sx 1 BULLETIN of the Vancouver Medical Association Volume XXII. 19 4 6 BULLETIN OF THE VANCOUVER MEDICAL ASSOCIATION 1945-46 INDEX AMBULATION, EARLY, IX APPLEBY, LYON H.—Early Page 3URGERY—Lyon H. Appleby ....... .". 81 Ambulation in Surgery 81 Trends in Medicine 185 116 4 BAILLIE, D. M.—Modern BOOK REVIEWS— Clinical Neurology—Bernard J. Alpers Lead Poisoning—^Cantarow and Trumper BREAST, CANCER, PATHOLOGY OF—H. H. Pitts 102 BREAST, CANCER, RADIOLOGICAL TREATMENT OF—B. J. Harrison 105 BREAST, CANCER, RESEARCH ON—D. M. Hardie 101 BREAST, CANCER, SURGERY OF—G. H. Clement 104 BRITISH COLUMBIA CANCER INSTITUTE, REVIEW OF CASES ADMITTED- A. Maxwell Evans BRITISH COLUMBIA MEDICAL ASSOCIATION— Annual Meeting : jj 96, 119, 144, 203 District No. 4 Medical Association Annual Meeting 39 Fraser Valley Medical Association Meeting i__ CANADIAN CANCER SOCIETY, Annual Provincial Meeting 90 CANADIAN MEDICAL ASSOCIATION, Annual Meeting 45, 71, 199 CANCER OF BREAST, SYMPOSIUM : 9? CHIVERS, N. C.—Disseminated lupus erythematosus 122 CLEMENT, G. H.—Surgery of Cancer of the Breast 104 CLEVELAND, D. E. H.—Fungous Infections of the Skin .... 12 Uses and Abuses of Penicillin 253: CLINICS—WEEKLY SCHEDULE i 121, 155, 181, 217 COLLEGE OF PHYSICIANS & SURGEONS OF B. C 120 Joint Committee on Medical Economics 28, 79, 32, 154, 205, 225, 248 CRANIOPHARYNGIOMA—R. E. Simpson J. ._. 249 a DEPARTMENT OF VETERANS AFFAIRS 172, 201| DOCTOR GOES TO COURT—Vincent C. Moscato 1 157! EVANS, A. MAXWELL—British Columbia Cancer Institute, Review of Cases Admitted .... 98 G- GARVIN, H. S. D.—Moukden Medical College in Recent Years 187 GENITRO-URINARY TUBERCULOSIS—Surg. Lt. Cmdr. John T. McLean, RCNVR . .... 30 GORDON, STUART D., LT. COL., R.C.A.M.C—The Transplantation of Skin 9 GUNDRY, C. H.—Mental Hygiene and Public Health 227 Psychopathic Personality—Use of Term 5 H HAEMOGLOBIN LEVELS OF CHILDREN IN BRITISH COLUMBIA—L. B. Pett, F W Hanley and Edith Perkins 128 HANLEY, F W, L. B. Pett and Edith Perkins—Haemoglob'n Levels of Children in British Columbia 128 HARDIE, D. M.—Research on Breast Cancer 101 HARRISON, B. J.—Radiological Treatment of Carcinoma of the Breast 105j INDEX iTCOME TAX RETURNS, DOMINION, by Members of the Medical Profession 136 INDUSTRIAL HEALTH J 41 INTERVERTEBRAL DISC, PROTRUDED—Major P. O. Lehmann, RCAMC 56 CEMS OF GENERAL INTEREST 46 ANEE, BEN—Generalized Scleroderma 190 BJMP, W. N.—The Vibration Syndrome 133 EHMANN, MAJOR P. O., RCAMC—Protruded Intervertebral Disc 56 ONG BONES, TREATMENT OF THE—By Cancellous Clrp Bone Grafts—T. R. Sarjeant 52 UPUS ERYTHEMATOSUS, DISSEMINATED—N. C. Chivers 122 JEDICAL SERVICES ASSOCIATION—Annual Report and Statement 61 JEDICAL SCHOOL AT UNIVERSITY OF BRITISH COLUMBIA—G. F. Strong 207 EDICAL SCHOOL, LOCATION OF _ 245 ODERN TRENDS IN MEDICINE—D. M. Baillie 185 IENTAL HYGIENE AND PUBLIC HEALTH—C. H. Gundry 227 OSCATO, VINCENT C.—The Doctor Goes to Court _. 157 OUKDEN MEDICAL COLLEGE IN RECENT YEARS (From a letter by H. S.D. Garvin) 187 MC AC LEAN, JOHN T., SURG. LT. CMDR., RCNVR—Genitro-Urinary Tuberculosis 30 N ARCOTICS REGULATIONS _...: 270 URSING SERVICE DEMANDS, MODERN TRENDS IN—R. A. Seymour 125 UTRITION SURVEY \ 91 BITU ARIES— ATKINSON, J. R 1 67 PLANCHE, H. H _ 86 . SUTHERLAND, J. A Ill GILLESPIE, J. A 164 GRAHAM, COLIN W 216 JONES, H. AUBREY 23 7 BOUCHER, ROBERT BEAUCHAMP 238 EL VIC PERITONITIS, ACUTE—N. W. Philpott 282 JENICILLIN, USES AND ABUSES OF—D. E. H. Cleveland 253 SETT, L. B., F. W. HANLEY AND EDITH PERKINS—Haemoglobin Levels of Children in British Columbia 128 ^2RKINS, EDITH, PETT, L. B., AND F. W. HANLEY—Haemoglobin Levels of Children in British Columbia „ 128 BMLPOTT—N. W.—Acute Pelvic Peritonitis 282 ITTS, H. H.