there maintain them. If the fragments are already in good anatomical position retention is all that is necessary. As a general proposition under ordinary circumstances a fair resuit by simple. reduction and fixation is more advisable than a possible better result by open operation.

One of the principal causes of displacement after fracture of the shaft of a long bone and also one of the principal difficulties met with in reduction is tonic contraction of the attached muscles due to the unsupported weight of the lower segment of the limb. When this condition exists the obstacle may be overcome by traction in the direction of its long axis, the different joints being usually held in partial flexion in order to assist muscular relaxation. In some cases by maintaining this traction the muscular resistance is overcome and after reduction the fragments remain fixed. In other instances traction over an extended period of time may be necessary to hold the fragments in proper apposition until sufficient healing takes place. Another serious obstacle to reduction may be the intervention of soft parts between the fragments. In the reduction of compound fractures, if it is found difficult to maintain the fragments in proper apposition, it may be well to enlarge the external wound through which the reduction may be guided. In impacted fractures it is sometimes necessary to break up the impaction in order to obtain the best results in reduction. In some fractures, such as Pott's fracture, the character of the displacement is so common that a formula can be made for its treatment.

The objects of retention are to prevent displacement of the fragments, to relieve the force of gravity and muscular contraction, to protect the limb from external violence during the process of repair, and to prevent pain that would be caused by movement of the frag

ments.

The means employed in maintaining fixation are varied and sundry, the fracture being dealt with suggesting the type of apparatus which should be used. Ordinarily in the course of treatment the first means of immobilization are employed temporarily and include removable dressings. As the process of repair advances and indications for close observation and supervision of the part no longer exist, permanent dressings are used. After removal of the permanent dressings hydrotherapy, massage, and gradual use of the part are begun and continued until the return to normal is accomplished. When fractures communicate with joints, the earliest possible motion of the joint is desirable in order to obtain the best functional result.

In fractures of the upper end of the tibia and fibula or the tibia alone, the line of fracture may be transverse, oblique, or longitudinal;

in the latter cases the knee joint is involved. The tuberosities of the tibia may be crushed. The mechanism in these fractures is usually brought about by the combination of body weight and lateral flexion of the leg upon the thigh. The diagnosis is made by recognition of the irregularity of outline, pain on local pressure, and on pressing the leg upward and possibly abnormal mobility and crepitus. In transverse fractures high up they are sometimes mistaken for a subluxation of the knee. The prognosis in these fractures is especially serious because of the close proximity of the knee joint and the possibility of inflammatory complications. The treatment consists of correcting the displacement by traction and direct pressure. Retention is effected either by permanent traction or a suspended posterior splint with the knee partly flexed. If the fracture is compound and suppuration of the joint occurs, free drainage of the pus must be established at once.

Separation of the epiphysis has been reported in a few cases. It appears to be caused by a wrench of the leg, abduction or adduction by which a transverse strain is produced.

Fracture of the spine of the tibia is probably produced by traction through the crucial ligament or by force transmitted through the external condyle of the femur. The most definite symptom is inability to fully extend the leg. The treatment is full extension when possible, and immobilization for a period of at least four weeks.

Avulsion of the tubercle of the tibia, or Osgood-Schlatter's disease, is usually caused by the action of the quadriceps muscle during some violent effort through the attachment of the patellar ligament. We have five such cases in the hospital at the present time. Inability to use the limb immediately after the accident, the recognition of a movable fragment of bone about 2 inches below the patella, localized pain upon pressure, and crepitus may be present. The knee joint and surrounding soft tissues are often swollen and painful, and effusion may be present. The treatment is to press the fragment into place if possible and hold it there by adhesive strips while the leg is held in full extension. In cases with wide separation of the fragment, open operation with suture of the periosteum or nailing may be indicated.

Fractures of the shaft by direct violence may occur at any point, while those due to indirect violence usually occur near the junction of the middle and lower thirds. In these fractures torsion often plays an important part. Any type of fracture common to long bones may be found in fractures of the tibia, and in addition a form of spiral, the V-shaped fracture. Fractures of the tibia produced by indirect violence are usually accompanied by fracture of the fibula. The superficial position of the tibia makes it especially prone to

result in being compound. Almost any form of displacement is met with, the most common being a projection of the lower end of the upper fragment when it terminates anteriorly. One usually finds the signs and symptoms of deformity, abnormal mobility, crepitus, loss of function, and pain. The subcutaneous portion of the tibia is readily examined by passing the finger over it. Reduction of displacement can usually be accomplished by traction at the foot and counterextension at the knee. Retention following reduction depends upon the type of fracture being dealt with. In simple fractures with little displacement, or where reduction has been accomplished, it has been my practice to put the patient to bed for a week to 10 days with the leg made secure and comfortable in a temporary splint. After this time the swelling has usually subsided, and the leg, together with the foot, knee, and lower third of the thigh, are incased in plaster of Paris. If any wounds are present requiring dressings, windows are left in the plaster dressing. Where prolonged or permanent traction are required, this can be accomplished by various means, depending upon the site of fracture and amount of traction needed.

