This is a summary of an extensive thesis (116 pages) form a doctor called Paul Lagèze about the cellulalgic infiltrates or nodular cellulalgia (another term to name the back mice). Paul Lagèze worked with two professors, PAVIOT and FAVRE, who also published about the nodules or infiltrates.
Lagèze defends on this thesis the relationship between the cellulalgic infiltrates and “certain type” of sciatiques (pseudo-sciatica or cluneal neuropathy). He stands that patients that suffered pain for many years improved mainly by MASSAGING (with a special technique) and DIET. He does not mention acupuncture or anesthetic injections at all (it is as if they did not know about it). They just focused on the massage. He defends that the Swedish by then had a good knowledge of the massage to resolve the cellulalgic infiltrates.
Lagèze explained that these infiltrates had received different names: “cellulitis”, “cellulalgic infiltrates”, “fibrous nodules of myalgia”, “cellulitic edemas”, “engorgements lymphatiques”, “fibrositis”, “panniculitis”… that were equivalent terms according to the personal preferences of the authors.
All the patients’ cases he presents improved after massage, but it seems it took a while (several sessions).
Lagèze et al. insist on the theory that the cellulalgic infiltrates DO NOT PRESENT any INFLAMMATORY signs. It is more an EXUDATIVE process (they define 4 stages). He relates the cellulalgic infiltrates with a kind of a LATENT LIVER INSUFFICIENCY and an ENDOCRINE DYSFUNCTION. He theorizes that not well-metabolized proteins could cause the exudates by a kind of anaphylactic vaso-motor reaction.
Lagèze points out that by then the sciatic pain that had no clear cause was called “sciatique essentielle”, which were the most common ones. Lagèze states that once many other causes of sciatic pain are discarded, then one should search for the cellulalgic infiltrates in certain particular areas.
The cellulalgic infiltrates also named “cellulite” can be present in different locations according to Lagèze. They seem to be painful in certain “specific” locations. They can present as a nodule, placard, painful spot or crepitation. They can be felt on palpation and can elicit a painful sensation on palpation but, clinically, they present as a neuralgia: hemicraneal headaches, neuralgies of the upper limb, torticollis, lumbago, and sciatic neuralgia. And many times the patient is unaware of the existence of the infiltrates.
Lagèze theorizes that the cellulalgic infiltrates could be related to an exudative vasomotor phenomenon that can undergo certain degree of sclerosis if the affection is abandoned to its natural evolution.
The cellulalgic infiltrates in the buttocks, sacroiliac region (back mice) and fascia lata can cause PSEUDO-SCIATICAS. The pain is not related really by the sciatic nerve itself. It is due to the interstitial neuritis of the SMALL SENSITIVE NERVOUS FILAMENTS (cluneal nerves) OF THE CELLULAR TISSUE, which are compressed by the exudative infiltrate.
The cellulalgic infiltrates can cause “true” sciatica by involvement and extension of the cellulalgic process to the connective tissue of the sheath or the nerve itself, or by lesions of the epidural fat.
The patients suffering from cellulalgic infiltrates OFTEN present hepatic or digestive disorders. Also the association with migraines, urticaria and asthma. Lagèze thought that the primary mechanism of dysfunction was a kind of latent hepatic insufficiency that would produce a kind of anaphylactic reaction to certain proteins.
The treatment would consist in general treatment with diet (avoiding certain proteins), “choc peptonique” and vaso-constrictors as adrenaline. And a local treatment with “special massage”.
Lagèze warns that if the infiltrates are abandoned to their natural evolution, these infiltrates have little tendency to spontaneous resorption, most often they organize themselves, become harder and tend to become chronic, suggesting that early massage is relevant.
Lagèze said that they considered that it was important to perform a RIGOROUS ANATOMICAL study of the cellulalgic infiltrates by biopsies (Personal note: they performed the biopsies with general anesthetic to obtain the biopsies without any local anesthetic injection).
Lagèze stated that the sacroiliac nodules (back mice) were the most common found and the easiest to study. Nevertheless, they were NEVER able to find them in AUTOPSY despite the fact that, for a long time, they tried to search them in a cadaver; they concluded that the exudate somehow reabsorbs after dead.
LAGÈZE stated that many doctors did not consider the cellular tissue “noble” enough to be examined or considered as a pain causative agent. He was aware that the “cellulalgic infiltrates” were so little known, so that before explaining what he considered “the false sciatica due to cellular infiltrates” (clunealgy) he explained this type of lesions, the symptoms they present, the diagnosis and the anatomical substratum, ALL THE THINGS THAT WERE TOO OFTEN IGNORED AND YET SO FREQUENT (Personal note: It seems the article could be contemporary, since still now these lesions are completely ignored by the medical community).
Notes on the thesis:
Sciatiques et infiltrats cellulalgiques
[Sciatic pain and cellulalgic infiltrates]
Par Paul Lagèze
Thesis from the Faculté de Médicine et de pharmacie de Lyon
Et soutenue publicament le 17 Juin 1929
Lagèze’s introduction of his thesis
Nothing is more banal in medicine that the general pain that is called “sciatica”. It is used to describe different affections that present a common thing: a pain that seems to be rebellious to therapy and it tends to recur in the leg.
Lagèze explains that doctors by then used the term “sciatique essentielle” to describe the sciatica pain whose cause was not clear. There were some related sciaticas that were described with certain terms like the “sciatique a frigore” (a sciatic pain related to exposure to coldness) or “sciatique rhumatismale”.
Certain authors had tried to study sciatic pain: Déjerine, Landouzy, Sicard et al., A Thomas, Guillain Barré. And they had tried to differentiate certain types. Some of these sciatic pains have been described to have a nerve origin, other have a muscular origin called “myalgias”. Verger et Delmas-Marsalet, Helweg et Linstedt considered that many sciatalgic syndromes that presented the pathognomonic symptoms of Valleix points and Lasègue sign correspond to MYALGIC events.
Other authors related the sciatic pain to pathological changes in the connective tissue and cellular subcutaneous tissue. Renaut studied the histopathology of this tissue deeply and Prof. Favre (1913) had emphasized that there was an “adipose douloureuse” in certain sciatic pains associated to a “cellulite primitive”.
Prof. Paviot (1926) described “les cellulites et leur pathogénie” and studied painful syndromes that may be presented as certain NEURALGIES. Since then, at his clinic “l’Hotel-Dieu de Lyon” they repeated examinations and biopsies and had clarified certain clinical syndromes, and they did the attempt to discuss their pathogenesis.
Professor PAVIOT shared his work of the “pseudo-sciatique de la cellulalgie” in his clinic with Lagèze and it allowed them to follow 11 patients.
He especially thanks Professeur FAVRE, who was the first one to talk to him about cellulite and encouraged him to look for it and to treat it.
He divides the thesis in 6 chapters:
- Chapter 1 – The sciatica
- Chapter 2 – The cellulalgic infiltrates: history, symptoms, diagnosis, and anatomical substratum
- Chapter 3 – Sciaticas by cellulalgic infiltrates: the false sciatica, the most frequent sciatica
- Chapter 4 – General pathology of the cellulalgic infiltrates.
- Chapter 5 – Therapeutic considerations
- Chapter 6 – Conclusions
Chapter 1 – The sciatica
Lagèze states that by then (Personal note: exactly like now in Spain) there was the tendency to use the term “sciatica” to refer to “any pain syndrome of the lower limb localized in the area of the sciatic nerve” without any further consideration (it is neuralgic, neuritis, radicular?).
History from the term sciatica by Lagèze
According to Lagèze “sciatica” was described for the first time in 1974 by COTUGNO, who named it “ischias nervosa postica”.
