and repeated abstraction of blood by leeches, accompanied with fomentations, and the internal exhibition of antimonials, purgatives, &c. When such is the case the cure is tedious, the joint long remains swelled and stiff, the patient is lame and incapable of exertion.

Leeching or puncturing at an early period, with the view of allowing extravasated blood to escape, is useless and hurtful. The effused and coagulated blood cannot be evacuated, and suppuration, followed by destruction of the cellular tissue, has often been the consequence of such ill-advised proceedings. Friction with stimulating liniments, or even simple friction, at an early period, is also hurtful, as tending to excite vascular action, and to convert simple swelling into inflammatory. The application of cold at any period is of little use, and ought certainly to be avoided immediately after the injury, as adding to the sufferings of the patient, and interfering with the natural processes which have commenced for the reparation of that injury.

In limbs that have remained stiff after severe and mismanaged sprain, the dashing of water, either cold or tepid, has been strongly recommended. The practice is not ineffectual; the vessels of the surface are excited, perhaps as by other friction, and perhaps by the reaction which follows the chill. But the limb is apt to become rheumatic; and, on this account, the state of matters will not be improved by this proceeding, unless it be resorted to with proper precautions.

In severe sprains there is reason to think that sometimes even the tendons yield a little—that many of the fibres give way, and that thus the tendon is thinned and elongated. Such injury happens often in horses, in what is called breaking down. In them the tendon is occasionally snapped entirely through, and the ends widely separated. The same occurs in the human subject. Separation of the muscular fibres, however, is rare; laceration of the tendon itself, or separation of the tendon from the muscle, is more common. The yielding of the broad tendons on the upper and fore, lateral and under parts of the abdomen, affords an example of laceration of tendinous fibre from violent exertion. The tendons of the limbs are more frequently injured, and in the lower oftener than in the upper. I have more than once seen the tendon of the biceps torn in violent exertion. In the thigh, too, some fibres occasionally give way from a similar cause. The supra-muscular fascia in the arm and thigh is apt to give way at one or more points during powerful exertion of the muscles, causing deformity by protrusion of muscle through the torn space. But it is in the apparatus for extending the foot, and raising the weight of the body, that laceration of tendon most frequently takes place. The accident is uncommon till after the middle period of life, when the body has become heavier, when muscular exertions have been less habitually practised, and when the fibre has grown more rigid. The person in raising himself over some slight obstruction in walking, perhaps attempting to pass a small ditch or stile, suddenly “breaks down.” Or in dancing,—an amusement which he has long discontinued—a sudden snap is felt, with immediate lameness and slight pain in the back of the limb; swelling and discoloration follow; and these symptoms and signs vary in intensity according to the extent of the injury. Laceration may have been slight; the pain, swelling, and lameness are proportional, and at first an inconsiderable void can be felt at the upper part of the tendinous termination of the gastrocnemii. Sometimes no change is perceptible, and in such cases some have been of opinion that the slender tendon of the plantaris has given way and caused the lameness; but this is doubtful, and it seems more probable that stretching and yielding has taken place in some part of the tendon of the gastrocnemii, which had been in powerful action—probably, the tendinous and muscular tissues have been separated to a slight extent. Occasionally the tendo-Achillis is found completely torn through, and its upper end retracted; in such cases a large space is occasioned at the injured part, when the knee is extended and the foot bent. Sometimes the tendo-Achillis is cut through; I have seen both completely divided in the same individual—he received a wound by a cutlass across the back of both limbs, while endeavouring to escape from the mate of a vessel, in which he had been stealing. In rupture without breach of surface, the torn bloodvessels pour out their contents into the cellular tissue to a considerable extent, and if a proper mode of cure be not adopted immediately, inflammation quickly supervenes; and this is apt to terminate very unfavourably in the infiltrated tissue.

The tendon is united by the deposition of new matter, and the conversion of this into substance resembling the original structure from the vessels of which the deposit has taken place. The quantity of new formation necessarily depends on the extent of laceration and the space thereby occasioned. That such reparation of tendon does take place, and that to a very great extent occasionally, is placed beyond all doubt by the results of veterinary practice. “Knuckling over” in horses is occasioned by contraction of the flexor tendon; the heel does not reach the ground, and in order to effect this the tendon has been in many instances completely divided. The cut ends immediately separate, to the extent of some inches, and after a time this large space is filled up by a substance similar to tendon; so similar, indeed, that on post mortem examination, some years afterwards, a careless observer could scarcely distinguish any difference in the appearance of the various portions of the tendon. The same is observed after the operations for deformity of the foot in the human subject.

The treatment of lacerated tendon consists in placing the parts so as to relax the muscles whose tendons have suffered. In rupture of the tendo-Achillis, the knee should be bent and the foot extended, relaxing the muscle and approximating the separated ends. This is readily and conveniently affected by placing a slipper on the foot, and attaching to its heel a firm band, which is then fastened to a ring or strap placed on the thigh. This apparatus must be worn for six or eight weeks. Afterwards a high-heeled shoe should be used for some time; or if the union be still weak and imperfect, a splint may be placed on the fore part, resting on the dorsum of the foot and the fore part of the leg.

Bruise.—The effects of bruises or contusions are, separation of the cellular connexions, rupture of bloodvessels, and effusion of their contents into the cells; a cavity, often large, is thus formed partly by the direct injury, and partly by the subsequent effusion, and this is quickly filled with blood, partly fluid and partly coagulated. Immediate tumour forms; and the integument is discoloured, often beyond the principal swelling. The injury may, or may not, be attended with division of the integuments, or with fracture or displacement of the bones; but all injuries of the hard parts are attended with more or less bruising of the soft. Bruise is most frequently produced by a blow, and is most severe when the violence is resisted by an unyielding part, as by bone; a squeeze between two bodies, particularly if they be in motion, also inflicts extensive contusion. The swelling continues to increase for some time, and then gradually disappears along with the pain. As the tumour subsides, the discoloration increases; the thinner parts of the effusion have been absorbed, and the clot then shines through the skin, imparting to it various hues.