History of Brachial Plexus

Guillaume Benjamin Armand Duchenne (1806-1875) was a French physician who specialized in electrotherapy, electrodiagnosis, neurology and medical photography. He coined the term "obstetrical brachial plexus palsy" in 1872. Duchenne used electrodiagnosis to measure the severity of the paralysis, similar to what an Electromyogram (EMG) is used for today to assess nerve damage. Duchenne was interested in the prognostic and therapeutic aspects of treating brachial plexus injuries.

In addition to his work in the areas of electrotherapy, electrodiagnosis and neurology, Duchenne is considered a pioneer in medical photography. Many of his photographs are displayed in the Ecole Nationale Superieure des Beaux-Arts in Paris.

William Heinrich Erb (1840-1921) was a German neurologist who made significant contributions to establishing neurology as its own specialized field of medicine. He founded the German Journal of Neurology and the Society of German Neurologists. Through anatomical observations, Erb discovered the location of nerve damage to the brachial plexus that results in the most common form of neonatal brachial plexus injury. The site of these nerves, C5 and C6, is now known as Erb's point.

Augusta Dejerine-Klumpke (1859-1927) was the first woman to graduate from the University of Paris School of Medicine. She and her husband, Joseph Jules Dejerine, who were both neurologists, recognized that damage to the lower plexus, C8 and T1, affects the function and sensation in the forearm, wrist, hand and fingers. She also noted that Horner's Syndrome, which can include a drooping eyelid, often accompanies this type of damage. Now known as Klumpke's Palsy, this form of brachial plexus injury is less common than Erb's Palsy.

James Sever (1878-1964) was the chief of orthopaedics at Boston Children's Hospital for 40 years. Sever published many works, including an article that reviewed the pathology, etiology and clinical aspects of 470 cases of neonatal brachial plexus palsy. During his anatomical investigations, he was impressed by the vulnerability of the upper nerves of the brachial plexus under pressure and surprised that paralysis was not more common. Sever developed a surgical procedure that released muscles in the shoulder to treat children who had limited range of motion as the result of the nerve damage to the plexus.

Joseph B. L'Episcopo (1890-1947) was an orthopaedic surgeon who immigrated to New York from Italy when he was 9 years old. After working his way through school by cutting hair and managing a billiard's hall, he graduated with a medical degree from Long Island College Hospital in Brooklyn, New York. He became a first lieutenant in the United States Medical Corps and served in World War I. After the war, he returned to his alma mater as an orthopaedic surgeon. Eventually, he became director of orthopaedic surgery at Kings County, chief of orthopaedic surgical staff at the House of St. Giles the Cripple, and was a consultant for several other Brooklyn hospitals.

L'Episcopo published two critical articles on tendon transplantation and restoration of muscle balance in the shoulder for brachial plexus patients. He adapted Sever's procedure by devising a transfer technique that restored muscle balance and prevented the return of internal rotation postoperatively. Through the combination of muscle releases and transfers in the shoulder, this method resulted in increased external rotation (ability to move the arm outward) and abduction (ability to move the arm upward). Now known as the Sever-L'Episcopo procedure, it is still used with various modifications today.

Photo courtesy of SUNY Downstate Medical Center Archives.

Algimantas Otonas Narakas (1927-1993) was a surgeon whose unusual childhood experience led to his unique training as a physician. At 11 years old, Narakas sustained major leg injuries from a hand grenade he found nearby his home in Kaunas, Lithuania.

After developing osteomyelitis and arthritis from his injuries, he was sent to Switzerland for treatment in 1938 shortly before World War II began. While he was bedridden, Narakas taught himself several languages and read incessantly. Antiobiotics introduced toward the end of the war cured him of his debilitating condition.

Narakas remained in Switzerland and eventually graduated with a medical degree in 1957. Because Narakas could not practice medicine until he was granted Swiss citizenship, he continued his student training, which gave him vast exposure to many different areas of surgery, including neurosurgery, orthopaedic, and hand and limb reconstructive surgery. This extensive postgraduate work gave him exceptional familiarity with the many specialty areas involved in treating brachial plexus injuries.

Narakas is considered to be a pioneer in brachial plexus surgery. In 1966 he began performing major brachial plexus operations, one lasting nineteen hours. His skill at recording his observations and procedures in drawings and writing proved to be an invaluable tool in understanding brachial plexus injuries.

In 1986, he designed the Narakas Classification of Nerves to identify the level of nerve injury based on symptoms identified during a clinical examination. By observing the presentation, movement, and function of the arm and hand, he categorized the injury into four types to assess which nerves had been affected. The purpose of the classification was to predict prognosis (future recovery) of brachial plexus injuries and is still used today.