—Pathology of Cancer of the Breast 102 ROVINCIAL HEALTH DEPARTMENT—Discussion of the Plan for the Integration of Provincial Health Service 255 SYCHOPATHIC PERSONALITY—THE USE OF THIS TERM IN THE CANADIAN ARMY OVERSEAS—C. H. Gundry 5 P INDEX R RARE EARTHS FOUND IN B. C, CURATIVE PROPERTIES OF—Peloid Deposits. 231 SARJEANT, T. R.—The Treatment of Defects of the Long Bones by Cancellous Chip Bone Grafts 521 SCHEDULE OF WEEKLY CLINICS 121, 155, 181, 2171 SCLERODERMA, GENERALIZED—B. Kanee 1901 SEYMOUR, R. A.—Modern Trends in Nursing Service Demands 1251 SIMPSON, R. E.—Craniopharyngioma 2491 SKIN, FUNGOUS INFECTIONS OF THE—D. E. H. Cleveland 121 SKIN, THE TRANSPLANTATION OF—Lt.-Col. Stuart D. Gordon RCAMC 91 STRONG, G. F.—Problems Relating to a New Medical School, U.B.C 2071 STURDY, J. H.—The Pathology of Chronic Thyroiditis 2751 SYSTOLIC MURMURS, SOLITARY—Col. A. B. Walter, RCAMC 361 THYROIDITIS, THE PATHOLOGY OF CHRONIC—J. H. Sturdy 27! UNITED NATIONS RELIEF AND REHABILITATION ADMINISTRATION 64j U.S.S.R., NEW FIVE-YEAR HEALTH PLAN OF 841 VANCOUVER GENERAL HOSPITAL—CASE REPORTS, etc .... 12, 52, 122, 190, 249, 253, 275 MODERN TRENDS IN NURSING SERVICE DEMANDS—R. A. Seymour 125 VANCOUVER MEDICAL ASSOCIATION Library Notes 4, 24, 45, 73, 97, 116, 143, 171, 198, 224, 244, 270 Annual Dinner 1945 •. 25 Library—Jenner Letter 26, 72, 198] History of the V.M.A 49, 74, 117, 262 New Members 78, 116, 143 Summer School ; M 171, 198, 223, 245, 271 Annual Report—1945-46 173 V. D. BRIEFS 18, 48, 87, 139, 165, 227, 281 VIBRATION SYNDROME, THE—W. N. Kemp _ 133 W WALTER, COL. A. B., RCAMC—Solitary Systolic Murmurs THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices'. 203 Medical-Dental Building, Georgia Street, Vancouver, B.C. EDITORIAL BOARD: Db. J. H. MacDermot Dr. 6. A. Davidson Or. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. VOL. XXII. OCTOBER, 1945 No. 1 OFFICERS, 1945 - 1946 Dr. Frank Turnbull Dr. H. A. Des Beisay President Vice-President Dr. Gordon Burke Hon. Treasurer Dr. H. H. Pitts Past President Dr. G. A. Davidson Hon. Secretary Additional Members of Executive: Dr. R. A. Gilchrist, Dr. D. M. Meekison TRUSTEES Dr. J. A. Gillespie Dr. A. W. Hunter Dr. W. T. Lockhart Auditors: Messrs. Plommer, Whiting & Co. SECTIONS Clinical Section Dr. S. E. C. Turvey Chairman Dr. E. R. Hall_ .Secretary Eye, Ear, Nose and Throat Dr. Grant Lawrence President Dr. Roy Mustard Secretary Paediatric Section Dr. Howard Spohn Chairman Dr. R. P. Kinsman Secretary Orthopaedic and Traumatic Surgery Section Dr. D. M. Meekison Chairman Dr. J. R. Naden Secretary STANDING COMMITTEES Library: Dr. W. J. Dobbance, Chairman; Dr. F. J. Bullee, Dr. R. P. Kinsman, Dr. J. R. Neilson, Dr. D. E. H. Cleveland, Dr. S. E. C. Turvey. Publications'. Dr. J. H. MacDermot, Chairman; Dr. D. E. H.,Cleveland, Dr. G. A. Davidson, Dr. J. H. B. Gbant, Dr. S. E. C. Turvey, Dr. Grant Lawrence Summer School: Dr. J. C. Thomas, Dr. A. M. Agnew, Dr. L. H. Leeson, Db. L. G. Wood, Db. A. B. Manson, Db. A. Y. McNair. Credentials: Dr. J. R. Neilson, Dr. H. H. Pitts, Dr. A. E. Trites V. O. N. Advisory Board: Dr. Isabel Day, Dr. J. H. B. Grant, Dr. G. F. Strong Metropolitan Health Board Advisory Committee: Dr. W. D. Patton, Dr. W\ D. Kennedy, Dr. G. A. Lamont Representative to B. C. Medical Association: Dr. H. H. Pitts Sickness and Benevolent Fund: The President—The Trustees Increased circulation is often associated with the relief of arthritic pain. A-B-M-C Ointment increases blood supply by dilatation of the arterioles and capillaries. In 88 percent of 96 patients studied, A-B-M-C provided relief from pain without any untoward effects when used as directed. No urticaria was produced in any case.