TRACTION

INJURIES

OF

ROLAND
Front

During

the

Peripheral
Research
the

recent

Nerve
Council

plexus

anaesthetic
discussed
primary

the

war

which

were

BRACHIAL

BARNES,

Department

Injury
of Great

THE

GLASGOW,

of Orthopaedic

many

traction

Centres
Britain.
treated

in

were
paper

three

of

University

of the

ADULTS

were

treated

of Glasgow

brachial

established
is a review

these

IN

SCOTLAND

Surgery,

injuries

which
This

PLEXUS

plexus

in the

under
the aegis
of the Medical
of sixty-three
closed
injuries
of

centres.

It

does

not

include

lesions.
The mechanism
of injury,
and the factors
influencing
and evidence
is cited
to support
the principle
of conservative
nerve
lesion.

any

post-

the prognosis,
are
treatment
of the

scalenus
mediuv

vA2
1

FIG.

Mechanism
limb
by

of traction
the side,
the

injury
of the upper
head
and
shoulder
then
falls on the

MECHANISM

Motor-cycle
patient

accidents

is usually

conjectural.
separation

are

unconscious

It is agreed,
of the head and

determining
The

the
brachial

particular
plexus

OF

responsible
for

however,
shoulder,

some

roots
of the
are forcibly
upper
roots.

for
hours,

plexus.
separated.

traction

and

very

which
scalene

escape
the
10

on the
violence

upper
may

injury
lower

roots

roots,
and
even cause

if the
are

limb

side.

irreparably.

Some
It

the

of the

plexus.

mechanism

the essential
limb at the

fascia,
from
by

the

be

factor
shown
THE

must
by

JOURNAL

side

factor
moment

the

therefore

of deep

OF

BONE

AND

JOINT

scalene
arise,
stress

(Fig.
1).
roots still

operate
on the

is

is forcible
of impact

greatest

under
tension
but the lower

experiment

The

of injury

and rupture
the
which
the muscles

the lower
roots
of the first rib,

additional
can

upper
stress

will receive
the brunt
of injury.
muscles
and by a strong
layer

it is impossible
to put
downward
dislocation

is by the

damaged

injuries

often

cervical
fascia.
Violence
must
be severe
enough
to tear the
muscles,
or to avulse
the tubercles
of the transverse
processes
before
stretching
of the nerve
roots can occur.
\Vhen
the shoulder
is forcibly
depressed
with the arm
falls
The

the
Most

INJURY

most

that
in traction
injuries
the position
of the upper

roots of the plexus

is protected
by the

With

when
cadaver
SURGERY

TRACTION

INJURIES

OF

THE

BRACHIAL

PLEXUS

IN

11

ADULTS

that
tension
is exerted
the trunk
and the head

on all roots
of the plexus
when
the abducted
limb is forced
behind
is thrust
towards
the opposite
side (Fig. 2). The tension
on each root

varies

of the

limb:

upper
plexus

roots.
may

with

the

position

increases
tension
on the
for lesions
of the whole

elevation

paralysis
of all muscles
of the limb;
power
in muscles
innervated
by the

increases

tension

on the

lower

roots;

These
observations
are in accord
with
be divided
into three
types:
1) lesions

adduction

clinical
findings,
with permanent

2) lesions
in which
there
is early
return
lower roots,
and no recovery
in muscles

of voluntary
innervated
by

the upper
roots;
3) lesions
in which
there
is late return
of voluntary
power
in muscles
innervated
by the upper
roots,
and no recovery
in muscles
innervated
by the lower
roots.
The lower,
or D#{233}jerine-Klumpke,
type
of paralysis
is uncommon
in adults.
There
was

5calenus
medius

FIG.

Mechanism
of traction
injury
of the
whole
plexus.
limb
is forced
behind
the trunk,
and the head
is thrust
side.
All roots
of the plexus
are then
under

no

pure

lesion

of C.8

and

T.1

roots

in this

series,

but

two

The
abducted
towards
the
tension.

patients

had

upper
opposite

a lesion

of C.7,

C.8,

and T. 1 roots
which
were not caused
by motor-cycle
accidents.
One patient
was blown
up
by a land mine,
and the other
was involved
in an aeroplane
crash;
both
were unconscious
for several
hours
and it was not possible
to elicit
details
of the mechanism
of injury.
The
probable
explanation
of the rarity
of the D#{233}jerine-Klumpke
type
of palsy
is that
in adults
violent
traction
is seldom
applied
to the fully elevated
upper
limb,
and that
the shoulder
girdle

has

not

the

same

mobility

in adults
NATURE

Substantial
surgeons
believe
belief
VOL.

has
31 B,

1,

OF

FEBRUARY

the

treatment
1949

of traction

new

born.

