This is an article written in French about what Dr. Rubens-Duval called CELLULALGIE, related to the process of cellulite. Let’s say he named the “painful cellulite” as cellulalgie. But it seems this term has not been used subsequently.
The back mice would have been referred as “lumbago from cellulalgic origin” or “lumbar cellulalgie” or a “lumbar subcutaneous cellulalgic infiltrate”.
It is important to POINT OUT the importance with the wrong use of the MEDICAL SUFFIXES. In Spanish “cellulite” is translated as “cellulitis”, since -itis means inflammation. Cellulitis would mean inflammation of the “cellular subcutaneous tissue” (usually by a bacterial infection), whereas “cellulite” means no INFLAMMATION, despite it is related to an anatomical characteristic of a painful infiltrate.
The article does NOT show any photo or diagram.
Dr. Rubens-Duval also relates (as other authors do) the presence of the cellulalgic infiltrates or nodules with concomitant “osteoarthritis lesions”, with exuberant osteophytic proliferations of the unco-vertebral joints as a cause of reflex mechanism of the cellulalgic process. (Personal note: I wonder if it is a consequence of the ostheoarthritis process, or both entities are related to an endocrine dysfunction and run simultaneously).
Cellulalgie (cellulalgia)
By Rubens-Duval
Under the name of “cellulalgia”, any painful affection related to permanent or transient diffuse or localized alteration of the subcutaneous connective tissue is meant.
This is an extremely vast and often UNRECOGNIZED pathological field. However, it should be considered in rheumatology since the pathology of the interstitial connective tissue is intimately linked to that of the muscle apparatus, skeleton and joints.
The “interstitial connective tissue”, also called “cellular tissue”, consists of a large network of connective cells that has close connections with the adipose tissue. It has ABUNDANT vascularization, which makes it very sensitive to vasomotor disturbances and a very rich sensory innervation, which makes it extremely delicate.
There is a “deep connective tissue” which occupies the interstices between the muscles and the skeleton, the tendons and surrounds the neuro-vascular pedicles. The pain related to this tissue is usually confused with peri-arthritis or myalgia.
Ruben-Duval explains that there are also perpendicular fibers in the subcutaneous planes like walls that constituted a kind of ligaments.
“Cellulalgia” is a synonym of ADIPOSIS DOLOROSA for some, and for others it is considered a VASOMOTOR phenomenon related to an allergic character.
Lagèze underwent a histological research of the “NODULE CELLULITIQUE”: he described an initial stage characterized by a SEROUS FLUID, later a “collagen metamorphosis” and, lastly, a fibroblastic cellular reaction leading to fibrosis. Lagèze insisted that all this evolution is due to VASOMOTOR DISTURBANCES and physiochemical changes WITHOUT LEUCOCYTE influx (that means WITHOUT ANY INFLAMMATION). Sometimes in the “old cellulite nodules” small perivascular lymphoid infiltrates can be observed.
When the “cellulite process” affects the hypodermis, the lesions are more complex because of the presence of ADIPOSE TISSUE. And the tissue becomes encapsulated in a fibrous tissue shell forming small adipose nodules.
They studied the clinic characteristics of this CELLULITE infiltrates that present as: grains, nodules, “trainées”, and “nappe infiltrats”.
About etiology:
- There are cellulalgies from VASOMOTOR disturbances (neuro-endocrine imbalance).
- The cellulalgies related to the obesity or ADIPOSIS DOLOROSA.
PART 1- The CELLULALGIA and the VASOMOTOR disturbances
Rubens-Duval warns that the cellulalgie is essentially feminine sex affection that has a neuropathic character, which may be related to an endocrine disruption affecting the HYPOPHYSO-THYRO-OVARIAN endocrine regulations. It shows certain resurgence at the time of the menopause.
It often includes a small functional liver disorder characterized by dyspepsia or even a “latent hepatitis” that does NOT usually externalize.
Some authors related it to a FOCUS of chronic INFECTIOUS FOCUS (Paviot and Guy Laroche) such as chronic sinusitis, dental infections, intestinal fermentations, chronic suppurations, which would be the seat of a toxic discharge and a consequent allergic reaction determining the cellulite infiltrate.
But there could also be LOCAL factors: accidental traumas and repeated touching in phobic patients can present a CELLULITE NODULE.
There are also cellulite infiltrates related to a close affected joint: as an example, the cellulite perirotuliana or pretibial related to the arthrosis of the knee.
