`CICATRIX. (Fr. Cicatrice ; Germ. Narbe.) When from accident or disease a portion of any organ in the body has been destroyed, a process is set up by Nature for the repair of the breach, a new structure is generated, which possesses many properties of conside rable interest and importance both in a phy siological and a pathological view. The new formation constitutes what is termed a cicatrix, and the process by which it is completed, the process of cicatrization. We shall in this article give a general view both of the mode of of repair and of the product when completed.
The restorative process, when a part of the skin has been destroyed, is extremely in teresting. The first stage varies according as the part is removed at once, as by exci sion, or secondarily, as by sloughing. The immediate effect of removing a portion of skin is, that the surrounding integument, by its inherent elasticity, retracts, and to a certain extent, enlarges the breach made by the wound. In a short time after the infliction of the injury inflammation and suppuration take place. As the next step, fibrine is effused, which very shortly becoming organized, constitutes those red, soft, roundish elevations known by the name of granulations. As these form, a con traction of them occurs, by which the edges of the sore,which had at first retracted, are now brought back again towards their original si tuation.
John Hunter informs us that this contracting tendency in the granulations is in some degree proportioned to the general healing disposition of the sore, and the looseness of the parts on which the granulations are formed, for when there is not a tendency to skin, the granulations do not so readily contract.1' The contraction continues till the whole is healed over, but its greatest effect is at the beginning; one cause of which is that the resistance to it from the surrounding parts is then least.
While this is going on within the circum ference of the sore, and immediately pre ceding the commencement of actual cicatri zation, the surrounding old skin, close to the granulations, becomes smooth and rounded with a whitish cast, as if covered with some thing white, and the nearer to the cicatrizing edge, the more white it is. At this moment the process of cicatrization is actually begin ning, and the new cuticle may now be ob served to be spreading from the circumference of the sore towards the centre, not uniformly, but creeping irregularly over the granulations, or rather formed irregularly from them, but always, in recent sores, spreading in a con tinuous surface from the circumference. In large and old ulcers, however, in which the edges of the surrounding skin have but little tendency to contract, or the cellular membrane underneath to yield, the old skin also having but little disposition to skinning in itself, the nearest granulations do not receive from it a cicatrizing tendency. In such cases new skin
forms in different parts of the ulcer, standing upon the surface of the granulations like little islands. The rapidity with which the skinning process takes place in this stage is but an un certain criterion whereby to judge of the time that will be occupied in the cure. Generally speaking, the latter stages of the process are much slower than the earlier, particularly when the breach of surface has been large.
And here a question arises : is the new skin that is formed the result of an altered state of the granulations themselves, or is it an entirely new product from them ? Bichat inclined to the former opinion, holding that the granu lations having discharged their fluid contents, collapsed, and uniting one to another, became converted into the uniform smooth membrane in question. Hunter, on the contrary, con sidered the new cutis as a new product, the secretion of the granulations. Our own ob servations lead us to adopt the opinion of Bichat. It seems that, as soon as the surface of a granulation is covered over with epidermis, which is often the case before the least shrink ing or collapse of the granulation occurs, then the secreting orifices of those numerous vessels of the granulation which had hitherto been pouring out pus are now sealed up, and having no longer any use, the same change takes place which occurs in other parts of the system similarly circumstanced : an or gan no longer in use shrinks and the fluid parts become absorbed, and the elevated soft and spongy granulations shrink into the thin and somewhat dense fibrous structure of the cicatrix. We cannot agree with the opinion of M. Dupuytren, that the chorion is formed first, and the epidermis added subsequently, since we have often detected the epidermis creeping over granulations so little altered in appearance that its presence could only be dis covered by placing the part in such a light that its dry shining surface could be distin guished from the soft villous appearance of the neighbouring granulations. The process of contraction, we believe, generally, if not always, does not precede but follows the formation of the cuticle, and consequently the cutis formed by this contraction does in the order of time follow the cuticle. The reason of this we can not explain, but of the fact we cannot doubt; and this fact accounts for the very slow formation of the cuticle in the first healing of an ulcer where that membrane is formed from the granulations. The organization of these bodies may be said to be much inferior to that of the cutis when completed; hence, when the cuticle of a cicatrix is abraded, it is readily formed again, because it has now a more perfect organ to secrete it.