The sacroiliac painful points from A. GRAIS correlate with the location of the back mice.
In this article A. GRAIS discusses about the presence of what he calls “nodosités sous-cutané douleurouses” [the painful subcutaneous nodules] and the PAINFUL POINTS. They relate the nodules with what they called by then “CELLULITE” or celulitique nodules.
GRAIS makes it clear that the EXQUISITE PAINFUL POINTS correlate with the site of the sensitive nerve emergence to the superficial planes (some may be called a TRIGGER POINT nowadays). In the case of the lumbar back mice, it corresponds with the emergence of the posterior lumbar branches or CLUNEAL NERVES.
Grais describes 3 phases of the cellulite: “CONGESTIVE, HYPERTHROPHIQUE and ARTOPHIC SCLEROUSE”. By early massage treatment, passing from the first phase to the next ones can be avoided.
THE CONCLUSIONS OF GRAIS’S THESIS:
1-The SUBCUTANEOUS CELLULAR TISSUE and CONNECTIVE TISSUE are the tissues where the pain is LOCATED in the pains known as “névralgies, topoalgies, rheumatisme musculaire, odynies, myites and névrites”.
2-The pain is a symptom but there are SIGNS or LESIONS that can be PALPATED related to edematization “périnévrite” [next to the peripheral nerves] that present as PAINFUL EXQUISITE CUTANEOUS POINTS.
3-The PAINFUL POINTS correspond to the CERTAIN LOCATIONS that correspond to the points where the SENSITIVE NERVES emerge to the superficial planes.
4-THE NEURO-DERMIQUE MANUAL TREATMENT with malaxation works as a curative or palliative method.
5-The CELLULITE is the edema soft and hard, sometimes macroscopic, and others microscopic RELATED to the “diathèse arthritique”.
6-They theorize that the CELLULLITE is a kind of “senility” of the conjunctive tissue:
“présclérose, a sénilité, souvent précoce, des tissus, débutant par la prolifération et hypertrophie du tissue conjonctif, aboutissant à la rétraction, á l’atrophie, à la scérose”.
(Personal note: These French authors seem to know a lot about the fact that the painful subcutaneous nodules were due to EDEMATIZATION OR FIBROSIS of the tissue causing PERIPHERAL NERVE NEUROPATHIES. They insist that the treatment, especially at early stages, consists of MASSAGE AND GYMNASTICS. They mention certain subcutaneous injections as they were used by other doctors by then like local cocaine injection; later, the Germans develop less toxic molecules like NOVOCAINE).
Les points douloureux cutanés et leur traitement manuel
(Cellulite and sensitive nerves)
Dr. Adolphe Grais
de la Faculté de Médicine de Paris
Alfred LECLERC, EDITEUR
Président de thèse: Professeur ACHARD
Related to the work of Monsieur le Docteur STAPFER and WETTERWALD
PART I Des points douloureux cutanes [The skin painful points]
GRAIS starts his thesis with these sentences:
“When a patient complains of pain in any area of the body, whether it is in the arms, legs, head, or stomach; our first care is always to make it clear WHERE THE PAIN SITS”. -Show us with the finger where you suffer. Then the patient may point at a NERVE TRACT, as it often happens with the sciatica or the intercostal pain (as Valleix pointed). Then the doctor, knowing the area, by palpation tries to find the PRECISE POINT. It is important to press with the end of the finger “.
GRAIS states that after eliminating the traumatic or infection cause, by then the doctor diagnoses NEURALGIA “SINE MATERIA and rheumatic pain”.
“Mais si au lieu presser ainsi, nous MALAXIONS LA PEAU, notre examen purrail peul-être nous donner un résultat différent de celui que nous avons obtenu”[But if, instead of pressing, we “malaxed” the skin, we could obtain a different result].
The integument contains CUTANEOUS NERVE TERMINATIONS, necessary for the body to communicate with the external world. By pressing these points, the patient would experience pain. This pressure provokes a REFLEX and involuntary defense movement and the miscellaneous contraction, which often prevents the doctor from continuing the investigation.