INJURY

stretching
of nerve
roots
is possible
that
rupture
of the roots
of the

dominated
NO.

as in the

before
brachial

injuries

actual
plexus
of

the

rupture
occurs.
Many
is frequent,
and
this

plexus.

It

is one

of

the

12

R.

BARNES

favourite
arguments
advanced
in support
of early
operation.
Nevertheless,
Stevens
(1934)
stated
that
rupture
of nerve
roots
with
complete
separation
of the torn
ends
was
a rare
lesion,
and this view is supported
fully in this series
by observations
made
at the time
of
operation.
Ten severe
injuries
of the brachial
plexus
were
was there
complete
rupture
of the nerve
roots.
Moderate
stretching
of a nerve
root causes
temporary
affects

the

motor

to the lesion
Traction
disturbance
may

be

rather

than

sensory

fibres.

though

before

connection

it is slow
with

because

their

many

end-plates
before
the axons
Traction
injury
of still

not

of the

great

violence

may

clean cut, and it is always

on each side of the rupture.

rupture

one

associated
For this

with
reason

axons

in the intrinsic
by irreversible

of the

or more

roots

of the

severe
scarring
it is impossible

which
nerve

to

axons

hand.
Failure
in the motor

and

considerable

scarring
altogether.

plexus.

rupture

of both
stumps
for
to perform
satisfactory

suture
of the ruptured
nerve
after
adequate
resection
of the stumps,
and
the only feasible
method
of restoring
continuity.
Most brachial
plexus
injuries
are mixed
lesions,
for there is wide variation

long

treatment,

Intraneural
be prevented
The

distal

travel

proper

muscles
of the
changes
occurring

connective
tissue.
or it may even

patient

axons
but no
of function

have

With

with them.
disruption

one

of conductivity

is established.

re-establish
connection
greater
severity
causes

to the intraneural
blood
vessels
and
; recovery
is patchy
and incomplete,

Very

inhibition

in only

is no degeneration

regenerating

end-organs

complete
recovery
may be expected,
though
of recovery
in these
muscles
may be explained

damage
inevitable

There

and

and complete
recovery
occurs
within
two months
of injury.
injuries
of greater
severity
cause
a degenerative
lesion
of the
of the internal
architecture
of the nerve.
Spontaneous
recovery

expected,

distances

the

explored

is then
is never

some

nerve

distance
end-to-end.
grafting

in the

is

traction

violence
applied
to individual
nerve
roots.
All traction
injuries
are of considerable
extent
and, in the more severe
lesions,
several
centimetres
of the nerve
may suffer gross intraneural
damage.
It is important
to appreciate
that
it is intraneural
damage,
and not extraneural
scarring
caused
by associated
soft tissue
injury,
which
is the barrier
to recovery.
CLINICAL

Traction

injuries

of the

brachial

FEATURES

plexus

may

be divided

into

four

of C.5 and 6; 2) lesions

of C.5, 6, and 7;
C.8, and T. 1. The distribution
of anaesthesia

3) lesions
of the whole
and muscular
paralysis

is too

The

well-known

to

require

description.

from the same

roots
of the plexus
and
of paralysis
in each
group.
Sometimes
in the traction
injury,
in which
case
on to the side of the neck.
Paralysis
is always
most
extensive
has
produced
no evidence
to
(1947)
that
subsequent
extensive
many
originally
incomplete
motor

axons,

lesions

a lesion

the nerve
root,
nature
of the
infrequent,
by naked-eye

with

rupture

nerve

roots.

of axons

immediately

after

the
contention
tissue
formation

The
and

are identical.
Early
operation
lesion
but
unless
the nerve

there
is nothing
examination

branches

are

not

plexus,
This
to

injury.