* A-B-M-C Ointment is spread, without rubbing, on the affected part and heat is applied for 20 minutes. A-B-M-C Ointment is a trademark of Wyeth for its brand of ointment containing acetyl-beta-methylcholine chloride 0.25%, thymol, eucalyptol and methyl salicylate in an emollient base. A-B-M-C OINTMENT ♦Archives of Physical Therapy, 21, 12 (Jan.) 1940. SUPPLIED IN 1-OUNCE TUBES. JOHN WYETH & BROTHER (CANADA) LIMITED, WALKERVILLE, ONTARI VANCOUVER HEALTH DEPARTMENT STATISTICS—AUGUST, 1945 Total population—estimated 311,799 Japanese Population—Estimated « Evacuated Chinese population—estimated | 6,395 Hindu population—estimated 3S5 Number Total deaths 291 Chinese deaths ; ! 15 Deaths—Residents only 240 BIRTH REGISTRATIONS: Male, 318; Female, 317 635 INFANT MORTALITY: August, 1945 Deaths under one year of age 27 Death rate—per 1,000 births ! 42.4 Stillbirths (not included above) 14 Rate per 1,000 Population 11.0 27.6 9.1 24.0 August, 1944 17 27.2 14 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY July, 1945 August, 1945 Cases Deaths Cases Deaths Scarlet Fever Diphtheria Diphtheria Carrier Chicken Pox Measles Rubella Mumps 12 0 0 31 24 3 5 0 0 2 ! 32 1 2 0 8 : 0 1 108 Gonorrhoea 189 Cancer (Reportable)— Resident — Non-Resident - Whopping Cough Typhoid Fever Undulant Fever Poliomyelitis Tuberculosis Erysipelas Meningococcus Meningitis Paratyphoid Fever Infectious Jaundice Salmonellosis Salmonellosis (Carrier) Dysentery Syphilis 0 0 0 0 0 0 0 0 0 0 0 16 0 H 0 1 0 0 3 0 4 0 0 10 3 4 2 1 0 2 1 52 0 1 0 0 10 1 1 103 228 72 43 0 0 0 0 0 0 0 1 0 0 0 19 0 0 0 0 0 0 0 2 0 0 0 Sept. 1- Cases 9 0 0 8 3 1 5 0 0 0 4 0 0 0 0 3 2 0 15,1945 Deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 BIOGLAN"C" Prepared separately for male and female. Composition: Anti-thyroid principles of the pancreas, duodenum, em- bryonin, suprarenal cortex, tests (or ovary). Each 1 c.c. ampoule contains the equivalent of approximately 29 grams of fresh substance. Indications: Graves's disease, hyperthyroidism, exophthalmic goitre, thyrotoxicosis. The most effective therapy available. Stanley N. Bayne, Representative Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C. Descriptive Literature on Request THE SCIENTIFIC HORMONE TREATMENT Page 1 UVOGEN Trade Mark The Rational Tonic Livogen, providing liquid extract of liver B.P., and liquid extract of yeast, is a balanced tonic/ clinically effective but free from the evanescent effects of tonics containing strychnine <and other stimulating drugs which contribute little to the correction of function and structure of nutritionally-depleted tissues. Livogen, by virtue of its liver content; prevents the appearance or corrects the subclinical degrees of anaemia which may impair the oxygenation of body tissues. Then, having provided for oxygenation, it provides also for the efficient utilisation of the oxygen by providing vitamins of the 'B' group in the form of yeast extract. Clinically, therefore, Livogen provides a convenient means of administration of factors essential for maintenance of normal functioning of the body, for aiding in growth, in maintaining appetite, and for assisting in the utilisation of foodstuffs. Further, the use of yeast extract, providing the whole of the vitamin 'B' group, is to be preferred to that of mixtures of a few of the constituent members of the group. It appears that the reason for this is that most of the vitamins 'B' are directly or indirectly essential factors for normal human metabolism. Stocks of Livogen are held by leading druggists throughout the Dominion, and full particulars are obtainable from THE BRITISH DRUG HOUSES (CANADA) LTD. Toronto Canada Lgn/Can/4510 «7«4e ZdUoxk PcUfA The Council of the British Columbia College of Physicians and Surgeons is to be congratulated