Swelling of subcutaneous adipose tissue of the lumbar region
The data from the general inspectionskin should receive the correct interpretation. Bright hyperemia of the entire skin is observed as a physiological phenomenon in newborns of the first days of life and in premature infants; it occurs in older children under the influence of mental and thermal moments and physical stresses. As a symptom of the disease, general skin hyperemia in children is most often observed with scarlet fever.
Diffuse pallor of external skinindicates either insufficiency of the blood supply of peripheral vessels, or a low hemoglobin content in the peripheral blood. Pale skin is noted with acute cardiac weakness (during diphtheria, pneumonia, etc.), with various forms of anemia, which occur with true oligemia or oligochromia and with kidney diseases; Pallor can occur temporarily with spasm of peripheral vessels under the influence of mental and other moments. One must remember that one pallor of the skin does not give the right to diagnose anemia, since it can depend on other causes, for example, on the individual anatomical and histological features of the skin, low blood pressure, etc .; in these cases there is only apparent anemia. Cyanosis of the skin is usually observed in disorders of both the respiratory system and the cardiovascular system. Common cyanosis is often seen in newborns (various forms of asphyxia at birth, congenital heart defects, intracranial hemorrhages, extensive lung atelectasis, etc.). Cyanosis of the skin in case of decompensation of cardiac activity (congenital and acquired defects, acute heart failure) can persist or permanently, or is detected only when crying, straining, etc.
Acute respiratory disorders (stenotic croup,pharyngeal abscess, foreign body, rapidly increasing inflammation of the lungs or exudative pleurisy, etc.) also commonly cause phenomena of general cyanosis. Local cyanosis, especially in the area of hands and feet, ears, nose and lips, may be the earliest manifestation of general cyanosis, but may also depend on the play of vasomotors in vasolabile subjects (acrocyanosis).
Diffuse yellow coloration of the entire skin is observedwith various forms of jaundice-with jaundice of newborns, jaundice of hepatogenic and hematogenous origin. With jaundice of hepatic origin, characteristic changes in urine and feces are noted, with jaundice hemolytic - typical changes in the physical, morphological and biological characteristics of the blood. Jaundice coloration of the skin is less pronounced in severe forms of sepsis, with prolonged use of acrichine and streptocides, with excessive use of carrot juice, egg yolks, oranges and other foods rich in coloring pigments.
In addition to diffuse skin color changes, it is necessary to pay attention to focal deviations from the norm;
we will name only some of them, most often observed.
Superficial cutaneous veins, poorly visible inhealthy children of early age, distinctly protrude on the skull with rickets, syphilis, intracranial circulation disorders (headache, brain tumors) and with considerable thinness; a pronounced venous network on the chest and venous capillaries in the interblade area are often noted with a significant increase in bronchial and mediastinal lymph nodes.
Focal changes in skin color and surface(erythema, scaling, various forms of eczema, purulent and ulcerative skin lesions, etc.), intra- and subcutaneous hemorrhages and infiltrates are often the only and the main sign of not local, but common suffering (manifestation of tuberculosis, syphilis, hemorrhagic diathesis and t etc.).
It is necessary to pay attention to the peculiarity of growthhair: for example, the appearance of significant vegetation on a small area in the sacro-lumbar region often indicates the presence of spina bifida occutla; scallop hair growth on the head is observed in children with exudative diathesis, the abundance of gun and coarser vegetation on the forehead is characteristic of children with pylorospasm; The abundant vegetation on the limbs and back is often noted with tuberculosis. Untimely appearance and abnormal hair growth in the pubic region is mostly associated with impaired function of the endocrine glands.
Following the skin, usually visiblemucous membranes (lower eyelid and oral cavity) and note the degree of their blood filling (pale, moderate hyperemia, severe hyperemia, the presence of any raids, etc.). A detailed examination of the oral cavity as a procedure that is unpleasant for the child should be postponed to the end of objective research.
Upon completion of the examination, they proceed to further study of the patient, the surface and deep disintegrating into palpation, percussion and auscultation.
In starting this part of the study, the physician shouldwash and warm hands; the first is especially necessary for children of the earliest age, newborns and nurses whose skin is very easily injured and prone to purulent infections; Cold hands often cause an unpleasant sensation not only in very young children, but also in older children.
