Jules Tinel

Biography

• Born October 13, 1879 in Rouen, France, into a Norman medical family. His grandfather Jules Hélot (1814–1873) was a surgeon at Rouen and father Charles-Armand Tinel (1831–1914) was a surgeon and professor of anatomy at the Rouen medical school
• 1900 – Began medical studies in Rouen, passed the competitive examination for externes des hôpitaux de Paris.
• 1903 – Early neurological training with Louis Théophile Joseph Landouzy (1845–1917) at Hôpital Laennec.
• 1904 – Trained with Joseph Jules Dejerine (1849–1917) at La Salpêtrière
• 1905 – Ranked third in the competitive internat examination
• 1910 – Received his medical doctorate with the thesis Radiculites et tabes
• 1910–1912 – Served as chef de clinique under Landouzy, then returned to La Salpêtrière to hold the same role under Dejerine.
• 1913 – Head of the pathological anatomy laboratory at the Nervous Disease Clinic. By the end of 1913 he had produced more than 40 publications, mostly in neurology.
• 1914 – Elected member of the Société Française de Neurologie. Mobilised as a military physician with the 18th territorial infantry regiment. Assisted in treating neurological war casualties at La Salpêtrière, then operating as a military neurological centre.
• 1915 – Appointed head of the Neurological Centre of the Fourth Region at Le Mans, where he studied peripheral nerve injuries caused by ballistic trauma. Published Le signe du ‘fourmillement’ describing the tingling sign in peripheral nerve lesions.
• 1916 – Published Les blessures des nerfs, based on extensive experience with war-related peripheral nerve injuries.
• 1919 – Promoted to médecin major de deuxième classe and demobilised on August 6. Returned to La Salpêtrière as laboratory head in the service of Henri Claude (1869–1945).
• 1922 – Appointed médecin des hôpitaux.
• 1928 – Appointed chef de service at Hôpital de la Charité.
• 1932 – Appointed chef de service at Hôpital de la Rochefoucauld, where he established a nervous-system physiology laboratory and pursued research into the autonomic nervous system.
• 1936 – President of the Société de Neurologie.
• 1937 – Appointed to Hôpital Beaujon, Clichy.
• 1941 – Appointed to Hôpital Boucicaut, Paris.
• 1942–1943 – Active in the French Resistance with his son Jacques Tinel, sheltering British and American airmen and assisting their escape toward Spain. Jacques was arrested in May 1943 and died during deportation to Dora-Mittelbau concentration camp. Tinel spent three months in prison in Bordeaux whilst his wife spent a year imprisoned at Fresnes.
• 1945 – Retired on January 1, but continued seeing patients at Hôpital Boucicaut.
• 1947 – Suffered an episode of aphasia, later recovered, and returned to clinical work.
• 1952 – Died March 4, 1952 aged 72.

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Medical Eponyms

Tinel sign (Hoffmann-Tinel sign) (1915)

The Tinel sign, more historically the Hoffmann-Tinel sign, is paraesthesia or tingling elicited by pressure or percussion over an injured or compressed peripheral nerve, with the sensation referred distally into the cutaneous distribution of that nerve. Tinel called it le signe du fourmillement — the “tingling” or “formication” sign.

In October 1915, Tinel published Le signe du ‘fourmillement’ dans les lésions des nerfs périphériques in La Presse Médicale. He emphasised that the tingling of regeneration was not pain, but an unpleasant electric-like sensation, felt most clearly in the distal sensory territory of the injured nerve rather than at the point of pressure.

Tinel proposed that systematic study of the tingling produced by pressure over a nerve could help determine whether the nerve was completely or incompletely interrupted, locate the lesion, identify early axonal regeneration, and follow the progress of regeneration over time.

He noted that the sign usually appeared after the fourth week, usually between the fourth and sixth week after trauma, corresponding to the beginning of axonal regeneration. He noted that progressive distal migration of the sign suggested regeneration, whereas a fixed or non-progressing sign suggested mechanical obstruction, neuroma, or failed repair.

In his 1916 review of 639 war related peripheral nerve injuries, Tinel added percussion to the technique of the objective examination of the nerve.

Formication provoked by pressure. When compression or percussion is lightly applied to the injured nerve trunk, we often find, in the cutaneous region of the nerve, a creeping sensation usually compared by the patient to that caused by electricity. This formication is quite distinct from the pain on pressure, which exists in nerve irritations.

Tinel 1916: 34 [English translation 1918: 34]

Paul Hoffmann (1884–1962) independently described the same phenomenon earlier in March 1915, with a second paper in August 1915 describing percussion technique in more detail. Tinel and Hoffmann were on opposite sides of the First World War and were apparently unaware of one another’s publications. The term Tinel sign became dominant in clinical practice, although Hoffmann–Tinel sign is historically more accurate.

Modern use has extended the use from traumatic nerve regeneration to entrapment neuropathies such as carpal tunnel syndrome, cubital tunnel syndrome, and tarsal tunnel syndrome. Reported sensitivity is variable, while specificity is generally higher. However a negative sign does not exclude nerve compression.