The “malaxation de la peau consiste à faire un pliau pannicule, en saisissant entre la pulpe du pouce et celle de l’index et du medius, la peu et le tissue cellulaire sous-cutané.”
On page 348 from Valleix’s book “Les névralgies”, he stated that the pain could sometimes be very violent just by touching the skin very gently. By examination
a “pli ctané, épaissi, lardacé. Et mieux encore des noyaux et des grains” can be felt, and the patient says: “”Assez! Vous avez trouvé nion mail!”” C’est là!”
The pain of the patient is usually disproportionate with the intensity of the pressure. Then it is a “HYPERESTHÉSIA NERVEUSE”. It is useful to examine the contralateral region of the same person to compare (according to STAPFER).
According to WETTERWALD:
- There are CERTAIN LOCALIZATIONS of the pain
- There is often the presence of “noyaux indurés” [indurated grains]
- The skin is thickened, infiltrated and lardaceous
- Sometimes the skin shows NO change
GRAIS mentions that these SUBCUTANEOUS PAINFUL POINTS ARE the ones explained by other authors:
- The “PANNICULITE” from STAPFER
- The “cellulite” from WETTERWALD
- The “points nerveux” from CORNELIUS
GRAIS said that in many patients that complained of a vague unlocalized pain, by examination they could find these points with an indurated grain. In larger painful masses, there would also be an exquisite point. They called it the “POINT PRINCEPS”.
He also mentions the relation of DEEP POINTS and CUTANEOUS POINTS, especially in the abdominal wall.
He states that some authors relate some abdominal intestinal lesions that cause “ganglionaire” compression with the existence of the POINTS PROFUNDS.
WETTERWALD had a technique to prove that the superficial points are not related to deep pain. He folded the skin between the two fingers, and then he palpated the deep abdomen, and there was no pain. That meant that the pain was located superficially.
They knew that the superficial lateral branches of the last thoracic and first lumbar perforate the abdominal wall, becoming superficial nerves. These perforating points can be marked and are rather constant between individuals.
The Pathological Anatomy of the Painful Points
Grais warns that the investigation about these entities was little by then (Personal note: exactly the same after 100 years), since the pathology is benign and these lesions do not lead to death, they are not mentioned in the autopsy.
The painful points can present themselves as:
- A pure and simple painful point, showing nothing objective to the pulp of the finger.
- A subcutaneous nodule whose size varies from a grain of oak to that of a nut.
- A subcutaneous mass that invades a whole region, of the thigh, posterior aspect of the leg, the abdominal wall (as in Dercum’s disease).
While kneading of the skin gives the following feeling: the skin seems to be adhered to deeper planes, the presence of a pasty edema, hard and renitent, as frozen fat. It seems no malleable and sometimes very hard.
STAPFER designates the word “cellulite” to the pain related to the “oedème douloureux” of the abdomino-pelvic walls. He mentions that the Swedish considered all could start with an edema of the size of a “grains de riz” [rice grains] within the conjunctive tissue.
According to the help received from Dr. DUREY (from Clinique de l’Hotel-Dieu), other English authors, BALFOUR, JAWGER, RALPH STOCKMAN, MANWELL TELLING, described these nodules as “ nodular firbromyositis”. According to Grais, they considered that the indurations, the infiltrations were the result of a “hyperplasie inflammatoire locale du tissue conjunctive”. The hyperplasia presented thus an edema and a certain degree of fibrosis.
They mention that they can be located in certain places as the lumbar region or the fascia lata or all over the body. Some times deep, other times superficial.
Grais thinks that the English’s SUBCUTANEOUS PAINFUL POINTS or NODULES are the same that they consider the exudates of the connective tissue.
GEOFFROY ST-HILAIRE on his thesis “Sur les oedèmes abdomino-pelviens en gynécologie” also mentions these lesions as certain edemas that surround the genital organs, which can undergo later fibrosis of the connective tissue.
DERCUM also mentioned the “névrite interstitielle” on the patients with adiposis dolorosa. He also mentions that the first stages were the edema and, later, the sclerosis.