In 1841, VALLEIX did a detailed study in his “Traitédes névralgies” signaling the existence of PAINFUL PAIN POINTS pathognomonic of nerve pain, which have since then remained classic.
LASÈGUE described other symptoms. (Personal note: His sign is still in used today).
LANDOUZY distinguished the “benign” form NEURALGIA, and the “la forme grave”: “névrite”.
In 1896, BABINSKY reported modifications in the Achilles reflex.
DÉJERINE describes the “sciatique radiculaire”.
Finally, during the war, the works of GUILLAIN et BARRÉ, SICARD, ROUSSY, FOIX, STOEBER, CHAVANNY also contributed to the study of sciatic syndrome.
The topographic forms of sciatica
-“Sciatique radiculaire”. Sciatic nerve is irritated at the level of the roots.
-“Sciatique funiculaire”. Sciatic nerve is irritated at the bone tunnel, called “funiculites by SICARD et FORESTIER”.
-“Sciatique del plexite sacreé”
-“Sciatique tronculaire”. Sciatic nerve itself.
Sciatica is considered a painful syndrome. It usually presents with paroxysmal crises.
The beginning is usually slow and insidious, and it gets worse despite the patients’ rest. Other times the pain abruptly breaks down with a sharp violent pain preventing any movement.
Sometimes it locates in the buttock like in the “Sciatiques hautes de Sicard”, other times in the posterior aspect of the thigh, rarely to the calf and the external region of the leg. Frequently, they extend to the entirely surface of the limb.
It is usually a continuous pain that presents paroxysmal access. The pain’s character is “sourdes, mal localisées, le malade à l’impression d’étre contusionné”. The paroxysmal pains can be very painful and usually present at night or with movements or efforts.
The patient presents “impotence of the limb function” and a certain “antiallgic posture”. Sometimes walking is impossible or it gets in a certain way “minimizing the support of the body on the painful leg”. It can also get a scoliotic position with the concavity of the back looking to one side or the other.
On physical examination it is important to explore the VALLEIX’s points:
- lumbar point (angle sacro-vertebral).
- sacroiliac point (sacro-iliac articulation)
- the gluteal point (over the “echancrure sciatique”)
- the trochanteric point
- the three femoral points (posterior aspect of the thigh)
- the peroneo-tibial point (head of the fibula)
- the maleolar external points, dorsal foot and plantar
Other exploratory signs are:
- “the adducteurs de BARRÉ”: painful sharp pain by piercing the internal border of the adductors
- “le signe de LASÈGUE”: pain caused by bending the thigh on the pelvis, while the leg is maintained in extension
- “le signe de BONNET”
- “le signe de sciatique poplité externe de SICARD”
- “le signe de la toux de DÉJERINE
It is also important to explore the SENSITIVITY and muscular strength
- The thermal and pain sensitivities are respected.
- There may be a degree of HYPOESTHESIA (rare anesthesia).
- The muscular strength is usually conserved.
-There may be muscular hypotone, it can be felt by the palpation of the muscles in comparison of the healthy side, especially of the gluteus muscle, it can be seen as a “lowering of the gluteal fold of the sick side” which is known as the “signe de BONNET”. The hypotone of the calf muscles is shown by the “signe de l’esquerre de BARRÉ”.
-In 1896, Babinski showed that the patellar reflex is still normal in sciatica BUT the Achilles reflex is changed, it is often diminished compared to the healthy side, rarely it is abolished. The external retro-malleolar reflex is also decreased.
If muscular atrophy exists, it means that there is an old neuritis.
VASOMOTOR disturbances can also be found, especially the decrease of the temperature of the limb (reported by LANDOUZY and BARRÉ).
They also saw that there could be highlighted faradic and galvanic hyper-excitability. Serious neuritis would show partial degeneration.
The “nevralgie sciatique”
It is the most benign form of sciatic pain. It can present with continuous or paroxysmal pain with long periods of latency. Tendon reflexes remain normal; there are no trophic disorders. It is usually a transient pain, frequently recurrent, very sensitive to external cold and damp and to muscle fatigue of the affected limb.
The “nevrite sciatique”
It is a more serious form. The pain becomes continuous in the interval of attacks, weakening of the Achilles reflex soon appears with atrophic muscular disorders and antiallgic scoliosis. There can appear zones of hypoesthesia. They cause considerable functional impotence.
The “sciatique radiculaire”
They were recently described by DÉJERINE (1896), LORTAT-JACOB et SABARÉANU (1904). The pains are very sharp, especially during the night; zones of hypoesthesia appear with radicular topography in long strips. There is pain with cough. The lumbar puncture frequently shows lymphocytosis with hyperalbuminosis of cerebrospinal fluid.
The DIFFERENTIAL diagnosis
- Chronic arthritis of the hip
- Sacrocoxalgia and funiculities
- Vertebral rheumatism: Lumbarthrie de Léri, lumbalgies de Sicard et Foriester
- Meralgie paresthésique the ROTH
- Local sciatiques like traumas or tabes
CLASSIFICATION OF SCIATIQUES
Sciatiques de causes locales
According to Sicard, there are several causes:
-Evident causes such as traumas or direct lesions on the nerve, consolidation of pelvic fracture compressing the nerve, intramuscular injections that pierce the nerve or irritate it, obstetrical causes. In all these cases, the sciatic pain syndrome is easily explained.
But there are other causes that are more difficult to explain.
He classifies the sciatic pain in HIGH (Haute), MEDIUM (Moyenne) or LOW (Basse).
“Sciatiques hautes” or high sciaticas
They are due to radiculitis or “funiculities”. Due to chronic meningitis (syphilitic), tabes. The lumbar puncture shows findings like lymphocytosis. They can also be due to lumbosacral mal de Pott (especially in young people and when the pain calms with rest and immobilization). Also by a medullary tumor (xantochromic lumbago of SICARD and LAPLANE) or vertebral cancer by metastasis. The “sciatique funiculaire” (J. FORESTIER) due to “arthite apophysaire” and lesions “osteophytiques” (it usually presents stiffness of the column and pain with percussion of the apophyses. It is usually related to abnormalities of development of the lumbosacral segment).
BERTOLOTTI, LÉRI, NOVÉ-JOSSERAND insisted about the frequency of the SACRALIZATION of the V lumbar vertebrae. And LÉRI and ENGELHARD also described the lumbalization of the first sacral vertebra.
“Sciatiques moyennes” or medium sciaticas
They are due mainly to plexitis. They can be due to a local sacroiliac arthritis (sciatiques sacro-iliaques de BARRÉ et LE MANSOIS-DUPREY) or to other local affections such as a local cancer (bladder, uterus, ovarian).
“Sciatiques basses or tronculaires” or low sciaticas or truncal
Sometimes by a neighboring tumor (OSTÉOSARCOMA of the femur), or by compression of varicose veins (sciatqiues variqueuses de QUÉNU).
SCIATIQUES DE CAUSES GENERALES
- Diabetes, often bilateral and resistant to analgesics
- Tuberculosis (sciatique pretuberculeuse de LANDOUZY)
- During malaria, gonorrhea, influenza or puerperal infection
SCIATIQUES “ESSENTIELLES” or essential sciatica
Lagèze points out that sometimes, after doing the complete investigation, no CLEAR CAUSE of the sciatica can be found, then they used the term “essential sciatica” or “rheumatic sciatica” or “sciatica a frigore”.
IT WAS BY THEN THE MOST FREQUENT FORM OF SCIATICA and LASÈGUE even asked if it was a kind of epidemic disease.