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Key Medical Contributions

Peripheral nerve injuries in war

Tinel’s major neurological contribution arose from his First World War work with soldiers who had ballistic peripheral nerve injuries. His 1916 book Les blessures des nerfs drew on experience at Le Mans and provided detailed clinical descriptions of peripheral nerve lesions, sensory mapping, motor deficits, and prognosis. Koehler records that Tinel described 628 peripheral nerve injuries, including 409 upper-limb and 219 lower-limb lesions.

Phaeochromocytoma and paroxysmal hypertension

In 1922, with Marcel Labbé (1870–1939) and Édouard Doumer (1891–1980), Tinel reported a detailed account of paroxysmal hypertension associated with an adrenal tumour. An early description of hypertensive crisis due to phaeochromocytoma. Note phaeochromocytoma first termed in 1912 by Ludwig Pick (1868-1944).

Exertional headache

In 1932, Tinel described a syndrome of severe headache provoked by muscular effort or thoracic pressure events such as coughing, shouting or singing, which he attributed to retrograde intracranial venous hypertension. One of the earliest descriptions of exertional headache.

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Controversies

Hoffmann-Tinel-sign

• March 1915 – Paul Hoffmann observed the progress of nerve regeneration by tapping over the carpal tunnel. Hoffman described his test in relation to a single soldier with radial nerve (nervus musculospiralis) injury.
• October 1915 – Jules Tinel, observed the progress of nerve regeneration after gunshot wounds by pressing over the carpal tunnel. Tinel described “Le signe du Fourmillement” in numerous injured nerves

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Major Publications

• Tinel J. Le diagnostic des anesthésies par l’exploration au diapason. Revue neurologique (Paris) 1909; 17: 634–5.
• Tinel J. Les lésions radiculaires dans les méningites. Revue neurologique (Paris) 1909; 17(12): 741–5.
• Tinel J. Radiculites et tabes: les lésions radiculaires dans les méningites, pathogénie du tabes. Thèse Paris n°8. 1910
• Dejerine J, Tinel J, Angheloff A. Sur l’état de la moelle épinière dans trois cas de Crises gastriques Tabétiques. Revue neurologique(Paris) 1913;25:348–50.
• Tinel J. Titres et travaux scientifiques. Paris: Alfred Leclerc. 1913
• Tinel J. Le signe du ‘fourmillement’ dans les lésions des nerfs périphériques. La Presse Médicale. 1915; 47: 388–389 [Translation: Kaplan EB The “tingling” sign in peripheral nerve lesions. 1972:8-13.[PDF]]
• Tinel J. Les blessures des nerfs : sémiologie des lésions nerveuses périphériques par blessures de guerre 1916. [Translation: Joll CA. Nerve wounds, symptomatology of peripheral nerve lesions caused by war wounds. 1918.]
• Labbé M, Tinel J, Doumer E. Crises solaires et hypertension paroxystique en rapport avec une tumeur surrénale. Bulletins et Mémoires de la Société médicale des hôpitaux de Paris 1922; 46: 982–990
• Tinel J. Conception générale du système nerveux végétatif et de ses manifestations morbides. Paris: Expansion Scientifique Française; 1930.
• Tinel J, Ungar G. La régulation de la circulation cérébrale. La Presse Médicale. 1936; 44(9): 169–172.

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References

Biography

• Brincourt J. Nécrologie: Jules Tinel (1879-1952). Press Med 1952; 60: 979–80.
• Pietrzak K, Grzybowski A, Kaczmarczyk J. Jules Tinel (1879–1952) J Neurol. 2016; 263: 1471–1472.
• Walusinski O. Jules Tinel (1879-1952): Beyond the eponym, the man and his forgotten neurological contributions. Rev Neurol (Paris). 2017 Jun;173(6):364-373.
• Turgut AÇ, Tubbs RS, Turgut M. Paul Hoffmann (1884-1962 AD) and Jules Tinel (1879-1952 AD), and their legacy to neuroscience: the Hoffmann-Tinel sign. Childs Nerv Syst. 2019; 35(5): 733-734.

Eponymous terms

• Koehler PJ, Bruyn GW, Pearce JMS. The Hoffmann-Tinel Sign. Neurological Eponyms. 2000: 136-143
• Sansone JM, Gatzke AM, Aslinia F, Rolak LA, Yale SH. Jules Tinel (1879–1952) and Paul Hoffmann (1884–1962). Clin Med Res. 2006; 4(1): 85–89.
• Buck-Gramcko D, Lubahn JD. The Hoffmann-Tinel sign. J Hand Surg Br. 1993; 18(6): 800-805.
• Koehler PJ. Publications on Peripheral Nerve Injuries during World War I: A Dramatic Increase in Knowledge. In: Frontiers of Neurology and Neuroscience. S. Karger AG; 2016:43-55
• Cadogan O. Clinical Signs in Carpal Tunnel Syndrome. LITFL
• Carpal Tunnel Exam. Stanford Medicine 25