As an example of edema of the cellular tissue he mentions of F. FÉRÉOL’s work about the “nodosités éphémères”. M. TOISIER’s work about the “nodosités sous-cutanées rhumatismales”. And the pseudo-lipomes from VERNBEUIL and POTAIN.
He presents a theory about a kind of “cercle vicieux” where the edema produces neuritis and the neuritis an edema. WETTERWALD understands it as “phénomènes cellulonévritiques”.
STAPFER described the “nodosités sous-cutanées douloureuses” as a localized “cellulite” and named them “phlebectasie peristente, oedème séreux, oedème plastique and néoformations conjonctives”. At the first stages, it would be a PRESCLÉROSE and, later, it would become a SCLEROSE.
Grais summarizes the etiopathogenic factors as follows: many diverse causes would produce a “stase circulatoire” in the connective tissue, that stasis could lead to a kind of FIBROUS ORGANIZATION.
The topography and symptomatology of the painful points
- GRAIS says that by “malaxation” of the tissue it is possible to identify certain “NODOISTÉS” within the cellullar subcutaneous tissue that tend to become “FIBROUSE.”
- GRAIS named as “POINT PRINCEPS” the point that is ultra sensible on pressure while exploring the painful region of the patient.
He presented a diagram with all the typical locations of the “point princeps”. He also refers the work of WETTERWALD called “Topographie des Névralgies”.
GRAIS presents a diagram of the PAINFUL POINTS of the head, superior limbs, inferior limbs, thoracico-abdominal wall, and dorso-lumbar wall.
He also mentions that the points are a consequence of a more complex organic dysfunction. And that it can present different problems:
-“TROUBLES DE LA SENSIBILITÉ” et VASOMOTEURS: Pain that can radiate, there can be a HYPO or HYPERESTESIA, also a sensation of coldness or heat.
-“TROUBLES MOTEURS”: There can be asthenia, fatigue, certain paresis or “impotence fonctionelle”. When the painful point is at the thorax there can be difficulty for breathing.
-“TROUBLES SECRÉTOIRES”: dyspepsia with hypo or hyperchlorhydire, brachial secretions as in the certain “catarrheux”.
-“TROUBLES TROPHIQUES”: The tendency is to a FIBROSIS by a repetition of the congestion. The last phase is the “dégénérescence adipo-scléreuse”.
GRAIS DESCRIBES 5 DIAGRAMS. THE PAINFUL POINTS correspond to the POINTS OF EMERGENCE (many after some anastomoses).
DIAGRAMS OF THE PAINFUL POINTS
The painful points correspond to the emergence of the sensitive branches from the deeper planes.
1-DIAGRAM of the “POINTS DOULOUREUX CUTANÉS DE LA TÊTE” 19 POINTS
GANGLION DE GASSER AND THE 3 BRANCHES OF THE TRIGEMINAL NERVE
- OPHTALMIC NERVE: the nasal, the frontal, the lachrymal
- SUPERIOR MAXILAR
- INFERIOR MAXILAR: bucal, auriculo-temporal…
FROM THE FIRST 4 POSTERIOR CERVICAL BRANCHES (sensitive branches of the cervical and nuchal region, including the “GRAND NERF OCCIPITAL D’ARNOLD”
FROM THE FIRST 4 ANTERIOR CERVICAL BRANCHES
2-DIAGRAM of the “POINTS DOULOUREUX CUTANÉS de MEMBRE SUPÉRIEUR 15 points
Grais explains the several nerves from the superior limb and the corresponding points: nerve circumflexe, brachial cutané-interne, musculo-cutane, médian, cubital, radial…
3- DIAGRAM of the “POINTS DOULOUREUX CUTANÉS U MEMBRE INFERIEUR”
Grais explains the nerves from the anatomic region: grand abdomino-génital, petit abdomino-génital, fémoro-cutané, obturateur, crural, anal, sciatique, etc.
The points correspond to these nerves as they become superficial. 26 POINTS.