LAGÉZE wants to present certain findings that may help to find the pathogenesis of it. He also says that most of the treatments by then failed with this type of sciatica.
He warns that there are CERTAIN LESIONS that are too obvious (when the doctor wants to look for them) to be ignored and they studied them. He refers to what he called “nodules cellulalgiques” or “infiltrats cellulitiques douloureux”.
LAGÈZE states that it seemed that many doctors did not consider the cellular tissue “noble” enough to be examined.
He is also aware that what he calls “cellulalgic infiltrates” are little known, so before explaining what he considered “the false sciatica due to cellular infiltrates” he would explain this type of lesions, the symptoms they present, the diagnosis, and the anatomical substratum, ALL THE THINGS THAT WERE TOO OFTEN IGNORED AND YET SO FREQUENT (Personal note: It seems the article could be contemporary, since now these lesions are still completely ignored by the medical community).
CHAPTER II. THE CELLULALGIC INFILTRATES in general
The pathology with the WRONG name, Paviot and Lagèze proposed a new term for the nodules: cellulalgic infiltrates (another name for back mice)
Lagèze explained that these infiltrates had received different names: “cellulitis”, “cellulalgic infiltrates”, “fibrous nodules of myalgia”, “cellulitic edemas”, “engorgements lymphatiques”, “fibrositis”, “panniculitis”… that were equivalent terms according to the personal preferences of the authors.
Lagèze said that the term “cellulite” (cellulitis) was the most common one used by then, although he considered it is a WRONG ONE.
The term “pelvic cellulitis” is correctly used to describe an acute septic inflammation of the cellular tissue related to post-surgical complication, but according to Lagèze, the affection he explained would be better termed “INFILTRATS CELLULALGIQUES”.
LAGÈZE warns that the term “cellulite” or [cellulitis] is not correct. First of all, it localizes the pathology just to the cellular tissue and it should consider all the CONNECTIVE TISSUE.
Moreover, the termination “-ite” [-itis] gives the idea of an INFLAMMATION (like adenitis, lymphangitis…) but in the “cellulitie arthritique” there is ABSENCE of an INFLAMMATORY REACTION (L. ALQUIER).
Dr. Prof. PAVIOT substituted the term “cellulite” by “cellulalgic infiltrate”, which describes the anatomical lesions better.
THE HISTORY OF THE STUDY OF THE cellulalgic infiltrates (or back mice)
(Personal note: There exist as many names as authors for naming the subcutaneous painful nodules)
The first description Lagèze points out was from a book about CHRONIC RHEUMATISM by WILLIAM BALFOUR in 1816. He described patients in whom the fascia of the muscles and the tendon sheaths were thickened, gnarled, and swollen; presenting a large number of small nodules and painful thickenings on which the pain arose.
In 1827, SCUDAMORE described similar facts: small nodules in the thickness of the fascia lata, tendons gnarly on their insertions and aponeurotic thickness.
In England the painful infiltrates were considered the cause of chronic rheumatism and they were called “nodules rheumatismaux” by authors like HELLEDAY, EWER, DUCKWORTH, FOWELER AND MIDDLETON.
The “cellulalgie nodulaire” have been also studied by the Swedish masseurs.
In 1888, NORDSTROOM published a work in France, which explained the healing of rebel headaches by massage of the indurated and painful cervical and dorsal muscles.
In 1896, RICHARD HOGNER, a Swedish doctor, published an article on “cellulite” or “adipose panniculitis” as a common complication of women’s disease.
In 1905, J. TEISSIER described the subcutaneous nodosities as a rheumatic condition of the “former French physicians”.
In 1909, WETTERWALD referred to cellulite and its painful nodules as the neuralgic points described by Valleix.
In 1913, FAVRE and TOURNADE talked about the role of the “celullite” into the sciatica.
HANRIOT in his thèse 1913 “Contribution to the study of one of the manifestations of arthritis: la cellulitis” did a summary of all the semiology of the “nodule cellulitique”.
In 1917, ALQUIER considers “cellulite” as a special infiltrate of the interstitial tissue. He suggested treating it by massage and the physical agents.
In 1923, H.FORESTIER isolates the “vertebral cellulitis” from the neck characterized by nodules all along the vertebral gutters of the cervical region.
Prof. PAVIOT cast new light on the pathogenesis by showing ITS relationship with the hepato-digestive disorders.
In England, R. STOCKMAN studied in 1904 what he called the rheumatic nodosity and published his histological findings. In the BATH Congress in 1928, this author suggested a latent infectious pathogenesis of what they called “fibrositis” or “panniculitis”.
Some authors have denied any scientific interest in these lesions, especially since its treatment seems to be massage and it seemed that some thought that these lesions are not “digne” of a doctor. LAGÈZE wonders why it seems that the cellular tissue was so neglected and ignored, as there was a certain degree of “discrédit”.
He says that it was clear that in front of the certain LOCAL painful process the consistency of the tissue was changed.
THE SYMPTOMS RELATED TO THE CELLULALGIC INFILTRATES (or back mice)
The celullagic infiltrates can be identified by a SYSTEMATIC METHODIC PALPATION of certain localization “d’éllection” in the SUPERFICIAL PLANES.
The soft and superficial palpation reveals the presence of the NODULES CELLULALGIQUES. They are infiltrates of ALL SHAPES AND SIZES.
They can be like nodosites like “billes” [balls] or “gros plombs” [big lead balls] or elongated like [olives or dates], also like cords “sinueux et trapus”, or bulging plate or “placard”.
The consistency is variable, some of recent formation are SOFT, RENITENT, sometimes they are little “crépitent” under the fingers. Others are hard and fibrous.
These nodules are usually VERY PAINFUL with palpation, as soon as the finger comes in contact with it and crushes them. The patient reacts with a movement of withdrawal and an exclamation of pain.
This infiltrates are very often NOT painful spontaneously, usually the patient does not suffer from it and does not know about its existence. The palpation of these latent nodules, nevertheless, causes a rather sharp pain.
They may be present in the subcutaneous cellular tissue, in the superficial aponeuroses and in the conjunctive tissue of the muscular and tendinous sheaths, in the muscles themselves and the tendons. It seems that all the “milieu intérieur” from RENAUT is susceptible of being, in certain subjects, of these “deposits” of certain “humeurs” whose composition or exchange are no longer normal.
Then because of the stasis, the points of engorgement, stagnation the nets of PERIPHERAL SENSORY NERVES are trapped there and can produce spontaneous and paroxysmal pain of neuralgic character or with the movement of the muscles.
To search for these INFILTRATES it is important to start by the territory that the patient indicates, the CELLULALGIC INFILTRATES then are located always in certain specific locations.
- In the LOWER EXTREMITIES: If it presents as a PSEUDO-SCIATIC SYNDROME, the buttock and the inferior border of the iliac crest, immediately outside the posterior iliac spine ELONGATED NODULES at the insertion of the fascial sheaths can be palpated (Personal note: exactly where back mice are located). There are also common in the external surface of the thigh, in the aponeurosis of the fascia lata, the popliteal fossa, the calf, and the lateral parts of the Achilles tendon).
- They can be found in the DORSAL REGION: the vertebral muscles, the inner edge and the spine of the scapula, the supraespinous fossa (Personal note: where “cervical” back mice are usually located).
- In the CERVICAL REGION: the muscles of the neck, the anterior edge of the trapezius and the sheaths of the muscles of the “bouquet of RIOLAN”. Also in the mastoid region and in the vicinity of the occipital nerve.
- In the FACE: in the supraorbital temporal muscles.
