178 THE CANADIAN MEDICAL ASSOCIATION JOURNAL

SUMMARY AND CONCLUSIONS (The author wishes to express his appreciation of Idiopathic anae'mia of the the assistance' of Dr. Evans of the Montreal General hypochromic type Hospital, and of the Charles E. Frosst Company for tends to persist for years unless treated. preparing and donating the capsules.) In our experience, treatment by iron alone or combined with vitamine E is not effective in RzrmNcEs raising the haemoglobin level appreciably in 1. HART, E. B., STEENBOCK, H., WADDELL, J., ELVEHJEM, these cases. C. A., J. Biol. Chem. 77: 797,1 1928. Cases of this disease of long duration 2. ELDEN, C. A., SPERRY, W., M., ROBSCHEIT-ROBBINS, F. S., AND WHIPPLE, G. H., J. Biol. Chem. 79: were treated with a combination of iron and 577, 1928. copper given in capsules by mouth. Prompt 3. ELVEHJEM, C. A., AND HART, E. B., J. Biol. Chem. improvement followed in all cases with restor- 84: 131, 1929. ation of the blood to about its normal level. 4. WADDELL, J., STEENBOCH, H., AND HART, E. B., T. The improvement noted in two of our cases Biol. Chem. 84: 115, 1929. during a period when Blaud's and calf's liver 5. FLINN, F. B., AND INOUIE, J. M., J. Biol. Chem. 86: were given ,simultaneously may be explained 101, 1929. on the basis of the content of the 6. ROBSCHEIT-ROBBINS, F. S., ELDEN, C. A., SPERRY, high copper W. M., AND WHIPPLE, G. H., J. Biol. Chem. 79: liver. 563, 1928.

THE PATHOLOGY OF CERVICAL ECTROPION (CERVICAL EROSION) By J. R. GOODALL, O.B.E., B.A., M.D., C.M., D.Sc., F.A.C.S. Montreal 4

THE ectropion visible as a zone of redness fades almost insensibly into the surrounding and granulation about the cervical canal is pearly portio vaginalis. It is always associated variously described in text-books as eversion, with a marked chronic endocervicitis, though erosion, ulceration, and outgrowth of the not all cases of chronic endocervicitis are asso- cervical mucosa. It is associated usually with ciated with ectropion. Chronic endocervicitis one symptom, leucorrheea, due not to the ectro- is a necessary antecedent to ectropion; and the pion but to the associated and causative chronic ectropion is a sequel to chronic endocervicitis, endocervicitis. The work that is now to be if the latter is of long duration and of the described constitutes a new chapter in the path- proliferative type. ology of the cervix. The conclusions have been Ectropion begins as a chronic irritative drawn from the study of material removed at microbic endocervicitis. It is found in virgins operation, and from the study of cases before and in parous women. It is seen more com- treatment and during convalescence. monly among the parous women because endo- From this research it may be stated that cervicitis is so frequently a sequel of parturi- ectropion is not erosion, nor is it eversion, nor tion. A close study of cases of chronic endo- is it ulceration. Erosion implies loss of tissue, cervicitis permits one to divide these cases into so does ulceration, and eversioni means the out- three great groups: first, those in which the ward growth of the columnar epithelium to re- microbic irritation tends to manifest itself in place the squamous surface of the portio. hypersecretion, as cervical leucorrhcea; second- What then is ectropion? Some of its attributes' ly, those in which the microbic irritation pro- are well known. It is a circular, red; granular duces hypertrophy and cervical polypi7 and, surface surrounding the external cervical os. thirdly, there may be cases when the irritation It -has- no secretion of its' own, but is' usually expresses itself in both hypersecretion and bathed in cervical discharge. It bleeds readily hypertrophy. Whether the infection will maui- if Wiped with gauze or cotton and has a margin fest, itself. in any, one of the above ways will which is often difficult to define because it depend upon the attenuation of the microbe GoODALL: THE PATHOLOGY OF.CERVIcAL ECTROPION17179 andl the reaction of the cervical tissues to that lost, giving.place to a bluish tinge due to under- infection. lying veins showing through the thinning I have foun'd that in virgins with marked squamousI layers, and ending in the, redness of cervical hypertrophy there is usually a con- granulation tissue. In other cases small stitutional tendency to. hypertrophy of mucous arteries and veins break thr'ough and course membranes and adenoid tissue elsewhere in the centrifugally from the margin of the area of body. The~cervical mucosa in its pathology ectropion into the healthier distal parts of the has a closely analogous parallel in the nasal portio. These vessels and their consequent mucous membrane. Now, the irritation of the hypernutrition are the forerunners of rapid cervical infection leads to determination, of division and lessened. differentiation. blood to that That in part-hyperawmia. turn, The clinical proofs of the above are to be if long continued, leads to the development of found i'n the following statements. Try as you new blood and. that also in turn means vessels, may, you cannot cure an ectropion without first. over which itself in nutrition, expresses hyper- or simultaneously curing the endocervicitis. secretion or hypertrophy. The processes of The irritation of microbic endocervicitis is the infection in the delicate columnar always begin primary cauise of the ectropion, and the con- mucous membrane of the cervical canal, whichi tinuance of the irritation causes the ectropion is more susceptible to infection than is the to persist. squamous covered portio vaginalis. But the squamous surface nearest the, cervical canal After cauterization of the cervical canal, not cannot ignore indefinitely this vascular distur- by deep incisions, but by careful superficial bance in its immediate neighbourhood. It soon cauterization with a nasal cautery, followed by feels the effect of the over-nutrition, and it superficial radial cautery lines over the area of feels it most in its deepest ba-sal layer, whichi ectropion with a dull heat, a careful study of will begin to divide more rapidly, and, as the the regeneration of the tissue in the area of division speeds up, the superficial keratinized ectropion will prove interesting. A dull heat layers gradually fall off, and then division will for~the radial lines is to be desired because the be at the expense of differentiation. The super- only purpose one wishes to accomplish with this ficial layers no l'onger have time to differentiate heat is to coagulate the underlying blood vessels into squamous, keratinized, imbricated layers, which are p1romoting the hypernutrition. Dull but are pushed off and desquamated by the heat is much more efficacious than red heat for rapid division. Rapidly dividing cells have that purpose. Dull heat may be applied for a no time to become adult but remain in an longer period; it does not char, it penetrates embryonal state. So that ectropion is an area miore de-eply, and it is a better coagulator. covered with embryonal squamous cells. -Call The interesting sequel is that the squamous it -granulation tissue, if you will, but it is cells at the periphery do not grow in and cover special granulation tissue which will revert if the area of ectropion, as in any ulcer of the normal nutritional conditions and normal sub- skin. No, you can'actually see th'e reversion of stratum are established. the basal cells to their former type. They The result is a slow spreading of the process gradually lose their embryonal type and revert from the cervical canal outwards and a gradual to the adult squamous type. This can be enlargement of the area of ectropion. It 'is in beautifully demonstrated by another method. reality a skin disease, and simula'tes closely the First, cauterize the cervical canal with a dull- changes that a'ccompany acne rosacea, which, heated nasal cautery, to destroy its hyper- according to text-books on dermatology, begins trophied tissues. and to coagulate its blood as a hyperfemia,. then follows the development vessels. Then take the coagulation needle of of new blood vessels and is followed again by the diathermia apparatus. Place one pole any- division of basal cells without proper diffe'ren-' where'upon the patient and then plunge the tiation. If we exami'ne -a number of 'cases of coagulation~needle about one-quarter of an ectropion, we find that' the outer border is ill inch into many spots in the area of ectropion. defined, and you can actually see the pearly This effectually coagulates the underlying opalescence of the portio vaginalis being slowly cervical blood vessels and the whole area of 180 THE CANADIAN MEDicAL AssocuTIoN JouRNAL ectropion gradually reverts, and in about four Ectropion is a granular surface composed of weeks has taken on the pearly whiteness of the embryonal squamous-celled granulation tissue. normal portio vaginalis. This embryonal type of cell is the result of rapid division of basal cells consequent upon CONCLUSIONS over-nutrition. Ectropion never exists without endocervicitis. Removal of the causes of over-nutrition Endocervicitis is a necessary antecedent to and permits the basal cells to cease rapid division is the causative agent of ectropion. and allows differentiation and reversion to It is impossible to cure ectropion permanently adult types to take place. without previously or simultaneously curing The best known means of accomplishing the endocervicitis. Incomplete cure of the these objects will be found in dull heat for the endocervicitis will frequently be found to be destruction of hypertrophic tissues and for the the cause of disappointing results, with cure of co6agulation and destruction of the new the associated ectropion. vascular channels.