of
tends

of C.7,
groups
derived

in the extent
are involved.
the shoulder

Study

of these

cases

Davis,
Martin,
and
to impair
to various

Perret
degrees

and
gives
rise to disseminated
view
is still widely
held
and

surgery.
determine

clinical

1) lesions

always

this reason
there
is some variation
the third
and fourth
cervical
roots
the area of anaesthesia
extends
over

futile
and even mischievous
by clinical
examination
of the

groups:

for

uninjured
portions
of the
and
sensory
disturbances.

responsible
for much
It is impossible
degenerative

support
scar

muscular

main

plexus;
4) lesions
in each of these

the

picture

intraneural

prospects

scarring,

is often
advised
roots
are ruptured,

and

JOURNAL

OF

recovery
lesion

a complete

in order
which

in
of the

rupture

of

to discover
the exact
as we have
seen is

to be gained.
If the nerve
is in continuity
to give a satisfactory
prognosis.
THE

of

of a degenerative

and
it is

it is quite

BONE

AND

JOINT

impossible

SURGERY

TRACTION

The

lesion

somewhere

INJURIES

is always

between

the

OF

THE

supraclavicular

BRACHIAL

and

intervertebral

the

foramina

PLEXUS

most

and

IN

common

the

point

situation
where

is in the

the

roots

the three
main
trunks.
Signs
pointing
to a high lesion
of the fifth and
paralysis
of the diaphragm,
rhomboids,
and serratus
anterior;
and in the
Homers
syndrome.
In this series,
signs
of a high lesion
were present
in
traction
injuries
of the upper
roots,
and in fifteen
out of thirty
traction
thoracic
root.
Pain may be an early
and distressing
traction
lesions
of the lower
roots
of the
Oedema
is always
a troublesome
feature
by

prompt

and

energetic

treatment,

OF

it causes

RECOVERY

IN

Satisfactory

Roots
involved

Number

rapidly

increasing

LESIONS

OF

functional

3,4,5

4,5

3,4,5,6

5,6

10

3,4,5,6,7

4,5,6,7

5,6,7

17

Within
months

to form

sixth
roots
include
first thoracic
root,
seven
out of forty
injuries
of the first

stiffness

of the

joints.

I
C.5,

6,

six

RooTs

recovery

of

cases

roots,

join

symptom.
It is usually
most persistent
in severe
plexus
and it is an unfavourable
prognostic
sign.
when
paralysis
is extensive
and, unless
prevented

TABLE
ANALYSIS

13

ADULTS

Incomplete
recovery

Over
six
months

1
-

No
recovery

PROGNOSIS

Perusal

of

the

surgical

literature

leaves

one

with

the

impression

that

injuries
of the plexus
are hopeless
surgical
problems.
So gloomy
a view
this
survey,
for many
lesions
of the plexus
recovered
satisfactorily
meticulous
attention
was given
to the details
of conservative
treatment.
are

Non-degenerative
distinguished

lesions
of the plexus
always
recover
quickly
and
from degenerative
lesions
by persistence
of normal

easily

for longer
than
eighteen
loss in the areas
normally
series,
lesions
C.5,

days after
innervated

thirteen
of the sixty-three
and, as one would
expect,
6 nerve

injury
by

most

traction

is not supported
provided
only
completely.
electrical

and by absent,
or no more than
the damaged
nerve
roots
(Seddon

patchy,
1943).

by
that

They
reactions
sensory
In this

injuries
of the plexus
could be described
as non-degenerative
they were more common
when the damage
was confined

to

roots.

In degenerative
lesions
the pattern
of recovery
was fairly
constant;
lesions
of C.5, 6
recovered
well, whereas
some residual
palsy
was inevitable
in lesions
of the whole
plexus.
The prognosis
of lesions
of the upper
roots
of the plexus
was not influenced
by the level of
the lesion,
main roots
Lesions

roots

nor by involvement
of the
of the plexus
(Table
I).
of C.5, 6 nerve
roots-There

(Table

I).

Eleven

and external
rotation
capable
of sustained
VOL.

31 B,

NO.

1,

patients

1949

were

regained

of the shoulder,
effort.
Two cases

FEBRUARY

third

and

fourth

fourteen
flexion

cervical
patients

of the

with

elbow,

against
gravity
and
were rated
as failures

nerves

in

lesions

abduction

resistance,
although,

addition

to

of C.5,

or C.5,

of the

shoulder,

though
in fact,

the

not all were

the follow-up

14

R.

period

was

not

sufficient

for

in the flexors
of the
noted
In the paralysed
Lesions
greater

of C.5,
violence,

final

BARNES

assessment.