- On the thorax, it is possible to find nodules in the external third of the PECTORIS MAJOR, in the submammary region and in the union of the last ribs and costal cartilages.
- Also in the abdominal muscles.
- In the upper limb, in the deltoid region, the posterior aspect of the arm, the superior insertions of the epicondylar muscles.
The cellulalgic infiltrates according to their seat, they present themselves in slightly different ways.
- Sometimes they appear immediately subcutaneous, mobile, and very superficial.
- Sometimes they form a body with the aponeurosis or the muscle, which appears to be padded with it.
- When the palpation is exercised on a resistant plane, the bone, for example, feels that the tissue presents “grains and discontinues trainées”, very painful.
- When the pressure is exerted on the contrary, on soft masses planes, they seem to be greasy lobules.
- On the level of the lower third of the leg, these infiltrates awaken the idea of a scleroderma or scleroadipose edema.
The cellulalgic infiltrate from the ankle: Duvernay’s ball
The cellulalgic infiltrates can be found in many locations and be palpated rather easily, but DUVERNAY recently described under the name “boule prémalléolaire” a nodular cellulalgy [premmalleolar ball nodular cellulalgia] that can be often found in the rheumatic patients or arthritic in AIX-LES-BAINS. DUVERNAY said in his article that he often met women’s ankles deformed by a kind of swelling localized to the outer perimalleolar region, especially in front of the malleolus. This swelling was not diffused; it was clearly limited, forming a mass the size of a walnut or a chicken egg. The finger leaves no imprint on it, but under finger’s pressure the mass widens, spreads and he could observe the edges projecting similar to a synovial cyst. Nevertheless, while palpating he did not have the impression of a lipoma but more like small well-defined lobulated masses. This premalleolar ball was not accompanied by edema of the neighboring tissues. Lagèze said that they also had the opportunity to observe many of these infiltrates described by Dr. DUVERNAY in patients who also had other cellulalgic infiltrates. Nevertheless, Lagèze remembers one patient that just presented this cellulalgic manifestation, Dr. Lagèze and Prof. Favre decided to do a biopsy under local anesthesia. The ball was made of subcutaneous cellular tissue a little sclerous; the histological examination showed that it was NOT an inflammatory process, but a cellulalgic process.
The evolution of the cellulalgic infiltrates (back mice)
LAGÈZE said that the evolution of the cellulalgic infiltrates was variable according to the ground on which they have appeared, according to the nature or the absence of treatment.
If abandoned to their natural evolution, these infiltrates have little tendency to spontaneous resorption, most often they organize themselves, become harder and tend to become chronic.
They had the opportunity to observe patients in whom cellulalgic nodules existed at all stages of their evolution.
Young infiltrates are still soft, crackling easily under the finger; others, older, were felt much firmer. Others, finally, very old appeared as hard and fibrous as scar tissue. This is explained by the fact that the painful manifestations that accompany them have no tendency to regress.
Of all the forms that the cellulalgic infiltrates can present, the most common one is the PSEUDO-NEURALGIC FORM: torticollis, painful stiffness of the cervical spine, migraine, intercostal neuralgia, brachialgia, lumbago and sciatica. Once the syndromes are more or less settled, they may move to chronicity, calming down at times to reappear later. These algias may alternate with one another, despairing the patient by their tenacity, sometimes even making the person impotent. These pains can be so sharp and so rebellious to the usual painkillers that they become the sole concern of the patient.
Professor VEYRASSAT (de Genève) had informed them of the observation of one of his patients, who for a very long time had had painful cellulite nodules in the lumbosacral region. The lesions were accompanied by chronic lumbalgia with bilateral sciatica syndrome, which were particularly stubborn and resistant to all the usual sciatic treatments that had been tried. He said that “the patients’ pains were so violent that they prevented the patient from turning in his bed and deprived him of any possibility of sleep”. The patient told the doctor about his plan to commit suicide out of his state of exasperation. The doctor gave him morphine that only gave him a sedative sedation”. Dr. Lagèze then was called. The patient told him “he was so tired that he was ready to suffer anything so that he would not suffer anymore”. Then they decided to operate on him and remove the cellulalgic masses, the patient then was completely cured at least for the following 3 years.
Dr. Lagèze expresses that the hypothesis of the pseudo-sciatic syndrome by cellulalgic infiltrates was a clinical fact, they had many experiences in the Clinique Medicale of M. Professor PAVIOT. They could not yet give prevalence, but they could see many patients during 6 months that passed through inefficacy of the previous treatments. They also repeated the histological examinations to find these cellulalgic infiltrates after biopsy of the nodules.
The PSEUDO-NEURALGIC FORMS of the cellulalgic infiltrates
The cellulalgic infiltrates usually present as a painful affection. Dr. Lagèze said: They are NOT a neuralgia strictly speaking, because they may be accompanied only EXCEPTIONALLY by spontaneous paroxysmal attacks (that are characteristic of neuralgies). That’s why they like to call them PSEUDO-NEURALGIES.
The pains are usually provoked by the muscular movement, the effort, or the fatigue. There are usually antecedents.
The SUÉDOIS had for long time the knowledge to cure certain migraines by the massage of the neck or the temporal region.
NORDSTROOM published in 1888 a memoir on the healing of rebellious cephaleas by the massage of INDURATED AND PAINFUL CERVICAL MUSCLES.
H. FORESTIER isolated “vertebral cellulite” with a syndrome of cervico-occipital and brachial pains.
VERGER and DELMAS-MARSALET in several publications and in his thesis of his student LANZALAVI described the “pseudosciatic myalgies”.
HELWEG and LINSTEDT in recent articles insisted on the muscular localization on a large number of sciatic neuralgies.
The pseudo-neuralgic forms of the cellulalgic infiltrates according to Dr. Lagèze are indeed very frequent. Some may present in the form of migraines or headaches, which are usually persistent and durable despite the rest. Others simulate the different neuralgies of the upper limb like the cervico-brachialgias rehumatiques or the “sciatiques du bras” descibed by ROGER.
Others present as intercostal neuralgias or trigemin neuralgies, cervicalgies or torticollis, scapular neuralgies, low back pain, or lumbago. But according to LAGÈZE, the most frequent one is the PSEUDO-SCIATICA.
Lageze states that there was a period of “vogue” of the cellulite, which seemed to be forgotten by them. It was in 1924 when H. FORESTIER wrote: “the question de la cellulite est à l’ordre du jour, l’idée de DIATHÈSE RHEUMATISMALE se matérialise”. This “call” by H. Forestier was in vain and the silence was again almost complete. Several reasons may have contributed to this silence. (Personal note: This silence had repeated many times during the history of the study of the role of the fibro-fatty tissue as a causative agent, the work of Ries, Copeman, Curtis… all warned the medical community about their findings and failed like Forestier).
Lagèze says that the reasons may be the following: “Les pathogénies les plus dissemblables, les plus théoriques et nous dirons même les plus fausses ont été successivement proposées à l’origine de ces lésions.”
Also Lagèze said that another reason may have been that some authors tried to explain “everything” by cellulite, some authors considered that appendicitis, pharyngitis, neurasthenia could also be explained by the cellulalgic infiltrates. This systematic generalization led to the disapproval of some doctors and the hostility of the true clinicians.
Lagèze said that, for that reason, they considered that it was so important to perform a RIGOROUS ANATOMICAL study of the cellulalgic infiltrates by biopsies.
The differential diagnosis of the cellulalgic infiltrates (back mice)
The cellulalgic infiltrates can be palpated and can be easily differentiated from the “nodosités cutanées inflammatoires” that one can observe in certain acute febrile erythemas: the erythema nodosum, for example.
