HEM (cicatrix) — the site of connecting fabric replacing the defect of skin, mucous membrane, body or fabric which resulted from their damage or pathological process. Process of education of R. is called scarring and serves as manifestation reparative regenerations (see). At the same time instead of fabric, identical died, connecting cicatricial fabric develops. Sometimes cicatricial fabric not completely replaces the site of a necrosis, and delimits (encapsulates) it from surrounding fabric.
Lead to R.'s development burns (see), freezing injuries (see), various others damages (see) and hron. inflammatory processes. Scarring, especially on the big site, is followed by tightening of edges of the healing wound that leads to deformation of bodies and fabrics. Even large R. in the thickness of body can
sometimes not cause functional disturbances while small R., but localized, e.g., in the carrying-out system of heart, a visual tract, the spinal channel cause heavy functional frustration. Rubles on a face result in cosmetic defects, in joints — to development contractures (see). At R.'s localization in the field of natural foramens and in hollow bodies development of partial or full obstruction is possible. E.g., R. which is formed during the healing of stomach ulcer and a duodenum quite often is the reason of a piloroduodenalny stenosis or deformation stomach (see), R. in covers and tissue of a brain can be the cause of focal brain frustration, epileptic seizures (see. Epilepsy ). Inclusion of a nervous trunk in a zone of scarring quite often is followed by development kauzalgiya (see).
R.'s kind are so-called synechias, or commissures (see), arising in perigastriums at the organization of exudate, the centers of a necrosis, hemorrhages, etc.
R. on skin at the beginning of the development usually has pinkish coloring, but further turns pale owing to reduction of number of vessels in cicatricial fabric. In process of so-called maturing it more and more is condensed and becomes hardly visible (atrophic R.), however the long time can it is noticeable act over the surface of skin (hypertrophic R.). Rubles can have the form of strips, stars, fields of the wrong outlines. In some cases, especially after burns, normal maturing of R. is broken, in it is long vessels remain, and fibroblasts continue to produce collagenic fibers, atipichesky on chemical structure and a structure. Such so-called false keloid R. sharply acts over the surface of skin, has reddish or purple-red color, is covered with a thin coat of an epithelium, to-ry quite often ulcerates (see. Keloid ).
R.'s formation is usually preceded by an inflammation and development granulyatsionny fabric (see). Microscopically R. consists of vessels, fibroblasts and the collagenic fibers produced by them (see. Collagen ). Occasionally in it also plasmocytes meet corpulent. In process of formation (maturing) of R. the number of vessels and cellular elements decreases, the mass of collagenic fibers increases. In cicatricial fabric, napr, in an easy, renal pelvis, a bladder, bunches of elastic and smooth muscle fibers can appear over time. Neuroglial elements participate in so-called gliozny R.'s formation in nervous tissue.
The sizes, a form and a condition of R. developing on site an operational section of skin depend on the direction of a section, the nature of healing of an operational wound, technology of its closing and features of scarring. E.g., during the healing of an operational wound first intention forms, as a rule, the thin R. which is not causing complications. At a wound repair second intention rough, complicated the River, as a rule, develops. At the choice of the direction of an operational section it is necessary to consider the course of nerve fibrils and vessels, crossing to-rykh can lead to disturbances of sensitivity and a trophicity, emergence of pains and an itch. The rough, deforming R. arises at deep suture at the same time on skin and hypodermic cellulose. Rough R. forms also, as a rule, and when operation comes to an end with drainage or packing of a wound.
At deep hypertrophic R.'s development disturbances of a trophicity in its center with education can be observed it is long not healing ulcer (see. Trophic ulcers ). R.'s presence in fabric of gland (e.g., milk), on mucous membranes is considered by a number of researchers as one of important factors carcinogenesis (see).
The course of the frustration caused by R., usually chronic, but can gain also acuity. First of all, it belongs to development of acute impassability at cicatricial narrowings of hollow bodies. Also the flash of latent infection or accession it can be the cause of the acute phenomena at R.'s ulceration and a recurrence of an erysipelatous inflammation (see. Ugly face ).