Fractures of the lower end of the tibia with fracture of the fibula are usually caused either by direct violence acting upon its side to crush it, or indirectly through inversion or eversion of the foot to produce a transverse strain which may be aided by body weight. The diagnosis is made by recognition of abnormal mobility and the mobility of the fragments, local pain, and the other signs of fracture. The X ray may be required for diagnosis or details. The treatment should consist of as perfect reduction as possible and is accomplished by traction through the foot and by direct pressure. When the joint is involved the foot should be held in a position at right angles to the leg. Early passive motion should be a part of the treatment. In severe cases of compound fracture it may be best to amputate.

In supramalleolar fractures the mechanism is probably either forcible inversion or eversion of the foot. The diagnosis is made by pain upon pressure over the site of fracture, together with one or more of the usual signs or symptoms. In its treatment the lower fragments should be held in position by a fixed dressing.

Separation of the lower epiphysis of the tibia are more frequent than those of the upper epiphysis. The most common cause apparently comes through a cross strain in eversion or inversion of the foot, or it may be produced by simple twisting of the foot. It may be accompanied by the breaking off of a fragment of bone, and is usually accompanied by fracture of the fibula. The diagnosis and treatment of these fractures are the same as for supramalleolar fracture.

Pott's fracture is caused by eversion and abduction of the foot, assisted by the body weight. The details of this type of fracture. vary greatly with the predominating mechanical element in its production. If eversion predominates the force is exerted above the malleolus and rupture of the tibio-fibular ligament takes place. If abduction of the front of the foot predominates there occurs a break of the internal malleolus at its base, or a rupture of the internal lateral ligament, followed by rupture of the tibio-fibular ligament, and as the movement is continued an oblique fracture of the fibula takes place through torsion 3 or 4 inches above the tip of the fibula. With all a widening of the intermalleoli mortise and a backward displacement of the astragalus takes place. The appearance of the part in Pott's fracture is usually so characteristic that the diagnosis can be made by sight. The foot is displaced outward with abnormal prominence of the internal malleolus or adjoining portion of the tibia, and in marked cases the backward displacement is also readily seen. Pathognomonic signs are points of tenderness over the lower portion of the internal malleolus, the site of the tibio-fibular ligament, and over the fibula a little above the external malleolus; abnormal mobility; sometimes a click between fragments upon manipulations, and marked ecchymosis beneath the malleoli, especially the external. The prognosis is good if proper reduction is made and maintained. Reduction is made. by pressing the calcaneum forward and inward, and retention is perhaps best made by posterior and lateral splints of plaster of Paris so molded that they maintain the corrected backward and lateral displacements.

Fractures of the malleoli by inversion of the foot are quite common and result in a variety of lesions. There may be a fracture of the fibula alone, the tip of the internal malleolus may also be broken, or a considerable portion of the tibia may be broken obliquely off along with the internal malleolus. The type of fracture depends upon the amount of force of the inversion and the degree to which the body weight enters in as a factor. Tearing of the tibio-fibular ligament adds greatly to the seriousness of fractures thus produced by allowing displacement of the astragalus. If there is only fracture of the fibula and internal malleolus, the diagnosis is largely made through recognition of their points of tenderness and independent mobility. If the lower shaft of the tibia is also implicated, upward and inward displacement adds deformity. In the former reduction with immobilization by plaster encasement is all that is necessary, but in the latter downward and outer pressure over the tibial fragment aided by traction through the foot may be needed. When immobilized, one must guard against backward displacement.

Fractures of the posterior portion of the articular surface of the tibia may occur as complications in Pott's fracture, or may occur independently. They may be small and only detected by the X rays or be quite extensive and capable of being diagnosed by palpation. The treatment is as much reduction as possible and fixation. Backward displacement of the astragalus should be looked for. In some cases removal of the fragment with ultimate ankylosis of the ankle joint may give the best functional result. The foot should be at right angles to the leg.

Fracture of the anterior portion of the tibia is a rare fracture and could probably be corrected by traction through the anterior portion of the capsule and forced depression of the front of the foot together with pressure upon the fragment.

Fracture of the upper end of the fibula alone or separation of the epiphysis is caused by direct violence, muscular action of the biceps, or forcible adduction of the leg acting through the external lateral ligament. It is treated by the best possible approximation of the fragments by bandaging or with adhesive strips and fixing the leg by plaster of Paris with the knee in partial flexion and in such a way as to prevent adduction. In cases where the peroneal nerve is injured it may be necessary to treat the nerve by open operation.

Fractures of the shaft of the fibula are usually produced by direct violence and are diagnosed by localized pain, and possibly deformity, abnormal mobility, and crepitus. Displacement is usually slight because of the splintlike action of the tibia. The treatment is immobilization by a plaster case from toes to above knee, to protect against twisting of the foot and external violence.

Separation of the lower epiphysis of the fibula without other fracture has occurred, but is rare.

In the treatment of compound and pathological fractures the complications must be treated along surgical and indicated lines. The operative treatment of fractures of the tibia and fibula call for the same surgical judgment and consideration as do fractures of other long bones.

UROLOGY AND ITS PLACE IN GROUP MEDICINE.1

By W. H. CONNOR, Lieutenant Commander, Medical Corps, United States Navy.

Urology, or what is perhaps better known as genitourinary surgery, became a distinct branch of medicine in America in 1851, when Gross published a book devoted to that subject. His was the first American publication, and at that time there were only two other books published in the English language. From that time

1Paper read at the monthly conference of medical officers at the United States naval hospital, San Diego, Calif.