They can also be differentiated from the banal adipose grains that can be felt in obese people, the grains are enchased in the adipose tissue. They can be of great volume and are NOT painful, neither spontaneously or on palpation. They correspond to fibrous nodules sprinkled irregularly in the adipose membrane.
The cellulalgic infiltrates are also different from the subcutaneous lipomas. The palpation of lipomas is usually painless, the consistency is soft and sometimes a little renitent, they can present irregular lobules. They can present symmetrically (symmetrical lipomatosis). They usually present themselves as small indolent tumors.
The painful adiposis or DERCUM disease can present as a nodular form. In 1888 in the memoir from Dercum he described the case of a woman “le cas d’une femme atteinte d’adipose douloureuse, d’asthénie physique et de troubles psychiques”. Dr. Lagèze could observe a patient suffering from this PAINFUL NODULAR LIPOMATOSIS under the hands of the Docteur GALLAVARDIN. The patient presented a sharp form of this syndrome, she presented a considerable number of small, rounded nodules with the characteristic consistency of the lipoma, scattered at the most diverse points of its subcutaneous cellular tissue. One of these painful nodules was taken by Dr. GATÉ and showed that it was indeed a lipoma with normal fatty tissue. The lipomas were noticeably painful on palpation but did not present any spontaneous pain of the neuralgic type. The evolution of these cases is quite benign. The pathogenesis was still unknown. They described it as a genuine PAINFUL NODULAR LIPOMATOSIS. They usually present as large, painful, irregular, scleroadipose compartments, varying in their consistency.
Similar lesions were described by SUÉDOIS RICHARD HOGNER in 1896 with the name “panniculite adipeuse”.
Localized edemas of the QUINCKE type are considered nowadays as anaphylactic manifestations. The edema appears abruptly, disappears in the same way, and it repeats itself at irregular intervals.
The cellulalgic infiltrates have to be differentiated from the synovial cysts or ganglia.
The anatomical substratum of the cellulalgic infiltrates (back mice)
Lagèze admits to being surprised that so little anatomical material has been collected so far in consideration about the work related to “cellulite”. HANRIOT remarked in his thesis that “the pathological anatomy and histology of cellulite are very little known because the research was recent and it is a pathology rarely observed in the hospital, since it is usually a benign condition that does not lead to death and, therefore, does not attract the attention at the time of the autopsies.”
The oldest study that LAGÈZE could find was of the thesis of GEOFFROY SAINT-HILAIRE in 1898. His histological analysis of what SAINT-HILAIRE called “l’oedème fibroplastique” in the abdominal-pelvic region.
DERCUM also published the result of autopsies of patients that suffered that syndrome. He described possible neuritis by the nerves filaments that were imbedded in the subcutaneous fat masses. He described 3 states of lesions.
According to STAPFER, the finding with cellulite is the DILATATION of the veins and the tightening of the arteries with a certain degree of local or diffused infiltration and thickening of conjunctive tissue creating tumefactions. He related it to certain degree of neuritis that would produce the motor, sensitive, vasomotor and secretory effects and a vicious circle. These could be the cellulo-neurotic phenomena of WETTERWALD.
LAGÈZE said that many of the microscopic analysis of the cellulalgic infiltrates had been by then AFTER DEATH, and that was a limitation on their study. He considered that after death just the very OLD CELLULALGIC INFILTRATES LESIONS or nodules could be found.
LAGÈZE et al. do not find cellulalgic infiltrates in the autopsies
LAGÈZE and PAVIOT wrote in 1926 about the subject of the NODULES CELLULALGIC SACRO-ILIAQUES (Personal note: another way to name the back mice from Peter Curtis et al.)
“Ce sont les plus fréquemment rencontrés, ils ont fini par être pour nous un des moyens d’exploration et de diagnostic les plus faciles et les plus rapides sur le vivant. Or jamais nous n’avons pu les retrouver à une autopsie, et pendant longtemps nous les avons chercés sur le cadavre. Si bien que nous avons été conduit à penser que la mort, succédant en général, à une dénutrition même courte, nén laissait plus trace; que ces nodosités sont en grande partie de constitution LIQUIDE, cellulaire, donc très résorbables, et que la turgescence vasculaire tombée après la mort, les derniers vestiges en disparaissaient sur le cadavre, ou que du moins il n’en substait pas suffisamment pour que nous puissions les sentir et les y retrouver”
[The sacroiliac nodules are the most commonly found. For them they were the easiest and fastest ones to study. They were NEVER able to find them in AUTOPSY despite for a long time they tried to search them in a cadaver. They then realized they have a LIQUID CONSTITUTION and somehow they are reabsorbable after death. It seems that vestiges might have disappeared on the corpse, or at least they did not remain so they could be felt or found. LAGÈZE says that they searched for six months in many autopsies that were done in the l’HOTEL-DIEU in certain localizations that they called POINTS OF ELECTION of the cellulalgic infiltrates, and they never found the slightest trace.
Lagèze et al. The BIOPSIES findings
They could perform BIOPSIES in patients that were willing to volunteer. They did it in an aseptic room, with the same surgical precautions as if it were a laparotomy and under general anesthesia (just one was done under local anesthesia). They thought that the regional anesthesia with NOVOCAINE could lead to VASO-MOTOR disturbances or artificial infiltrations of the removed tissues. That’s why, after a first one, they decided to use GENERAL ANESTHESIA.
The first case was one of the DUVERNAY’s cases with “bule prémaléolaire extrene”.
For six months they were able to perform biopsies in patients suffering from sciatica, lumbago, torticollis, intestinal pain, and migraines.
They collected several cellulalgic infiltrates in their different stages (nodules, cords, “placards”).
They also collected muscle fragments in two patients with gluteal pain.
All the specimens were immediately removed, washed with artificial serum, and fixed with saline formalin or BOUIN liquid.
They had a collection of 20 specimens that were stained with éosin-hématéine-safran or trichrome de P. MASSON stain.
Other fragments were examined by the LABORATORIE d’ANATOMIE PATHOLOGIQUE with other methods: freezing sections, elective stains for fat, elastic tissue, and nerves.
By these methods they were able to detect the smallest anatomical modifications of these lesions at the different stages.
STOCKMAN’s findings in 1904
In 1904, Stockman published his study of the biopsies in patients with cellulalgic infiltrates by then called “indurations rheumatismales chroniques”.
“Le nodule de la fesse droite, distinctement senti à travers la peau, donnait l’impression d’être de la grosseur d’une petite amande. Il était très douloureux et, de ce nodule, la douleur en sciatique smablait s’irradier en bas dans la jambe. Après avoir soigneusement repéré sa place, le Dr RENTON incisa jusque sur lui. Une fois découvert il apparut comme étant une portion épaissie et saillantede la gaine du moyen fessier, de la grosseur d’un demipouce. Cet épaississement avec des fragments de muscle voisin fut enlevé, durci à l’alcool-formol, puis coupé. Les coupes montrèrent qu’il s’agissait de tissu fibreux engainant le muscle, tissu fibreux blanc largement hypertrophié à l’intérieur des fibres musculaires, dont un tout petit nombre sont partiellement dégénérées, plus probablement par l’action d’une toxine que sous l’influence de la pression. Les fibroblastes ne sont pas nombreux et il n’y a pas d’amas de leucocytes au voisinage de la zone enflammée. Les vaisseaux sanguins présentent nettement de la périartérite et de l’endartérite avec profilération du tissu conjonctif, indiquant qu’ils ont aussi souffert d’une action irritante”.
