fragmentation of the humérus.

The nerve injury is

Stelle, von der An ästhetisches situated 8 cm. proximal to the elbow ( see Fig. 1 ).
Empfindung hervor¬ Gebiet
In the hand, anesthesia in the distribution of the
gerufen werden kann,
die ins anästhetische radial nerve. . . .

Gebiet verlegt wird.

ikiav- Nerve suture on October 8, 1914. Continuity
established.
January 15, 1915. It is possible to create a
I € ;
prickling sensation radiating into the anesthetic
area of the radial nerve in the hand by pressing
Stelle der Verletzung und Naht. with a finger on the area of the forearm depicted
in Fig. 1. This sensation cannot be elicited further
peripherally. The border of this area is relatively
nothing about the success of the suture. . . .

sharp. It is best to use finger pressure to elicit this

However, there are sensory fibers in the proxi¬ sensation, faradic current also works, but not as
mal nerve stump, and stimulation of these fibers well.
should create a sensation referred to the insensitive The patient can extend the
cutaneous area. These fibers will grow after the
February 15. . . .

hand alittle.
nerve has been sutured. If stimulation of the
Thus, four weeks prior to the return of motor
growing fibers elicits a sensation in the anesthetic function it was determined with certainty that
area, we can conclude that the suture site is
conductive, i.e., growth of the fibers actually is impulses could pass the sutured area. . . .

taking place. The site of the suture is the critical As can be seen from these facts, one is dealing
location, and once the growing nerve has sur¬ with the stimulation of newly growing fibers. . . .

mounted it, a restitution of function is very likely. It is not necessary to apply great pressure to elicit
Experiments have convinced me that this this sensation. One can do it best by tapping with
method is quite practical in suitable cases. I would the extended finger. . . .

like to demonstrate its possibilities in two typical It is also clear that one can use this technique
and comparable cases: in cases where restitution of nerve function takes
I. A noncommissioned officer, 22 years old, place without nerve suture. The demonstration of
wounded on August 20, 1914. Shot through the such a pressure area peripheral to the site of
right arm; transection of the radial nerve. Slight injury proves that a nerve suture is not necessary.

The Sign of "Tingling" in Lesions

of the Peripheral Nerves*
by
J. Tinel
Too often there is difficulty making a precise of the nerve; tingling is a sign of regeneration; or
diagnosis in peripheral nerve lesions. Is the nerve more precisely, tingling indicates the presence of
divided, compressed, lacerated, or irritated? Is young axons, in the process of growing.
regeneration occurring? Is the palpable neuroma The pain of nerve irritation is almost always
permeable to the axons? Has a sutured nerve local, perceived at the point where the pressure is
reunited? .... exerted on the nerve. When the pain radiates
We think that the systematic study of tingling along the entire course of the nerve, it is still most
provoked by pressure on a nerve can help to vivid at the place under pressure. It almost always
answer these questions. coexists with pain on pressure of the muscle
Pressure on a damaged nerve trunk often pro¬ masses, and usually the muscles are more tender
duces a tingling sensation, projected to the periph¬ than the nerve.
ery of the nerve and localized to a very exact of regeneration is not painful; it is
The tingling
cutaneous area. vaguely disagreeable sensation that patients usu¬
a
It is important to differentiate this tingling ally compare to electricity. It is barely perceived at
from the pain sometimes produced by pressure on the pressure point, and is appreciated much more
an injured nerve. The pain is a sign of irritation vividly in the corresponding cutaneous area. The
muscles adjoining the nerve that "tingles" are not
*Translation of: Le signe du "fourmillement" dans
les l\l=e'\sionsdes nerfs p\l=e'\riph\l=e'\riques.La Presse M\l=e'\dicale painful.
23:388-389, 1915. These two kinds of phenomena aroused by