In one

6, 7 nerve
the results

C.5, 6 (Table
I). Even
of the wrist
and fingers,

roots-In
of conservative

and fingers,
trunk
(Fig.

so, eleven
of the nineteen
flexion
of the elbow,
and

Illustrative

and
and

the

Traction

limb.
of the

recovered

deltoid

even

Lesions
plexus

and all recovered

within
when
the

was

two

whole

had
muscles

incomplete
weak

by

the

on

the

and
hospital,

recovery

to

7 roots.
of

six

those

6, 7 were

usually
muscles

months

interesting.

limb

forearm

by

Half

months

of

being

plexus-There
completely

RECOVERY

recovery

was
injury

by

the

there
seventh

patients

behind

of stone

during

paralysis
of the left

and
radius,

good

was

cervical

the

recovery
nerve

root,

was

the

lesions

and

the

considerably.
Satisfactory

first

noticed

thirteen

of all muscles
or lower roots

TABLE

II
LESIONS

Cases
with
Homers
syndrome

Cases
with
severe
pain

OF

was
months

of the

after

in

the

injury.

lesions
of the whole
the other
twenty-four

In

of the limb,
of the plexus

THE

elbow

possible

WHOLE

or incomplete
(Table
II).

PLEXUS

Remarks

All
lesions.

of reappearance

flexors

recovery

paralysis
upper

TWENTY-EIGHT

time

The

were
four
non-degenerative
six months
of injury.

within

IN

of

mixed
varied

were

non-degenerative
Complete
recovery
six months

First
sign of recovery
in muscles
.
innervated
by C.5, 6 roots
noted
at six
to fifteen
months
from
the date
of injury

(b)
Lower
roots
No

paralysed

the

piece

immediate
a fracture

within

Incomplete
recovery

by
of

these
injuries
with
the limb
of the wrist

forced

a heavy

there
revealed

innervated

of injury.

contraction

Number
cases

(a)
Upper
roots

was

caused
in lesions

in the

of the shoulder;
of the shoulder
of the extensors

abducted

outwards,
and
examination

Within

exception

usually
than

of function

was

left

recovery

contraction

in this group
regained
extension
of the shoulder
against
gravity

recoveries

struck

was

either
permanent
innervated
by

OF

incomplete

caused

paralysed

of recovery

Complete

was

permanent.

voluntary

ANALYSIS

Degree

the

in the

often

cases the patient

recovery
in the

6, and

with

of C.5,

power

of

C.5,

paralysis

injuries

being

19 years,

patients
abduction

and external
rotators
by forcible
depression
had residual
paralysis

forced
backwards
On admission

muscles

muscles

of voluntary

aged

was

injury

paralysed

in these

injury

D.,

The
arm
of the whole

a traction
all

plexus

case-f.

an air-raid.
numbness
in

paralysis
of the abductors
were apparently
caused
The other
three
patients
the
2).

there

so far as lesions
of C.5, 6, 7 are
treatment
are less satisfactory

and some resistance.

In six patients
there was
muscles;
and two were failures.
The residual paralysis
in the six incomplete
had residual
of the plexus
by the side.

patient

elbow
joint.
In all cases
rated
as satisfactory,
muscles
within
nine months
of injury.

recovery

Homers

10

syndrome

is always

a grave

the lower
roots
and often
of the whole
syndrome;
seven were left with permanent
useful voluntary power in the abductors

Complete
innervated
within

recovery
by
C.8,
two
months

of

muscles
T. 1 roots
of injury

prognostic

sign.

It indicates

irreparable

injury

of

plexus.
Thirteen
of these
patients
had Horners
total paralysis of the upper limb; and six regained
of the shoulder
and flexors
of the elbow,
but no
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