[A nodule in the buttock gave the impression of a small kernel, it was very painful and seemed to give a sciatic type of pain. Dr. RENTON excised and it seemed to be white fibrous tissue engaged to muscle. There were signs of hypertrophy, and certain degree of degeneration. NO LEUCOCYTES. The blood vessels showed signs of pariarteritis or endarteritis, all indicated that they suffered from an irritant].
Lagèze said that this histological examination was the only one that seemed to be done under good conditions. And he said that the most relevant finding is the ABSENCE of banal INFLAMMATION signs or diapedesis.
The microscopic study of Lagèze et al. was done in specimens that showed signs of different evolution states of the cellulalgic infiltrates: “Infiltrat jeune mou, crépitant” versus the progressive “présclérose” and the définitive transformation to fibrotic tissue.
Lagèze et al. describe 4 stages of evolution for the cellulalgic infiltrates
1-“La phase congestive”: Lagèze said that this phase is just a simple vaso-dilatation of the small vessels, of the fatty tissue and the interstitial spaces. It presents as a congestive phenomenon and a net lesion cannot be demonstrated. It is a fast phase and it can go unnoticed.
2-“La phase exsudative”: The second stage presents an exudative state that can correspond with the first symptoms. There is a vaso-dilatation phenomenon. The exudation is exclusively plasmatic. This stage is difficult to see with microscopic examination since it is lost during fixing measures. They described it as an “exsudation palsmatique séreuse de RENAUT” with absence of inflammatory cells. Clinically, it can be felt as a CRÉPITATION state.
3-“La phase d’organisation”: Sometimes the exudate can disappear, also by the effects of massage. If they are abandoned to their natural evolution they may undergo “organization”. It seems there is a “phénomène du métamorphisme” (NAGEOTTE) with a gradual collagenization of the exudated fibrin, WITHOUT THE INTERVENTION OF THE INFLAMMATORY CELLS. The “endonèrve” or “perinèvre” could be also affected.
4-“La phase fibreuse”: This is the terminal phase. There is a regression of the cellulo-adipose tissue and there is just sclerous tissue. The blood vessels from the nodule present lesions like endarteritis and periarteritis. These nodules are not reversible.
CHAPTER III “Les sciatiques par infiltrats cellulalgiques”
Sciatica by cellulalgic infiltrates
Lagèze et al. state that just 2/10 sciatiques can be really considered “real sciatiques”. But most of the time there is NOT an explicit cause of the pain syndrome.
Before diagnosing a “sciatica a frigore” (term that had never satisfied anyone), they decided to explore the cellular tissue (after having previously excluded other known causes).
For example, if a patient suffers from a Pott’s disease it may be absurd, even if there are cellular nodules at election points, to speak of cellulalgia. On the other hand, in other cases it seems illogical to want to give as a pathogenic substratum a bone malformation to a sciatic neuralgia. For example, if the X-ray shows a sacralization of the V lumbar vertebra it will be remembered that often such a bone malformation is a radiographic finding in subjects with no pain syndrome. Lagèze criticizes that many lumbosacral pains have been attributed to sacralization or other X-ray findings that are just variations of normality (Personal note: This problem is still there nowadays).
Patients that suffer “essential sciatica” very often present cellulalgic infiltrates that sometimes get better by massage. These cellulalgic sciatiques can present as a pain syndrome that is not present while resting or by “pas de crises douloureuses spontanées”. The pain usually appears when there is muscular MOVEMENT, marching, standing, exertion.
SICARD described the “sciatiques hautes” form the gluteal region.
But Lagèze says that there are still many doubts about the classical signs that have been considered useful to diagnose a “classical sciatica”.
I-ETUDE CRITIQUE DE SIGNES DE SCIATIQUE
[Critical study of the classical signs of sciatica]
The classical signs of sciatica or sciatic neuralgia by then were: a patient suffers form the posterior gluteal region, thigh, popliteal region. Any muscular effort is very painful. Considerable functional impingement. The points douloureux de VALLEIX are present and the LASÈGUE and Bonnet sign also. A certain muscular atrophy of the buttock and a decrease ACHILLES reflex.
Lagèze goes through each of these “classical signs” and states that they can be present in certain “pseudo-sciaticas”:
1-LES POINTS DE VALLEIX
2-LE SIGNE DE LASÈGUE
4-LA DIMINUTION OU L’ABOLITION DU RÉFLEXE ACHILLÈEN
1-Les points de Valleix: They correspond to certain points of the sciatic nerves that can be painful when they are palpated, especially when they are placed superficially or against a bone plane. Nevertheless, WATTERWALD pointed out that not just the nerve is pressed, the skin, the muscles, the fascias and the cellular tissue are pressed, too. He even noticed that the patients could have pain just by the simple fact of lifting the skin. Even sometimes the sign of BARRÉ is present (of the obturator nerve. That’s why LAGEZE insists that the Valleix points have a limited value.
2-The LASÈGUE SIGN also has these limitations. So the muscles or tendons can be painful not just by pressure but also by stretching and elongation. By doing the LASÈGUE maneuver also not just the nerve is stretched. According to VERGER AND DELMAS-MARSALET, the experiments of BAUMANN (base of LASÈGUE) had the limitation to be done in cadavers. WATTERWALD also suggested that it is the whole limb that could be painful, not just the nerve.
3-The muscular atrophy can be also related or not to a true nerve degeneration. HELWEG pointed out the possibility of muscular atrophy by INACTIVITY of the muscle. LAGÈZE then said that there are also the so called REFLEX ATROPHIES studied during the war by BABINSKI and FROMENT that show the role that the sympathic nerves can have. The most common finding is a slight muscular hypotony on the ill side that may be suficient to cause lowering of the fold of the buttock (BONDET sign).
4-The abolition of the Achilles reflex: It had been said not to be a constant finding in sciatic patients and also may be present in healthy subjects. It should also be noticed that if the muscle is affected it may affect the reflex. So it is just not a sign of nerve affection but of a muscular one.
II-LES PSEUDO-SCIATIQUES PAR CELLULALGIE
LAGÈZE et al. prefer to call PSEUDO–SCITIQUES the sciatiques caused by cellulalgic infiltrates. They seem to be more related to the movement, and they are usually not painful while resting. They never present spontaneous exacerbations. There are never sensitivity disorders.
The patients seem to have hereditary or personal antecedents of “hépatisme” (migraine, urticaries, enterocolitis) or “modifications humorales” due to tubreculosis, syphilis, alcoholism, other infections or “dyscraise”.
Many of LAGÈZE et al. patients had undergone the most varied treatments that did not cure them. Some of them presented DESPERATE RESISTENCE to all therapies “injections locales d’alcool ou d’air, à l’électrothérapie ou à la radiothérapie, aux cures thermales…”.
They reported 9 cases of pseudo-sciatique per cellulalgic infiltrates. Some would diagnose them as “essential sciatica”, others as “myalgies”, and others -like them- consider the role of the cellular tissue in the production of these pains.
LAGÈZE mentions the “l’école de Bordeaux” with VERGER, DELMAS-MARSALET and their pupils. They considered that the nodules that presented the muscles would be similar to the nodules d’ASCHOFF. COOMBS also described similar nodules to those of ASCHOFF in the subcutaneous tissues during rheumatic fever. In 1924, SWIFT described subcutaneous fibrous fascial nodules in the tendinous sheaths, tendons and muscles in a way similar to the myocardium with the rheumatic process.
Nevertheless, LAGÈZE et al. just did two gluteal biopsies that did not show any alteration.
HELLWEG considered that the PSEUDO-SCIATICA occurred by a myalgia due to intoxication of the muscle by waste products (lactic acid) during overwork.