4-DIAGRAM of the “POINTS DOULOUREUX CUTANÉS DES RÉGIONS THORACIQUES et ABDOMINALES
Grais mentions the nerve trajectory of the intercostal nerves and others. He describes 13 points.
5-DIAGRAM of the “POINTS DOULOUREUX CUTANÉS DES RÉGIONS DORSO-LOMBO SACREE
MORBID ENTITIES RELATED TO THE POINTS
1-MORBID ENTITIES RELATED TO THE PAINFUL POINTS of the head region (points of sensitive nerve emergence)
-“névralgies du trijumeau” (related to Valleix points)
-cervical neuralgias (including the “bosses occipitales, les apophyses mastoïdes et les bord supériurs du trapèze”)
–Torticollis there is a SPASM REFLEX and contracture, but the primary lesion is the sensitive nerves
-The “NEUROASTHÉNIE” [Neuroasthenia]: It is related to the presence of MULTIPLE PAINFUL POINTS. Especially there is HEADACHE and “RACHIALGIE”. (Personal note: an old name for fibromyalgia)
- HEADEACHE: There is pain as they try to brush the hair. They have a FOG and “VERTIGE” [vertigo] sensation. The headache is “ douleur en casque” (the painful points correspond to the orbito-frontale, vertico-pariétele and occipito-cervical).
- RACHAILGIE: Especially cervico-dorsal and lumbosacral and the intermediate points of the trapezius, omo-vertebral and axillaire.
-CORNELIUS relates the vertigo with the point SUS-ORBITAIRE.
-In the MIGRAINE there also painful points.
2-MORBID ENTITIES RELATED TO THE PAINFUL POINTS of the superior limb
-“névralgies scapulaires et humérales” (also described by Valleix as “névralgies cervico-brachiales”)
-“crampes professionneles de cette dyskinedie” de Wetterwald
3-MORBID ENTITIES RELATED TO THE PAINFUL POINTS of the inferior limb
- Sciatic neuralgia (with the Valleix points, and the LASÈGUE sign) acute and chronic
- Varicouse ulcers
- Periarthrite and pseudo-arthite
- Métatarsalgie ou névralgie de MORTON
4-MORBID ENTITIES RELATED TO THE PAINFUL POINTS of the thoracic and abdominal wall
Grais mentions that it is difficult to differentiate between the pain from a superficial nerve and from a deep visceral algie. He also mentions the “névralgies sympathiques”.
He also mentions the “névralgies intercostales” and that the patients consult for pulmonary, gastric, hepatic or renal problems. Even for cardiac trouble. Also epigastralgy or mastodinia, and many others.
5-MORBID ENTITIES RELATED TO THE PAINFUL POINTS of the back
He mentions the backache and the sciatica and the lumbago.
ETIOLOGY of the PAINFUL POINTS
Grais thinks that the causes can be multiple and related to many different medical entities. For example, they can be related to a traumatism and to certain intoxications.
–Related to traumatism: It produces a local edema which, if it is not absorbed, it becomes a sclerotic tissue compressing the peripheral nerve terminations.
-Related to age
-Related to the sedentary lifestyle and the lack of circulation
-Related to the typical conjunctive tissue of the women
-JAWGER, VOGEL AND DE BRUN related to a nervous origin
-HELLEDAY-OPPOLZER related to inflammatory due to uric acid deposit. HANRIOT also suggested in his thesis “Una manifestation de l’artritisme. La cellulite”.
-JAWEGER, STOCKMANN and MAXWELL’s painful points are related to a MANIFESTATION of a TOXIC METABOLIC trouble. The AUTO-INTOXICATION also by AUTO microbiens with their toxins or by a kind of nutrition problem. They also related to the presence of “CHOLESTÉRINE”.
-It could also be related to a kind of “relentie” in the nutrition. A lack of equilibrium of the intra-cellular movement with the consequence of the edema, stagnation and engorgement.
–RENAULT described the “milieu intérieur” is not the BLOOD, but the CONNECTIVE TISSUE and it responds to many different alterations since it is everywhere.
