CLASS VI—NEW GROWTHS
CICATRLX

Synonyms.—Scar; Scar-tissue; Fr., Cicatrice; Ger., Narbe.

Definition.—Scar, is briefly defined, a connective­ tissue, soft or
firm, reddish or whitish, new formation replacing loss of substance.

The appearances of ordinary scars are well known, and have, to some
extent, been already described in the preliminary chapter on lesions of
the skin. According to the causes which have led to its formation a
scar may be linear or irregular, slight or pronounced. At first the color
is usually a pinkish or reddish, frequently with variable pigmentation,
later becoming, as a rule, white and glistening. The normal scar is flat,
on a level with the skin or somewhat sunken, or simply replacing tissue
loss. In others—atrophic scars—there is considerable depression, the
scar-formation developing only sufficiently to cover or skin over the
preceding depressed wound or ulcer. This is particularly noted in the
scars replacing substance loss in some diseases, as small­pox, acne vario-
liformis, etc On the other hand, the scar-tissue formation, instead of
ceasing at the point of compensatory replacement, continues, and the
result is a hypertrophic scar, sometimes projecting but slightly, at other
times becoming of considerable proportions; it never extends laterally
beyond the original substance loss which it replaces—does not, in fact,
invade the surrounding healthy tissue, in this respect differing essentially
from keloid, to which it bears resemblance. Indeed, ordinarily, from
a contraction of the constituent tissue of the scar, the surrounding healthy
parts are usually drawn upon somewhat and stretched, so that finally the
scar area is much smaller than the area of substance loss which it replaces.
The scar is thin or thick, depending chiefly upon the depth of the tissue
loss. Damage to the integument must involve at least the upper part
of the corium; destruction, which extends only to the corium, although
removing the whole epidermis, including the rete, does not leave a scar,
being replaced; hence in eczema and similar diseases the disease disap­
pears without trace. Destruction of the superficial part of the papillary
layer is doubtless often possible with scarcely perceptible, certainly
rarely permanent, scarring. Even with destruction of the whole depth
of the papillary layer there is usually but shallow scarring, and this
generally eventually practically disappears.

The division of cicatrices into traumatic scars and pathologic scars
is of scarcely any import—the former, as readily inferred, due to injury,
the latter the consequence of some morbid process. In the latter class
the shape often gives a clue to the causative malady, as in the circinate
or segmental scar grouping of the late syphilodermata. The syphilitic
scar is, moreover, usually quite soft; on the other hand, the cicatricial

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formation in lupus vulgaris is often thick, tough, and stringy. It is
true scars even from the same disease will sometimes vary considerably,
being soft and smooth, or hard, irregular, or keloidal in appearance. As
a rule, there are no subjective symptoms, but occasionally there may be
attacks of a “burning sensation’‘ or of pain, probably from an entrapped
and compressed nerve-fiber; when about the joints, mobility may be
more or less impaired, due to the tough and unyielding character of the
formation and to the resulting contractions; these latter are sometimes
sufficient to produce considerable distortion.

Pathology.—As is to be supposed, the principal and practically
entire constituent histologically of a scar is connective tissue, and this
is found to consist of coarse interlacing bundles, with absence of glandular
structures, hair-follicles and hairs, and furrows. In its earliest stage
the formation resulting from the granulation tissue is primarily of
myxomatous nature, rich in vascular supply; gradually this myx-
omatous and myxofibrous granulation tissue becomes changed into a
purely fibrous cicatricial tissue (Heitzmann),¹ and the blood-vessels be­
come lessened in size and may be obliterated. According to Heitzmann,
“the old view that papillæ are absent is erroneous, for these are found
in almost every scar, though, as a general rule, they are shallow and irreg­
ular. Even in cases where the surface appears smooth to the naked
eye shallow papillary formations are found to exist.” This is contrary
to the opinion of Kaposi and some others, who state that they are always
absent. The epithelial layers do not differ from those of normal thin
portions of skin (Heitzmann).

Treatment.—Scars are permanent formations, except those
following extremely superficial substance loss, which usually, after
some years, partly or completely disappear. There is, in fact, in almost
all scars of small and not too deep a character, a tendency to become
slightly less conspicuous as the years go on. Exceptionally, however,
there is an increased upward growth, which may reach a marked char­
acter, as in the so-called hypertrophic scar.

Treatment of these formations is usually without much effect.
When small, numerous, and close together, massage and slightly or
moderately stimulating applications, such as are sometimes of some
influence in lessening senile looseness of the skin, or wrinkled skin, may,
if persevered in, bring about some improvement. Ordinarily, however,
unless the scar is unnecessarily large and unsightly, nothing is to be
done; but in the latter cases, when practicable, an operation—excision
of the cicatrix—and slight undermining of the skin of the flaps, permit­
ting greater stretching and a closer adaptation, will sometimes result in
replacing an unsightly scar by a linear or narrow cicatricial band; or
the plan of plastic operation and transplantation can be adopted. Hy-
pertrophic scars can also be thus treated, sometimes, however, showing
a recurring tendency, as is exhibited in their closely analogous formation
—keloid. Vidal advised thoroughly hashing the part with parallel
and cross incisions. In fact, the various plans for the treatment of hyper-
trophic scars are the same as in keloid (q. v.). This may also be said of
¹ Heitzmann, Morrow‘s System, vol. iii (Dermatology), p. 471.

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NEW GROWTHS

the plans for the treatment of painful scars. Röntgen-ray treatment,¹
pushed to the point of moderate reaction, has proved of some service in
occasional instances, more especially in small­pox and acne scars.

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