M. DE LANGIENHAGEN interprets theses PSEUDO-SCIATIQUES as a consequence of chronic muscular rheumatism. He considered that it could be like a “fibromyosite arthritique” with indurated nodules and cords. The fibrous lesions would concern the sensory endings of the peripheral nerves. LAGÈZE criticized that they do NOT demonstrate the lesions histologically but agree on the involvement of the terminal sensory nerves.
LAGÈZE admits that the ELECTIVE location of the celullalgic infiltrates in certain regions seems a mystery to them.
They have the theory that it seems to be in certain regions where there could be STASIS like “dead spaces where the muscular contractions do not occur while muscular contractions”, so it seems that the infiltrates are common in the regions of insertion of the muscles or at their tendinous portion.
III-LES SCIATIQUES VRAIES PAR INFILTRATES CELLULALGIQUES
[The TRUE sciaticas by cellulalgic infiltrates]
LAGÈZE et al. named “the true sciaticas by cellulalgic infiltrates” the sciatic syndromes that they observed related to the presence of cellulalgic infiltrates.
They hypothesized that a cellulalgic infiltrate to the perineural connective tissue of certain nerves could also exist.
A. THOMAS also found a case of a sciatic nerve with a fibrous hyperplasia without the nervous fibers being altered.
SICARD observed a thickening of the nerve sheath by a kind of “oedème gélatineux sans altération inflammatoire”.
J. FORESTIER was able to observe certain modifications of the epidural cellulo-adipose tissue while performing laminectomies. He described a kind of HYPERTROPHY of the cellulo-fatty tissue of the epidural space and its prolongations in the holes of conjugation.
Docteur ROBINEAU and J. FORESTIER noted:
“L’aspect annelé de la gaine graisseuse, avec parties rétrécies comme par des anneaux fibreux correspondant aux ligaments jaunes et des parties saillantes faisant hernie en quelque sorte dans d’intrevallle. C’est l’aspect classique en montagne russe. Cet état de la graisse épidurale correspond à son hypertrophie de trouver un espace où se dilater. […] Cette compression su funicule est à l’origine de violentes algies sciatiques”.
(The fatty tissue presented herniation by tension due to an edema and hypertrophy.)
LAGÈZE proposed the 3 types of “true sciaticas”:
1- SCIATIQUE funiculite: the one described by SICARD et FORESTIER, the localization of the pathological process related to cellulo-adipose tissue is located near the conjugation holes
2-SCIATIQUE troncular: the infiltrates are located to the perinerve conjunctive tissue and endonerve.
3-SIATIQUE by peripheral branches: the nodules of tissue cellulaire compress the terminal branches.
Lagèze presents 11 CLINICAL OBSERVATIONS that presented cellulalgic infiltrates with PSEUDO-SCIATIC SYNDROME.
1-RIGHT SCIATICA in a 61-year-old patient. Pain for 6 months. No findings in examination except for a considerable number of painful spots on the buttock. Walking was almost impossible. No spontaneous pain but any movement was painful. Some of the nodules were very painful, the rest painless. Dr. ROLAND performed the biopsy of a dozen fragments. After a month of massage he was out of pain. He had later one episode of right shoulder brachial pain that resolved after massage.
2-RIGHT SCIATICA in a 71-year-old patient. She came to the clinic because for 6 months she was suffering from right sciatic pain and nothing could calm it. She could not walk anymore. On examination, Valleix points were painful, and Lasègue and Bonnet signs were positive. All movements were limited by pain. Painful cellulalgic infiltrates could be felt in the right buttock. She also had nodules on the left easily felt, also a pre-malleolar ball. After MASSAGE TREATMENT, she improved quickly.
3-LEFT SCIATICA in a 32-year-old man. Lumbar and sacral cellullalgia. He had antecedents of tuberculosis and gonorrhea. He presented hepatodigestive disorders and diarrhea. Valleix points, Lasègue and Bonnet were positive. Painful infiltrates of the left buttock and sacroiliac region “gros nodules allongés sous la crête iliaque postérieure à gouche”. After 6 or 7 massage treatments the patient improved.
4-RIGHT SCIATICA in a 33-year-old patient. Pain for more than 6 years resistant to any treatment. Reappearing at intervals and then calming down. No spontaneous pain, only during the walk. Enteritis in the childhood for 15 years. Torticollis several times. Painful heavy digestions and atrocious migraines. Several infiltrates could be felt in the external iliac fossa, fascia lata and gluteal muscles and in many other locations of the body. She improved by the massage and diet.
5-BILATERAL SCIATICA in a 54-year-old patient. Cellulalgic infiltrates in the sacroiliac region and fascia lata. She improved by massage.
6-RIGHT SCIATICA in a 41-year-old patient.
Pain for several years only in movement. She could not walk or even stay standing. Only decubitus relieved her. When she entered the hospital the patient had been in bed for one month.
7-RIGHT SCIATICA a personal observation from Dr. PAVIOT
Male patient that presented the sciatica, and the hepato-digestive disorders and that he cured by massage of the cellulalgic infiltrates. The patient presented in May 1928 with an acute sciatica rebel to all treatments. He presented painful digestive disorders since 1925 accompanied with severe headaches. Then they found the presence of MULTIPLE CELLULALGIC INFILTRATES (lumbar, paravertebral, and sacroiliac nodules/masses, fascia lata).
They insisted that the patient had to be treated by a qualified massager that should know the SWEDISH “méthode des pétrissages et malaxations”. They then went to VICHY to find a competent massager. The patient improved quickly, but after a fortnight he had a crisis again. After more massage, he improved.
8-RIGHT SCIATICA in a 27-year-old patient, a personal observation from Dr. PAVIOT. No modifications of the reflexes, icterus and urticaria. Cellulalgic infiltrates. Healed by massage.
The patient was visited in the Clinique Médicale de l’Hôtel-Dieu in February 1928 for a RIGHT SCIATICA that lasted more than two years. In his antecedents there was jaundice in 1922, he denied any venereal disease and drank less than a liter of wine a day. The pain was located in the right buttock under the iliac crest and the middle part of the leg. The man had been treated by several doctors by topical treatment, “pointes de feu”, intramuscular injections, without any improvement. Sometimes it affected him on the left side also. The LASÈGUE and BONNET signs were positive in both sides. He presented many bilateral pain points. NO muscular atrophy. Reflexes were normal. On palpation they found HARD CORDS arranged perpendicularly to the tract of sciatic nerve and cellulalgic infiltrates in the thigh. Some nodules were crackling. After ONE MONTH of massage treatment of the NODULAR CELLULALGIA, the patient improved and left the clinic.
9-RIGHT SCIATICA in a 28-year-old woman. A personal observation from Dr. PAVIOT.
Abolition of the Achilles reflex. Hyperalbuminosis of the cerebrospinal fluid without lymphocytosis. Muscular atrophy. CELLULALGIC INFILTRATES. Healing by MASSAGE.
The patient presented a RIGHT SCIATICA for three weeks. Not relevant antecedents, just the particular facility to suffer from ecchymoses. She suffered from SHARP PAIN in the right lower limb. The general examination revealed nothing abnormal. She presented the sciatic painful points: ischiotrocanteric, posterior thigh, peroneal point. Also the LASÈGUE AND BONNET were positive. Also pain while sneezing and coughing. The lowering of the right gluteal fold was clear. They even did a lumbar puncture that didn’t reveal any findings. THEY FOUND OF THE RIGHT SACRO-ILIAC LINE clearly painful CELLULALGIC NODULES ON PALPATION. She received 10 injections of “cyanure de mercure” which did not help her at all. LATER, THEY STARTED MASSAGING THE ZONE AND SHE QUICKLY IMPROVED. The Achilles reflex was affected even after she improved.