-They theorize that the alterations in the subcutaneous tissue could be related to an organic IMBALANCE due to an AUTO-INTOXICATION due to the “ralentissement of the nutrition” [nutrition slow-down].
-“L’arthritisme” is like a tendency of the connective tissue to a hyperplasia and fibrous retraction. Grais then mentions that “la cellulite” could be a manifestation of the l’ARTHRITISME, or maybe they are just the same “DIATHÈSE”?
-BRALANT considered “l’edema cellulitique” as “ une rouille organique”.
-Wetterwald considered that sometimes the nodules could be felt, and other times the infiltration may present a microscopic cellulite.
-GRAIS considered that all the painful manifestations are related to a macroscopic or microscopic congestion state that presents the subcutaneous tissue and the tissue perinervous. That’s why the PAINFUL POINTS are due to the election nerve site of the peripheral nerves.
-Cornelius, from Berlin, described what he called “POINTS NERVVOUSES”.
GRAIS’s MANUAL TREATMENT of the painful points
-“They used “révulsifs”: teinture d’iode, vésicatoire, points de feu, pulvérisations de chlorure d’éthile, ou stypage, analgésiques interns, salicylate, quinine, antipyrine, ou opiacés”
– Grais also mentions the use of local injections of “alcool a 50º, cocaïne, stovaïne, heroïne”.
-The MANUAL TREATMENT: It consists of a MASSAGE NEURO-DERMIQUE. KELLGREEN, HELLEDAY did petit effleurages. CORNELIUS did unidigital vibrations. WETTERWALD mentioned “malaxation digitale du nodule douloureux”.
GRAIS explains the manual treatment deeply.
–GYMNASTIQUE has to be done after the MASSAGE, ACTIVE and PASSIVE movements.
-Grais comments that through the massage, they could observe “réflexe dynamogène” which may lead to changes in blood pressure, increasing or decreasing.
-The massage treatment has other effects than just the local ones “le massage régénere le sang, et fait fonctioner les glandes endocrines, il a ainsi un pouvoir créateur de globules rouges, un pouvoir microbicide, un pouvoir antitoxique.”
GRAIS’s CASE REPORTS with CUTANEOUS PAINFUL POINTS
-Case 1: Névralgie du trijumeau, 35 ans
-Case 2: Occipitalgie, student
-Case 3: Sciatique and occipito-cervicale, 14 ans
-Case 4: “Crampes dites des écrivains, 43 ans.
-Case 5: Arthritic “rheumatismale de l’épaule droite”, 72 ans
-Case 6: Scapulalgie, 63 ans
-Case 7: Neuritis scapulo-humeral, 45 ans
-Case 8: Rheumatisme chronique. Dame.
-Case 9: Arthrite femorale chronique, 39 ans
-Case 10: Sciatique, 75 ans
-Case 11: Périarthite en plaque du genou
-Case 12: Myosite chronique, 48 ans
-Case 13: Arthitic chronique du genou. 82 ans
-Case 14: Neuritis plantaires, 50 ans
-Case 15: Neuralgies du 3er and 4rt métatarsiens, 47 ans
-Case 16: Pseudo-angine de poitrine, 48 ans
-Case 17: Cellulite simulant une colique hépatique, 20 ans
-Case 18: Dyspepsie cellulitique, 56 ans
-Case 19: Dyspnée nerveuse, 42 ans
-Case 20: Pseudo-appendicite, 31 ans
-Case 21: Pdeudo-appendicite, 24 ans
-Case 22: entérite chronique, 51 ans
-Case 23: Cellulite de la paroi abdominale, 24 ans
-Case 24: Cellulite cutanée (fibrome), 45 ans
-Case 25: cellulite pelvianne, 41 ans
-Case 26: Lumbago chronique, 38 ans
-Case 27: Lumbago chronique
-Case 28: Névralgie dorsale, 28 ans
Link to original text:
Published in March 2019 by Marta Cañis Parera
Les points douloureux cutanés et leur traitement manuel (Cellulite and sensitive nerves). Dr. Adolphe Grais. 1913. De la Faculté de Médicine de Paris. Alfred LECLERC, EDITEUR