Surface palpation should be carried outsystematically. gradually, starting with an assessment of the skin condition and only gradually moving to an evaluation of deeper tissues located. All research should be carried out as gently as possible, so that it causes the child a minimum of unpleasant sensations. We must closely monitor the facial expressions of the child, catching the sensation experienced by the patient. With the child all the time should be maintained conversation, trying to something to interest him and to distract his attention from the survey.
First of all, it is evaluated by touch, does the skinnormal velvety, differs more or less pronounced dryness and even roughness, or, conversely, increased humidity. Dry skin is observed with cachexes of various origins, hypovitaminosis, ichthyosis, diabetes, hypothyroidism um. etc. The increased skin moisture and increased sweating are noted in vasomotor-induced neuropaths, especially when falling asleep; the scalp strongly sweats in the patients with rickets; sharp general or focal sweating may be a manifestation of vegetative neurosis (akrodinia); is characteristic. sweating for the initial period of poliomyelitis, for a critical temperature drop (malaria, recurrent typhus, croupous pneumonia, etc.).
It is necessary to pay attention to the temperature of the skin;except for a general increase or decrease in it, associated with the overall temperature of the body, there may be deviations from normal both in the direction of local temperature rise (in the area of inflamed areas, in acute arthritis in the affected joints) and in its lowering (cold extremities in vascular spasms , with lesions of the central and peripheral nervous system, etc.).
Hyperesthesia and other disorders of skin sensitivity cause thinking about meningitis, spinal cord lesions (poliomyelitis, myelitis) and hysteria.
Grabbing the skin in a small crease large andthe index finger of the right hand, you can get an idea of the thickness of the skin and its elasticity; normal skin is straightened, as soon as fingers are taken away, captured it in the fold; the skin, which has lost its elasticity, remains for some time in the form of a crease and straightened only gradually. The skin loses its elasticity and becomes thinner with severe, debilitating diseases, leading to the development of cachexia, with severe acute water losses, endocrine disorders, etc.
Subcutaneous fat layer. Some idea of the amount and distribution of fat is created, as already indicated above, with a general examination of the child. A more accurate representation is obtained by grabbing the thumb and forefinger of the right hand with the folds of the skin along with the subcutaneous tissue. Depending on the thickness of the subcutaneous fat layer, one speaks of normal, excessive and insufficient deposition of fat. In special studies, the thickness of the fat fold is measured with a thick caliper. Measurement should always be done in the same place, for example on the abdominal wall, at the level of the navel.
When assessing the condition of a child's fatness,limited to the definition of the thickness of the subcutaneous fat layer only on one of any Part of the body, since in pathological cases the deposition of fat in different places is not the same.
Children with normal deposition of subcutaneous fatlayer under the condition of general harmonic development (physical and neuro-mental) and the proper functioning of all organs are called eutrophic. With a decrease in the subcutaneous fat layer on the trunk and partly of the limbs, one speaks of hypotrophy (or hypotension) of the first degree (Figure 58); if the subcutaneous fat layer almost completely disappears on the trunk and extremities, but still, although in a reduced amount, on the face, then the child has hypotrophy (or hypotension) of the second degree (Figure 59), with the disappearance of fat and on the face - atrophy (or atrepsia) (Figure 60).
This pattern in the disappearance of the subcutaneous fat layer (abdomen, trunk, limbs, face), one must think, is related to the peculiarities of the chemical composition of fat in various parts of the body.
With varying degrees of weight loss is most often found in young children with chronic eating and digestive disorders.
In older children, reduction of subcutaneous fatlayer can depend on various causes - quantitative and qualitative malnutrition, as a result of acute and chronic infections and other diseases. The most severe forms of emaciation are noted in diabetes mellitus and various forms of pituitary cachexia.
Excess fat deposition may be more orless uniform throughout the body or differ in some uneven distribution. The first - simple obesity - is observed in overfed children, in children, forced for some reason to lead a fixed lifestyle, and in children with anomalies of the constitution, with a reduced exchange of energy.
A plentiful but somewhat uneven depositfat, mainly in the thoracic, lower back, abdomen, buttocks and thighs, is noted for obesity of the endocrine origin (pituitary, genital and cerebral), proceeding with those or other morphological and functional abnormalities from the norm of the endocrine glands (rice 61).