10-RIGHT SCIATICA AND CRURAL PAIN in a 46-year-old patient. Observation in PAVIOT’s clinic. No modification of the tendinous reflex. Digestive disorders. Healing by massage. The patient was visited for neuralgic pains in the right lower limb. Antecedents of alcoholism (more than 1 liter a day) and amoebic dysentery contracted in the war of Salonica. One past episode of sciatica that resolved some years before. The patient presented important digestive disorders after eating. The pain presented as a crural neuralgia (crural arch, anterior thight, rotullian region).
There was no modification of the tendinous reflexes. No disturbance on the sensibility. They found numerous CELLULALGIC INFILTRATES at the level of the posterior iliac crests, in the fascia lata and the intercostal spaces and the neck. Everywhere these infiltrates roll under the finger, the palpation causes a SHARP PAIN. After 6 sessions of massage, the patient improved.
11-LEFT SCIATICA in a 22-year-old patient. The patient was visited by painful phenomena of the left buttock. It started with the efforts and later it forced him to stop working. All the general examination showed no findings except for certain degree of CRACKILING at the muscular interstices around the posterior iliac crest. One deep palpation revealed PAINFUL CORDS AND NODULES, in both sides but more in one of them.
CHAPTER IV- PATHOGÉNIE GÉNÉRALE DES INFILTRATS CELLULALGIQUES LEURS ASSOCIATIONS MORBIDES
[General pathogenesis of the cellulalgic infiltrates and their morbid associations]
LAGÈZE says it seems that the patients that present the cellullalgic infiltrates can be considered “rheumatisers”… since they suffer from neuralgic pains, migraine, painful joints or painful tendon sheaths. In GERMANY AND ENGLAND, they started to study the pathogenesis of cellulite just a few years before. The patients were placed in a basket of CHRONIC RHEUMATISM with or without osetoarticular manifestations.
LAGÈZE considered that the term “chronic rheumatism” had to be determined and dissociated since it was too vast.
THE CELLULALGIC INFILTRATES RELATED TO PATIENTS WITH HEPATO-DIGESTIVE DISORDERS
Some patients present digestive disorders that seem to coexist with the cellulalgic infiltrates. The hepato-digestive disorders seem to be common. They may present migraine, pruritus and asthma attacks. And they have antecedents of “hepatic” and “diabetic” disorders. They had past history of jaundices (related to emotional or catarrhal). Sometimes they present DYSPEPTIC DISORDERS. Some had past history of anemia, especially young girls.
Sometimes they are older patients that present a painful hepatic crisis without jaundice with digestive troubles and cellulalgic infiltrates. Other times it is more like a colitis syndrome.
It seems that there is hepatic insufficiency. It has been described by GLÉNARD like “small hépatism”, “hépatisme uricémique” and d’”hépatisme cholémique”. The patients are not even subicteric. Lagèze said that this liver insufficiency seems to be very common, but they lack a proper laboratory test.
Lagèze et al. state:
“Tous les infiltrats cellulalgiques, ou la presque totalitéd’entre eux, sont dûs à l’insuffisance fonctionnelle du foie et plus partculièrement au trouble de sa fonction protéo-pexique”.
Lagèze et al. present a theory related with the “possible toxic effect” of certain proteins that wouldn’t be properly metabolized.
For example, “albumine étrangère” could be deposit in the intersticial space creating a vasomotor exudation. It may also produce a anaphylactic reaction. So they had the hypothesis that the patients that present cellulalgic infiltrates present a kind of liver insufficiency that would lead to wrongly processed proteins that would provoke an anaphylactic reaction in the cellular tissue.
In 1926, Dr. Paviot points out this theory: the “insuffisance protéopexique du foie” [proteopexic insufficiency of the liver].
They never found any sign of INFLAMMATION in the BIOPSIES, never HYPERPLASTIC phenomena or cellular HYPERGENESIS.
They tried to reproduce the cellulalgic infiltrates by cholesterol oil and they failed.
The relationship of the hepatic dysfunction with the cellulalgic infiltrates had been pointed out by other authors and also the relationship of the cellulite infiltrates with arthritic manifestations.
- Hanriot, thèse de Paris 1913 “Contribution à létude d’une des manifestations de l’arthritisme: la cellulite”
- Watterwald (Congrès de l’arthritisme, Vittel, juin 1927)
- De Langenhagen (Fibromyosite arthritique)
Also Dr. Paviot related the cellulalgic infiltrates with patients that somehow survive a tuberculosis infection that may have led other members of the family to death. He explained some cases of tuberculosis patients that presented painful nodules cellulitiques in the lumbosacral region and pain in the thigh as “douleur en couture de pantalon”. Also syphilis patients present infiltrates.
All the “toxic” substances (wine, spirits) for the liver could then cause the infiltrates. Also the toxic gas by certain combustion (acid carbonic and carbon monoxide).
They also related to patients with past history of suppuration in any location. They theorize that the suppuration provokes a humoral alteration.
Sometimes the scars from these lesions may also remain painful. L. ALQUIER had the theory of the “barrage lymphatique”. He considered that the cellulalgic nodules were due to the “lymphatic engorgement”.
Lagèze makes it clear that before concluding that there is a disturbance in the nervous system it should be considered that there is a disturbance in the REGULATION OF THE ENDOCRINE SYSTEM. He said that further laboratory test should be developed to identify an underlying latent hepatic insufficiency.
CHAPTER V – THERAPEUTIC CONSIDERATIONS
According to Lagèze, first of all, the treatment is focused in calming the pain but also to treat the primary cause.
THE GENERAL TREATMENT OF THE HEPATIC FUNCTION
It is important to “rest the liver”: so diet with restriction of fats (milk, cheese, eggs).
He also mentions the patients that seem to have problems with digesting the milk. That provokes a kind of anaphylactic reaction.
He also proposes the use of a “choc peptonique” (he comments drugs like adrenaline, vasoconstrictors, calcium chloride, hyposulfite of sodium, peptone de Witte). These medications are used in the urticaria and migraines and will also be useful for the cellulalgies. He proposes 3 months of treatment with a strict control. Peptone should be taken every day for about half an hour before each meal.
THE LOCAL TREATMENT OF THE ALGIA of the celullalgic infiltrats
The massage is the clue.
Lagèze states that instead of proceeding like the Swedish, the Danes, the English to systematize the massage technique, the French doctors seem to ignore the results of the physiotherapist.
Lagèze said that French doctors should visit the Swedish institutes that are very scientific instead of trying to explain the good results by the effects of suggestion or moral influence. Lagèze says that the massage should be done with the “KELGREEN METHOD”.
In 1904, Stockman wrote: “the general massage is of no effect, the massage has to be done directly in the nodules and indurations or the regions which are painful”.
At the beginning the massage must be short, because a too prolonged session may be followed by a painful irritation of the infiltrates and a great deal of functional impotence. After a few days of treatment, the infiltrates become more painful and clear, and then they begin to shrink. More pressure can be exerted at that moment, then we see them become smaller and harder and finally disappear. The massage will be daily and will not exceed 10 to 15 minutes. The soft recent infiltrates can disappear in one to three weeks. Some others resist several months and some never go away. In some places the infiltrates are not accessible.
Published in March 2019 by By Marta Cañis Parera
Thesis form Paul Lagèze. 1929. Sciatiques et infiltrats cellulalgiques. Lyon.