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 pressure on a nerve, pain and tingling, are easy to show a lesion limited to the internal or external
differentiate in almost all cases. They rarely coexist part of the nerve when the tingling is localized to
at the same site on the nerve, but we shall see that the cutaneous area of the lateral popliteal or of the
they may succeed one another on the same nerve medial popliteal. . . .

trunk. 4. Incomplete interruptions of the nerve or,

In addition to these two different signs aroused more exactly, lesions permitting the passage of
by pressure on the nerve, examination of the skin regenerating axons are characterized by the gradu¬
may reveal certain sensory abnormalities. Irritation al extension of the area arousing tingling sensa¬
of a nerve is often accompanied by a painful tions.
cutaneous hyperesthesia, while nerve regeneration Thus,tingling appearing below the
we see
is associated with hypesthesia and dysesthesias, progressively extending toward
lesion and then
most commonly a painful sensation of tingling the periphery, along the course of the nerve. A
aroused by touching, by pricking, and above all bynerve that tingles below the lesion is a nerve that

lightly brushing the skin. . . . is regenerating partly or completely. In this way

we can, from week to week, follow the slow
1. In complete transections, we can find an progression of the axons; we can appreciate the
exact spot along the course of the nerve trunk rapidity of nerve restoration; we can, above all,
where pressure produces tingling in the cutaneous judge its degree by the intensity of the tingling
distribution of the nerve. evoked and the extent of the cutaneous area where
This area of tingling is small; no larger than 2 it manifests itself.
to 3 cm. It is permanent, absolutely fixed; it The situation is the same in cases of nerve
remains the same for weeks and months. It is suture, where we can quickly judge the success of
unique along the course of the nerve, and we do the operation by ascertaining the progressive ex¬
not find any other point above or below the lesion tension of the area of tingling.
where pressure can cause tingling. As the area of tingling extends and intensifies
This area indicates that here the interrupted peripherally, it diminishes and finally disappears at
axons have begun to regenerate and that, being the level of the injury. . .

unable to pass through an obstacle and to regain .

1. Tingling evoked by pressure on a nerve

the peripheral segment, they are clumping up in a
neuroma.
rarely appears before the fourth or even the sixth
week following trauma. The appearance of
complete interruption of by
. . .

2. In a nerve very induced tingling corresponds to the period of

tight compression, the same characteristics are
...

axon sprouting.
met with, but the area of tingling is larger. It may
2. The tingling disappears as soon as the nerve
reach 6, 8, 10 cm. or more along the course of the
has resumed its normal constitution and the newly
nerve.
formed
.

have reached is
. .

axons a mature state. It

3. We can, in certain cases, find two different
sites for eliciting tingling, corresponding to two generally at the end of eight to ten months that
lesions at different levels. tingling stops, though large variations exist. . . .

3. Finally, tingling may be absent in some

For example, we have seen two men suffering
cases. In such cases the lesion may be very
from a radial paralysis due to injury in the upper
...

arm. One area of tingling was on the radial nerve

at the level of the exit wound of the bullet, on the
posterior surface of the arm. A second larger area
was on the external surface of the limb, at the
level of a very large fracture callus. These two
areas were stationary and delimited, with no trace
of induced tingling encountered below the osseous
callus. Operation showed that the nerve had been
partly destroyed at the first area by the passage of
slight, notinvolving any major destruction of
nerve fibers. Or, no regeneration may have taken
place, as we sometimes see in elderly, sick or
infected subjects with profoundly disturbed nutri¬
tion.
Induced tingling does not, then, constitute an
absolutely constant sign, invariable and always
easy to interpret. It cannot replace meticulous and
repeated examination of the patient. But, . . .

the bullet and that the few fibers which escaped
the damage had been compressed and interrupted
in the fracture callus distally.
Furthermore, we can observe partial tingling of
a nerve. Pressure on the sciatic, for example, may
with all of these reservations, tingling appears to
us to be capable of clarifying certain problems of
neurological diagnosis and furnishing valuable in¬
formation on the prognosis and treatment of pe¬
ripheral nerve lesions.

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