Fig. 58. Hypotrophy of the first degree.
Boy VS 11 months, weight 6760 g, weight at birth 2900 g.
Fig. 59. Hypotrophy of the 2nd degree. The child MV of 8 months, weight 3810 g, weight at a birth of 2860 g, prematurely 3 weeks.
Fig. 60. Atrophy.
Boy 1,5 months, weight 2100 g.
Fig. 61. Obesity.
Girl L. Zh. 5 years old, weight 50 kg, body length 110 cm.
It is necessary to pay attention not only to the quantity,but also on the quality of the subcutaneous fat layer. With all these forms of excess and insufficient fat deposition, the subcutaneous fat layer has a uniform and usual consistency to it. In some cases, the subcutaneous fat layer becomes denser; This change can be limited only to individual small areas scattered across different parts of the body, or can capture almost all of the fiber.
The first form, relatively often observed inchildren of the first weeks of life, severely traumatized during childbirth, is called scleroderma of newborns; in these cases there are limited necrosis of subcutaneous fat. With the second, diffuse form of scleroderma, there are changes in the result of endocrine-vegetative disorders. The latter form is most often observed in weak newborns and especially premature babies and is known as the fatty sclerema (sclerema adiposum), or simply sclera.
When pressing your finger in the area, evenexcess fat accumulation is a deepening immediately aligned as soon as the pressure is stopped; if the pressure is a deepening, only gradually disappearing, you need to talk about swelling of the subcutaneous tissue. Edema can be common, exciting all the subcutaneous tissue and only not always equally pronounced; such swelling occurs with nephropathy, especially with nephrosis, decompensation of the cardiovascular system, malnutrition and prolonged debilitating diseases (protein starvation, colitis, beriberi).
Urinalysis, heart-side data, a general clinical picture and anamnesis data make it easy to establish the cause of overall puffiness.
In addition to general edema, childrenlimited and localized edema. These latter are of angioedevrotic origin; they are relatively often seen on the face and less frequently on other parts of the body in neuro-arthritic children. Reactive, inflammatory swelling near any inflammatory, often purulent foci, for example on the face, are in case of face, eczema, lymphadenitis of the cervical nodes, etc. Limited edema in the absence of inflammatory phenomena in surrounding soft tissues makes one think of more deeply localized inflammatory processes ; Edema of the eyelid often indicates etmoiditis, dacryocystitis or inflammation of the eye.
Hyphalic abscess, toxic forms of diphtheria,less often - scarlet fever, periostitis or osteomyelitis of the lower jaw cause edema of the neck tissue. With limited puffiness of the skin in the thorax, one should think about empyema of the pleural cavity, and in young children and about pneumonia; limited edema of the abdominal skin can be with a prisoned peritonitis, and in newborn children - with umbilical sepsis, etc. Of course, in all these cases it is necessary to prove the presence of the underlying disease by appropriate clinical methods of research.
- Limited edema can also be stagnantcharacter, for example, in the region of the newborn's present part of the body. Along with the listed acute edema, chronic edema is sometimes observed in children, most often in the area before the transferred inflammatory process. Apparently, the same origin of chronic idiopathic swelling of the genital organs in boys of the first weeks of life.
Peculiar chronic swelling of the subcutaneouscellulose, but, unlike ordinary edema, which does not give a permanent depression when pressed, it is noted in hypothyroidism of the thyroid: this is the so-called mucous edema. The presence of dry skin, stunted growth and other signs of hypothyroidism facilitate the establishment of a correct diagnosis.
Edema accompanied by a marked compactionof the affected tissues, the so-called scleroedema, is observed mainly in preterm and debilitated children. Scleredem should not be confused with the sclera, which was mentioned above and which manifests itself only in the compaction of cellulose, but without puffiness.
Having studied the features of the skin and subcutaneous tissue,it is necessary to form an idea of the turgor of soft tissues; under turgor is understood a subjectively perceived by us feeling of resistance, obtained by squeezing the fingers of the skin and subcutaneous tissue. Fabrics with normal turgor give a feeling of elasticity, elasticity; with a reduced turgor, the tissues appear flabby, sluggish. Turgor, as well as the elasticity of the skin, always decreases with acute and especially with chronic eating disorders and with rapidly flowing water losses.