DISABILITIES OF THE SHOULDER JOINT* BY H. H. M. LyIx, M.D., New York

NUMIEROUS articles have appeared in the shoulder was a weight-bearing joint. In the medical literature on the subject of stiff and process of evolution we have assumed the up-. painful shoulders. Since the days of Duplay right position, and the shoulder has become a (1872), various etiological factors have been hanging joint which must support the weight described, periarthritis, subdeltoid bursitis, par- of the arm. The weight of the adult arm is tial rupture of the supraspinatus muscle, mus- 10 to 15 pounds. This weight is borne by. four cular strain of the tendons of the teres major muscles; the biceps, triceps, coracobrachialis or latissimus dorsi, birth trauma, brachial and deltoid. The capsule plays but a minor neuritis, unrecognizable subluxations of the ro'le. humerus, lacerations of the axillary portions of Anatomically, the shoulder joint is a portion the capsule, bruising of the cartilage of the joint, of the shoulder girdle. The peculiarity of this sprains of the deltoid, biceps and internal girdle, compared with the pelvic, is its mobility. rotators. In shoulder joint injuries so many This mobility is secured by the fact that the structures are involved that it is often impossible main attachments to the body are muscular. to identify the exact ones involved. The only skeletal link is the clavicle. We shall not consider acute or chronic in- The shoulder possesses the greatest range of flammation, osteoarthritic changes, or neurologi- movement of any joint. The mobility is made cal lesions, but direct our attention to the treat- possible and enhanced by the fact that the ment of traumatisms of the shoulder girdle shoulder joint is mounted on a. movable base, that have resulted in pain, muscular weakness, the scapula. and limitation of motion. The musculature of the joint consists of two The shoulder joint is responsible for many half cones converging on the humerus. The clinical pitfalls. As a protection we insist on a infraspinatus, teres minor, and sub-scapularis careful x-ray study of every injured shoulder, converge on the head of the humerus; the no matter how slight the trauma. lower half cone, consisting of the latissimus ANATOMICAL CONSIDERATIONS dorsi, teres major, and pectoralis major con- The axis of When our ancestors walked on all fours the verges on the bicipital groove. this cone runs outward and slightly upward. * Bead at the Forty-ninth Annual Meeting of the In order to neutralize muscular cross tension Ontario Medical Association at Hamilton, on May 30, 1929. and strike a physiological balance, the humerus