Treatment depends on a look, prescription of existence of R., existence of complications. Conservative treatment is directed to R.'s softening and is effective at outside R., especially at the beginning of their education. For this purpose carry out fabric therapy (see), applications of ozokerite (see. Ozoceritotherapy ), paraffin (see. Paraffin therapy ), therapeutic muds (see. Mud cure ). Apply ultrasonic therapy (see), impulse currents (see), electro-and fonoforez resorptional substances, fermental and hormonal drugs.
Include the LFK various forms in complex treatment of R.: morning hygienic exercises to lay down. gymnastics, gymnastics in water, massage, etc. The technique of LFK in many respects depends on localization and extensiveness of River. Classes of LFK shall be given consistently, systematically and is long. Observations show that at patients in intervals between occupations with physical exercises the volume of movements in joints of the injured extremity considerably decreases, and the more having rummaged in occupations, the amplitude of movements is recovered worse. Therefore dense cicatricial fabric was not created yet, it is reasonable for the period of a night dream, and also in the afternoon in breaks between occupations of LFK to stack the injured extremity in functionally advantageous position on a plaster splint, the aluminum or plastic tire and to fix it in that situation, a cut it was succeeded to reach during the occupations. Repeated performance of physical exercises during the day, massage (see), exercises in water for the purpose of relaxation and simplification of movements, rational alternation mechanotherapies (see) and work therapies (see. Labour therapy ) allows to achieve resistant functional results in to prevention of cicatricial contractures and rigidity in joints. For stretching of commissures recommend the following methods of massage: moving, twitching, stretching, etc. Widely apply the applied movements (capture of various objects, clothing of clothes, the letter, a combing, sewing, etc.) and sports exercises (walking, a lasagna, elements of sports, etc.). Duration of daily occupations of LFK from 5 — 10 to 30 — 40 min. and more.
In the postoperative period after band operations the remedial gymnastics prevents formation of commissures and promotes full-fledged R.'s education in the field of an operational wound. At the same time apply elementary exercises to hands and legs, turns, inclinations of a trunk in combination with breathing exercises. In the presence of R. on a face exercises for mimic and chewing muscles are shown.
Radiation therapy (see) it is most effective in an initial stage of formation of keloid R. and it can be combined with other methods of treatment. As a result of radiation fibroblastichesky activity of cicatricial fabric is suppressed that leads to the termination of growth of R. or even to full regress of fibrous growths with formation on site of a keloid of the depigmented smooth hem. At «old» py R.' keloid use of radiation therapy can promote disappearance of an itch and feeling of tightening of skin, blanching and smoothing R. Naiboley widely use korotkodistantsionny roentgenotherapy (see). Perhaps also use of an electron beam with boundary energy of 6 — 8 Mev. There are data on use at superficial keloid R. of application beta-ray therapies (see) with 147rt. The Korotkodistantsionny roentgenotherapy at a voltage of generation of 30 — 100 kev is carried out in a single dose 150 I am glad (1,5 Gr) 3 times a week; a total dose — 1500 — 2000 I am glad (15 — 20 Gr). At a recurrence after excision R. the total dose shall not exceed 1000 is glad (10 Gr).
Sometimes after plastic surgeries radiation therapy is used with the preventive purpose for prevention of education of keloid R., especially in the presence in the anamnesis of data on tendency to their formation. Carry out a korotkodistantsionny roentgenotherapy under the specifications stated above once in a dose 300 — 400 I am glad (3-4 Gr).
Operational treatment is directed to elimination of the broken function or cosmetic defect. The direction of an operational section at R.'s excision is chosen taking into account the course of muscle fibers. Sometimes it is necessary to resort to Z-shaped plastics, free skin transplantation, and at extensive defeats and cicatricial deformations — to change of rags on a vascular microanastomosis (see. Skin plastics ). At cicatricial strictures, napr, gullet (see), carry out the plastic surgeries or operations eliminating impassability.
