The chief point of this paper is to advocate early exploratory incision in cases of severe shoulder injuries with negative X-Rays.T wish I had the best of reasons for defending this position-namely that I had repeatedly done what I advise and been glad that I had. As a matter of fact I have never done an exploratory operation on an early case of injury to the shoulder nor do I remember ever having the opportunity. Nor am I likely to see such cases in the future, for I have no connection with any clinic which receives accident eases. However, many of you men are seeing and treating acute traumatic shoulder lesions. I do see many chronic cases because for about ten years, thanks to Dr. Francis Donoghue's policy of sending cases for impartial examination for the Industrial Accident Board of Massachusetts to those who have given study to particular classes of work, I have seen many cases of long standing shoulder injuries. Also for a number of years some of our insurance companies have asked me to operate on their patients with obscure lesions in this region. This has formed the bulk of my experience on which to base my arguments about early incision. I realize that seeing these selected difficult cases gives me a biased point of view, for I do not see the perhaps large number of cases which are satisfactorily and promptly treated. My ideas of routine work comes from 15 years of experience in the outpatient department of the Massachusetts General Hospital when I intensively studied a series of 100 shoulder cases and wrote my papers on subacromial bursitis, a bibliography of which appears at the end of this article.Speaking from this point of view, therefore, it seems to me that shoulder injuries which are not obvious dislocations or fractures receive scant attention from the surgeons of New England.
but slight spasm of the extremities. The knee-jerks were not determined because of the continuous motion.Kernig's sign was absent.The urine was clear, acid and contained no albumin.Three cubic centimeters of very turbid fluid under low pressure were obtained by lumbar puncture. This fluid contained a large number of cells, 98% of which were polynuclear and 2% mononuclear, as well as very many bacteria which were later proved by Dr. Calvin Page to be influenza bacilli.The twitching of the extremities continued, but he had no convulsions. There was never any rigidity of the neck, but there was moderate rigidity of the extremities. The knee-jerks were never determined because of the twitching. Kernig's sign was at times present on one side, but not on the other. The fontanelle remained depressed until the day before death. The pupils became widely dilated and did not react to light. He died, after progressive failure, May 20. Influenza meningitis usually runs a short course and is almost invariably fatal. Treatment can be only symptomatic.--
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