TRACTION

INJURIES

OF THE

BRACHIAL

PLEXUS

IN

13

ADULTS

in any
muscle
of the forearm
or hand.
The first sign of recovery
in the muscles
of
shoulder
girdle
was observed
at intervals
varying
from
six to fifteen
months.
The ten cases
without
Homers
syndrome
were,
with
one exception,
mixed
lesions
of
the plexus.
Sensation
was often
unimpaired
in C.8, T.1 dermatomes.
The flexor
muscles
of the
forearm
and
the intrinsic
muscles
of the hand
recovered
completely
within
a few
weeks
of injury,
leaving
the patient
with residual
paralysis
of the muscles
innervated
by the
recovery

the

plexus.
C.7, C.8, T.1-In
the whole
series there were only two lesions
of C.7, C.8, T.1
roots.
There
was no recovery
in the one patient
who had a Horners
syndrome
; the other
had a transient
lesion
of C.7 root, and a degenerative
lesion
of C.8, T.1 roots,
which
did not
upper

of the

roots

Lesions

of

recover.
TREATMENT
Preventing

the

joint

joints

often

neglected

stiffness-In

causes

more

the severity
of injury,
and
elevating
the limb,
usually
range

of movement

joint,

but

on

Preventing

by

a day.

Fractures

movements

may

of the

brachial

plexus,
Oedema

groups

prevent

wrist

stretching

If opposing

the

paralysis.

to allow

sufficient

lesions

at least

twelve

time

of the

for

of

before

roots,

the

months
after injury.
some cases pain is very

of pain-In

of
to

full movement

and

digits

the

of muscles

recovery

upper

contracture
is proportionate

cause
of joint
stiffness
; it must
be prevented
splint.
All joints
should
be put through

wasting-Continuous
splinting.

degenerative

Relief

times
should

of

muscular

be

muscles

paralysed,

sign

distressing.

of

is prevented

the

mid-position

reconstructive

recovery

It may

shoulder

of

wasting
of the paralysed
all muscles
which
are
be necessary,
and it is

considering

first

of the

by
a full

neglected.

paralysed
are

is chosen.
Daily galvanic
stimulation
will prevent
excessive
During
the phase
of recovery
it is essential
to re-educate
feeble
voluntary
contraction.
Prolonged
treatment
may

important
until

than

it is the main
on an abduction

several
account

muscle

appropriate

the joint
muscles.
showing
In

no

injuries

disability

may

be relieved

operations.
not

be

observed

by elevating

the

limb so that
slowly
over
for persistent

the injured
roots
of the plexus
are not under
tension.
As a rule, pain subsides
a period
of several
months.
Only two operations
were performed
in this series
pain.
One, a patient
aged twenty-eight
years,
complained
of severe
pain three

years

a traction

after

without

success.

injury

The

other

of the

after irreparable
injury
of the
exploration
of the plexus.
Operative

treatment

within

ten

days

fifty

In this

cervical
years,

case

injury,

or not

lesion
and he believed
that
primary
two clean nerve ends were discovered

at all.

His

sympathectomy

complained

the

pain

still
much
difference
lesions
of the plexus.

in traction
of the

plexus;

aged

plexus.
is

treatment-There

operative

whole

patient,

was

relieved

of opinion
Jefferson

purpose

was

and the same

have
to consider

order

assess

to

damaged
injuries.

the

authors
then:

prospects

to determine

suture
might
sometimes
in an accessible
position.

be feasible
Recently

nerves
may
The decision

even advocate
exploration
1) whether
early
exploration

of recovery,

be possible;
presents

or on

is usually

hardly be considered.
Since only three lesions of the

whole

no direct evidence

of recovery
VOL.

31 B,

in these cases. We
NO.

1,

FEBRUARY

1949

as to the
have

plexus
value

if any,
lesions

that

were
of early

seen, however,

the

extent

explored

years
and

brachial
to the

that

plexus
injuries
soft parts
have
of the plexus.
is indicated

operative

operative

within

three

exploration

in assessing

that it is possible

to give

of the

cases where
Martin,
and

repair

for late exploration

are confined
to the

so satisfactory

four

amputation

in rare
Davis,

of old injuries
of the plexus

off-chance

2) the indications,
no difficulty
when

roots of the plexus, for recovery

there was

the

by

performed

pain

as to the
indications
for
(1930),
advocated
operation

Perret (1947) have stated that the best possible

results
following
may be obtained by operation
as soon as the acute
effects
of injury
subsided,
We

was

of severe

in

of the

of neglected
upper
three

treatment
months

need
of injury

the

prospects

a fairly

accurate

16

R.