Prevention of education of rough R. consists in timely primary surgical treatment of wounds after open damages (see Brines, wounds), early skin plastics at treatment of burns and freezing injuries, careful attitude to fabrics during operation, failure from unjustified packing of wounds, use of precision surgical tools and a synthetic suture material, two-row continuous suture on fabric at danger of development in the subsequent cicatricial deformations, active maintaining the postoperative period using means and methods of physical therapy and LFK.
A hem in the medicolegal relation
the Hem in the medicolegal relation as the effect of various damages, can be an object court. - medical examinations. At the same time find out the reason and prescription of education of R. (its origin). severity of the former damage. R.'s izgladimost, compliance of the version of emergence of damage, osvidetelstvuyemy about circumstances, to objective data. Localization and the sizes P. testify to the nature of the postponed damage, the mechanism and a way of healing. Pay attention to color P., to-ry depends on quantity of capillaries and possible impregnation by foreign parts (a soot, not burned down poroshinka, etc.). R.'s prescription is determined approximately by its color, and at gistol. research on degree of a maturity and structure of connecting fabric, condition of vascular network, quantity of cellular elements and elastic fibers.
In process court. - medical examinations of R. study the evidences, especially medical documents, anamnestic data on character, time of causing and treatment of the former damage yielded surveys and results a lab. researches. Sometimes for specification of circumstances of incident make an investigative experiment.
Rubles examine at day lighting naked eye and under a magnifying glass, palpate.
Hardly noticeable R. is revealed, imposing on it the fabric moistened with hot water or subject to mechanical irritation, napr, to friction. At the same time there comes the hyperemia of surrounding skin, and R., especially old, does not change the color (remains white). Hardly noticeable R. can be revealed in UV rays and with the help kapillyaroskopiya (see). At a research P. on a corpse use gistol. methods. Describe morfol. R.'s signs: localization, a form, the sizes, a relief, color, vascular seg surface layers of cicatricial fabric, density, mobility, a condition of edges of R. (at a linear form P. and its ends), a state surrounding and the subject fabrics, extent of the dysfunction caused
by R. Vopros about R.'s izgladimost court. - the medical expert solves in connection with definition of degree of an obezobrazheniye of the person by court (see. Obezobrazheniye ). At children, and also at keloid and hypertrophic R. at adults this issue is resolved upon termination of R.'s formation and after the end of treatment. Extent of disability is established by the medical-control commissions.
Bibliography: Bolkhovitinova JI. And. and Pavlova M. N. Keloid cicatrixes, M., 1977: Zoltan Ya. of Cicatrix optima, Operational equipment and conditions of optimum healing of wounds, Budapest, 1974; Medical physical culture in surgery, under the editorship of V. K. Dobrovolsky, L., 1976; Wounds and a wound fever, under the editorship of M. I. Kuzin and B. M. Kostyuchenk, M., 1981; Seleznyova L. G., D about-rogova E. V. and I. I. Beta-terapiya's Hussars of postburn keloid cicatrixes, Klin, hir., No. z, page 15, 1979; Serebrennikov I. M. Medicolegal research of hems of skin, M., 1962, bibliogr.; it, Forensic medical examination of keloid and hypertrophic cicatrixes, Court. - medical examination, t. 24, No. 1, page 38, 1981, bibliogr.; Sirs V. V. and Shekhter A. B. Connecting fabric, M., 1981; Strukov A. I. and Serov V. V. Pathological anatomy, M., 1979; Yudenich V. V. Treatment of burns and their effects, Atlas, M., 1980; Burns, ed. by of Page P. Artz and. the lake, Philadelphia — L., 1979; G a b b i a n i G. Reparative processes in mammalian wound healing, The role of contractile phenomena, Int. Rev. Cytol., v. 48, p. 187, 1977; Inalsingh of Page H. An experience in treating five hundred and one patients with keloids, Johns Hopk. Med. J., v. 134, p. 284, 1974; Schilling J. A. Wound healing, Surg. Clin. N. Amer., v. 56, p. 859, 1976.
V. A. Ivanov, A.S. Yermolov; Century M. Ben-tsianova (I am glad.), V. P. Illarionov (to lay down. physical.), D. S. Sarkisov (stalemate. An.), K. I. Hizh-nyakova (court.).