CICATRIX, 



003 



healed. The contractile action takes place in 

 every direction, producing that depression of 

 the cicatrix which is observed to follow the 

 spreading of the cuticle over the granulations. 

 Thus those parts which were soft and spongy 

 now acquire firmness, and form a condensed 

 layer, which occupies the position, and per- 

 forms some of the functions of the original 

 cutis which had been destroyed. 



It is an interesting question, why the cuticle 

 in covering an ulcer, though evidently formed 

 from the granulations, is arising not over the 

 whole surface of the ulcer at once, as it is 

 when abraded from the healthy skin, but creeps 

 from the circumference towards the centre, in 

 a slow, progressive manner ? It seems that a 

 greater perfection of organization is necessary 

 for the production of cuticle than for the for- 

 mation of granulations capable of secreting 

 pus. If we examine the vascular structure of 

 these newly formed parts, we find that the 

 bloodvessels apparent on the granulations are 

 few and very irregular in their course, and 

 often in figure also, having an appearance re- 

 sembling a varicose or unequally dilated state ; 

 this we take to be an indication of a feeble 

 and incomplete state of organization. On the 

 contrary, the vessels in the immediate vicinity 

 of the new skin, are more regular in form and 

 direction, and may often be seen running on- 

 wards through the neighbouring granulations 

 towards the centre of the sore, having a good 

 deal the appearance of the vessels of the in- 

 flamed cornea ; and where this is not remark- 

 ably apparent, the granulations in the imme- 

 diate neighbourhood of the parts in which the 

 skinning process is going on are more vascular 

 than the internal ones. Our observations 

 would lead us to believe that this more perfect 

 system of circulation commences by an anasto- 

 mosis newly set up from the vessels of the 

 edge of the healthy skin first, and by the action 

 of these newly formed vessels the cuticle is 

 secreted. From these, others are still sent on 

 over the surface of the sore, or immediately 

 under it, and thus by progressive steps the 

 necessary degree of perfection of structure is 

 acquired, and is immediately followed in its 

 progress by the development of the cuticle. 

 This, be it remembered, is still a different state 

 of the granulations from the contracted un- 

 secreting layer which constitutes the new cho- 

 rion. If this description of the process is 

 consistent with Nature, it is reasonable to sup- 

 pose that the new vessels shooting from the 

 edges of the healthy skin would be more per- 

 fect, and more equal to the task required than 

 those which would pass through the granu- 

 lations from the subjacent cellular tissue ; and 

 in the same way we may suppose that one part 

 being in the before-mentioned manner com- 

 pleted, is better fitted to send on new vessels 

 for the organization of the next portion of 

 granulations than the granulations themselves. 

 It is moreover to be expected that the power 

 of organizing its neighbouring parts must be 

 superior in the healthy skin to that of any 

 newly formed structure, and that this power 

 will in an extensive sore gradually diminish 



as the distance from the healthy parts in- 

 creases ; and this accords with the well-known 

 fact that the cicatrization goes on much more 

 slowly in the latter stages of healing than at 

 the commencement 



Thus the external process of skinning is 

 completed, but the internal changes are not 

 yet finished. A slow but remarkable change 

 is going on for a considerable time longer, by 

 which the appearance and structure of the 

 cicatrix becomes modified. From a red colour 

 it becomes gradually paler, till it is almost 

 white ; this at least is the general rule, though 

 under circumstances, to be presently mentioned, 

 the result is different. The cicatrix also conti- 

 nues to contract in all its dimensions, thus not 

 only diminishing in extent, but sinking below 

 the level of the surrounding skin, and becoming 

 more dense and thin and more perfect in its 

 organization, till it has assumed the appearance 

 and character which it will retain through the 

 rest of life. 



It is this power of contraction resident in the 

 new chorion of the cicatrix, that produces 

 those bridles which are such frequent causes of 

 deformity after the healing of extensive burns. 

 In these cases there does not seem any neces- 

 sity to have recourse to any peculiarity of 

 hypothesis in explaining the great degree of 

 shrinking that so commonly occurs. On the 

 contrary, we conceive that the phenomena at- 

 tending the healing up of burns are to be ac- 

 counted for by means of the usually recognized 

 causes of the shrinking in the cicatrices of 

 wounds in general. 



We have now described the process of re- 

 pair in wounds in the skin, with loss of the 

 entire substance of the cutis. When the de- 

 struction has been more superficial, the process 

 of restoration is more rapid, and the result 

 more perfect, inasmuch as the part upon which 

 the burden of repair devolves, is the inner 

 layers of the original cutis, a part much more 

 highly organized and more equal to the task 

 than the cellular tissue.* In wounds which 

 are united by the first intention, the stage of 

 suppuration does not take place. The sub- 

 stance which would have formed suppurating 

 granulations here becomes an immediate means 

 of union, and the only portion of new skin 

 formed is in the mere line where the divided 

 edges met, a line always visible by the white 

 colour before mentioned. 



In the healing of ulcers in any of the mucous 

 membranes, the process would appear to go on 

 much in the same way as on the skin. Granu- 

 lations shoot up from the bottom of the ulcer ; 

 the surrounding healthy membrane is drawn 

 inwards by their contractile power, and the 

 edges of the ulcer are turned in and become 

 continuous with the new membrane, which at 

 length covers the ulcer. When the destructive 

 process has merely gone through the mucous 

 membrane, the granulations shoot from the mus- 

 cular coat, and the contraction is of course ex- 

 ercised only upon the surrounding mucous coat; 

 but when the muscular tunic is destroyed, the 



* See Hunter on the Blood, 8v edit. p. 274, 



2 R 2 