BARNES

prognosis
on clinical
data alone,
and it is unlikely
that early exploration
of the plexus
could
give more information,
apart
from the rare occasions
when rupture
of the roots
is disclosed.
It could
be argued
that
the prognosis
in lesions
of the whole
plexus
is so bad that it is
reasonable
to attempt
any form of repair
of the damaged
roots,
no matter
how unpromising
it may

seem.

Lesions

complicated

be, amenable
to surgery,
of repair
impossible.
Lesions

by

for the
without

will

these
the upper
roots
sustain
the
forward
to useful
recovery
in the
the plexus
is attenuated
or swollen,
of the nerve.
The main
difficulty

still

to be proved

that

syndrome

are

not

now,

and

probably

never

as to make
any
more
promising.

type
In

brunt
of injury,
and one can with some
confidence
look
muscles
of the forearm
and hand.
If the upper
trunk
of
there need be no hesitation
in resecting
the damaged
part
is that
the lesion
is not always
accessible
and that,
even

if it is, primary
suture
is impossible
suitable
autografts
but the number
has

Horners

lesion
of C.8, T. 1 roots
is so high
Horners
syndrome
are a little

after
adequate
resection.
of cases in which
grafting

functional

recovery

after

The gap might

is feasible
will

grafting

is as satisfactory

be bridged
by
be few, and it
as the

results

of late reconstructive
surgery.
Seddon
(1947)
reported
one incomplete
recovery
and two
failures
in three
autogenous
cable
grafts
for traction
lesions
of C.5, 6 roots.
The failures
were ascribed
to inadequate
resection.
Late exploration
of the plexus
and freeing
of nerves
from scar tissue
may occasionally
be

justified

for

the

relief

of pain

which

has

not

responded

to conservative

treatment.

It

cannot

assist
recovery
because
the chief barrier
to regeneration
is the endoneural
scar.
When
the full extent
of recovery
is known
the function
of the limb can often be greatly
improved
by reconstructive
surgery.
Such
operative
measures
should
not be considered
earlier
than
fifteen months
from the date of the accident, because recovery in the proximal
muscles
of the limb has been observed
more than
one year after injury.
SUMMARY

1. Sixty-three traction injuries of the brachial plexus

in adults
patients were seen at regular
intervals
for more than three
years
The mechanism
of injury
is described.
the essential factor, but the type of lesion

Forcible
separation
is determined
by

2.

at the

time

of the

any damage
to uninjured
parts
of the plexus.
4. The prognosis
of each type
of lesion
of the
occurs
in most
lesions
of the upper
three
roots.
never
recover
completely.
Cases
with
Horners
paralysis.
5. Conservative
cited
against

treatment
early
or late

are

indicated.

I am

indebted

the detailed
investigation,
are the work

to the

Most

of the head
and
position
of the

of the

shoulder
is
upper
limb

accident.

3. In traction injuries the main damage

is intraneural,
extent. Extraneural
scarring
is a conspicuous
feature

sometimes

the

are reviewed.
after injury.

staffs

is advocated
operations

of the

on

Peripheral

the lesions
are of considerable
injuries,
but it does not cause

plexus
is discussed.
Satisfactory
recovery
Degenerative
lesions
of the whole
plexus
syndrome
always
have
severe
residual

for traction
the plexus.

Nerve

and
of old

Injury

injuries
of the
Reconstructive

Centres

at

case records
of the traction
injuries
of the brachial
plexus
and
especially
to Mr A. R. Parkes,
Mr H. J. Seddon,
of Mr G. Donald
of the Department
of Surgery,
Glasgow

plexus
and
surgical

Killearn, Oxford,
which
have
formed
and
Mr R. Roaf.
University.

evidence
procedures

and
the
The

Winwick
for
basis
of this
illustrations

REFERENCES
DAVIS,
JEFFERSON,
SEDDON,
SEDDON,
STEVENS,

printed

L.,

MARTIN,

J., and

PERRET,

G.

G. (1930):
Proceedings
of the
H. J. (1943):
Brain,
66, 237.
H. J. (1947):
British
Journal
of
J. H. (1934): Section
on Brachial
in Boston,
Massachusetts.

(1947):

Annals

Royal
Surgery,

Plexus

Society

of Surgery,

of Medicine.

35, 151.
Paralysis

125, 647.
Section

in the Shoulder

THE

JOURNAL

of Neurology,

by

OF

BONE

23,

E. A.

Codman,

AND

is

JOINT

1282.

Privately

SURGERY