Sometimes it affects a SENSITIVE territory of a nerve as in the CELLULALGIA OF THE INTERCOSTAL SPACE in intercostal neuralgia, of the posterior aspect of the thigh in a case of sciatica or in certain CUTANEOUS ZONES of reflection of certain VISCERALGIES.
CLINICAL ASPECTS of the SUPERFICIAL cellulalgia
Two aspects characterize the superficial cellulalgia:
-The existence of a point or a painful zone around which more or less extensive pains radiate
-VERIFICATION BY PALPATION of a subcutaneous cellulalgic infiltrate
They can present in different anatomical regions:
- “Cellulite (Cellulalgia)” of the NECK: This entity was well described by Henri Forestier. It causes cervico-occipital, cervico-brachial and sometimes precoridalgic pains accompanied by a more or less marked contracture of the muscles of the related nerves. At the palpation of the vertebral “gutters” with the neck bended forward, a whole series of hard nodules can be perceived, painful to the pressure, scattered in the form of cords or elongated bands in the interstices of the posterior cervical muscles. These may exist with association with osteoarthritis lesions, where the exuberant osteophytic proliferations of the unco-vertebral articulations may cause a reflex action responsible for the development.
- “Cellulite (or Cellulalgia)” of the SHOULDER: Mainly affecting the posterior side of the arm, usually at the delto-pectoral sulcus and the coracoid region, the cellulalgic infiltration can be usually felt while there is periarthritis of the shoulder.
- “Cellulite (Cellulalgia)”of the THORACIC WALL: It usually presents as a solitary “nodule cellulitique” that is felt like a PAINFUL POINT, which if persistent, it creates a state of anxiety and phobia difficult to treat. There can be “cellulites reflexes” that form as a result of an underlying problem like a chronic pleuritis. By a trauma they can form a small “stéato-nécrose nodule” that can be perpetuated by an anxious palpation.
- “Cellulite (Cellulalgia)” of the ABDOMINAL WALL: There are also “cellulites or cellulalgies réflexes” determinated by vesicular, appendicular or salpigian chronic lesions that project to the corresponding area.
- “Cellulite (or cellulalgia)” of the lumbar area: Professor Guy Laroche had insisted by then about the frequent CELLULALGIC origin of certain chronic low back pains. The pain character resembles a banal lumbago. But the PALPATION of the lumbar or sacral region, made with the flat palm of the hand (rolled palpation), highlights infiltrates of subcutaneous tissue irregular and painful. These infiltrates may extend to the posterior aspect of the buttocks or thigh, where they are related to sciatalgic irradiation. The lesions that are easily palpated are accompanied by deeper ones that can explain the painful intensity and the associated muscle contraction.
- “Cellulite (or cellulalgia)” of the lower limbs: It is mainly present in patients with “obésité cellulitique”. The lesions are located in the inside of the knee and must be distinguished from the lesions of the periarthritis of the knee.
Clinical aspects of the DEEP cellulalgia
Their clinical expression is much less precise, sometimes they are revealed as a deep and fixed painful spot and it is described as a neuralgia; sometimes they result in erratic, fleeting, variable pains which sit in the region of certain articulations or in the continuity of certain muscular groups; then they are called myalgia, arthro-myalgia.
The origin of these painful phenomena is the same as the “superficial cellulite”:
-more frequent in female sex
-complex endocrine disruption
-slight hepatic functional disorders
-awareness OF ATMOSPHERIC DISTURBANCES
The “deep cellulite” completely escapes direct clinical exploration: palpation is “difficult” and then it appears just like a painful syndrome, with functional symptomatology. The clinical examination DOES NOT REVEAL any objective modification of the joints or the soft parts. This means that these painful phenomena require a great deal of discernment and critical sense.
PROBLEMS OF DIAGNOSIS AND THERAPEUTICS ABOUT “CELLULAITIES” AND DISEASES ARTHRO-MYALGIES
Method of examination:
It should be suspected in patients that present “rheumatic type of pains” and that the classical examination DOES NOT REVEAL any obvious objective sign of organic affection, then it is necessary to consider a phenomenon of CELLULALGIC nature.
It can be superficial or deep and it is necessary to pay attention to the patient’s interpretations and descriptions.
It is necessary to locate the EXACT location of pain, important to TRY to awaken it by gentle pressure or by certain movements, and then search by the PALPATION OF THE FINGERTIPS if there is an INFILTRATION of the SUBCUTANEOUS CELLULAR TISSUE, OR NODULES or GRAINS revealing a “cellulite state”.
If there is a lack of these especially common palpating characters in the case of “DEEP CELLULITE”, then it is interesting to know that the painful phenomena have a particular schedule; they present a net recrudescence under the influence of certain factors:
-digestive
-circulatory
-weather disturbances (wind, humidity, cold, an approaching storm)
Other laboratory examinations such as globular sedimentation are also interesting.
DIFFERENTIAL DIAGNOSIS OF superficial and deep “cellulite” or “cellulalgie”
-By physical examination, it is easy to discern from the psychogenic rheumatism (where they present certain contradictions).
-In patients whose pains are accompanied by asthenic state, with muscular hypo-tone and chronic fatigue, a little energetic muscle contraction and a little pressure is painful.
ETIOLOGICAL DIAGNOSIS OF superficial and deep “cellulite” or “cellulalgie”
These patients present a perfectly normal psychic equilibrium that presents pains that do not seem to show a defined organic substratum. The inflammatory test such as globular sedimentation would be normal.
Sometimes the pains can be related to a concomitant infectious factor such as rheumatic fever, scarlet fever or septicemia. A focal infection must be carefully screened.
It is possible that certain CELLULOGICAL episodes are dependent on still unknown viruses.
-Specially women in whom the interview reveals various functional disorders in relation to hepatobiliary disturbances: migraine, dyspeptic disorders, diarrhea and constipation, urticarial flares, vesicular or colitic reactions. They usually present a discrete increase in the cholesterol level.
-Another characteristic patient is a man around his 50s, whose functional disturbances appear to affect the renal system. They may present hypertension, discrete hyperuricemia and hypercholesterolemia and the appearance of painful manifestations evokes the articular lesions of the gout.
TREATMENT OPTIONS
Treatment is quite complex.
-Local treatment in the form of massage of the “cellulite infiltrates”. The treatment must be gentle, gradual. It starts with effleurage or vibratory massage, and later it gets more aggressive with the intention to “crush the lesions”.
-It may also be necessary to treat certain underlying condition like the hepatico-renal disturbances.
Rubens-Duval mentioned the role of the “crénotherapie” (he mentions the Vichy, Pougues and Aix-les-Bains with more latent hepatism; and Vittel, Contrexéville, Bourbonne ou Capvern with renal dysfunctions).
He finally says that sometimes there is a “vicious circle” sustained by “réactions psychopathiques”.
THE OBESITY CELLULALGIQUE
Sometimes in these cases there is a “true dystrophy of the subcutaneous cellular tissue”. It has been related to women, after childbirth, after surgical castration or around the menopause. It is usually resistant to the caloric restriction and it has been related to the “WATER METABOLISM”.
Fat tissue predominates to the trunk and the base of the limbs. It presents a “consistance molle et grenue” and it is usually a little painful. It is also associated to the vascular acrocyanosis, varicose state of the limbs, vascular fragility with frequent bruising, and arterial hypertension at the time of menopause.
The patients in their forties present some pains, at first transient, then more and more tenacious in the ankles, knees, lumbar or cervicoscapular region, which are the prelude to the painful manifestations of degenerative osteo-articular lesions that develop very slowly around the age of fifty at the approach of menopause.
The progression of obesity, which then undergoes a push, increases the static loads that these joints support, aggravating indirectly the articular lesions.
The symptoms of postmenopausal oseteoporosis also appear.
This obesity is probably dependent on COMPLEX HORMONAL DISTURBANCES, probably of PITUITARY origin. Sometimes there are discrete signs of thyroid insufficiency (dry and brittle hair, hypothermia…), menstrual disorders (amenorrhea), and decrease in urinary excretion.
The treatment included diet and restriction of animal origin food. They also received diuretics and thyroid opotherapy in large doses. Later, after weight reduction, they treated them with ovarian hormones. Even with the weight loss, the regression of symptomatology is difficult. And it depends on the characteristics of each patient.
Published in December 2018 by Marta Cañis Parera
Reference:
Rubens-Duval. Cellulalgia. Le semaine des hopitaux: organe fonde par L‘Association d‘enseig. Hospitaux de Pari. (1950 26 858) p. 2817-22. ISSN/ISBN: 0037-1777