on a recent move on its part to establish a Rehabilitation and Benevolent Fund for the assistance of members of the medical profession in the Province of B. C. who may, from time to time, require help. The Fund established many years ago by the Vancouver Medical Association for such a purpose, as applied to those men within the jurisdiction of that body who might be in financial straits, has proved its value again and again—and we feel strongly that there should be a similar reservoir of financial aid which could be tapped to help those who practise medicine anywhere in British Columbia. Medical men particularly need such a scheme, since few of us can do more than provide a reasonable competence for our old age, and quite a few fall by the wayside, before they have been able to do even that. The average medical man and his immediate relatives, when in such a predicament, does his best to conceal the fact, and few of us hear about the matter. Gladly would we all pass the hat and help—but this is not a good way of helping: it is too precarious, and smacks too much of charity, and the recipient has to feel grateful. A far better way is that he and all his fellows alike should contribute regularly to a Fund to which any one of us may rightfully appeal, if, which Heaven forbid, the need should ever arise. The method of raising this Fund is one which we feel is eminently fair. The annual dues of the College are to be raised by a sum of ten dollars. This will immediately provide a respectable annual sum for the purpose outlined—and we shall, at little cost to ourselves, have the satisfaction of knowing that our less fortunate brethren—and this may some day, to speak more Hibernico, include ourselves—will be given a measure of security, and much-needed help, and will yet be able to retain their self-respect. And even with this sum added, the annual dues will not be unduly large. When one compares them with those exacted by other professions, and some quasi-professions, we, like Give (or was it Warren Hastings?), stand amazed at our own moderation, in taxing ourselves. The Medical School appears to be a certainty for next year. In the best traditions of medical schools of any consequence, it is having a humble and a difficult beginning. Housing for its essential laboratories, dissecting rooms, etc., is going to be a tough problem—and we dare not yet think of the clinical years. But it is wonderful to realise that at last it is going to be an accomplished fact. .It is up to us, the profession of medicine in B. C, and perhaps especially in Vancouver, but by no means only in Vancouver, to get squarely behind this medical school and do all we can to sell it to the people of British Columbia, and to make it their pride. There is no reason why British Columbia should not have as good a medical school as any province in Canada, and that says a great deal. We should ourselves take the greatest pride in it. We should urge our wealthier friends, if We have any, to endow chairs, laboratories, clinics,—to build for themselves by doing so, a memorial more enduring than brass—because these gifts will help the youth of the Province, and will advance the cause of scientific medicine. And there are many among our own ranks who could do something along that line themselves. A scholarship, the establishment of a museum or a library, even book prizes and medals, would be a gift that would help some student or group of students and would honour and commemorate the giver. This is worth our thinking over. This Medical School must not be just a provincial medical school—it must be the Medical School of British Columbia, and the treasured pride of its people. Page 3 LIBRARY NOTES RECENT ACCESSIONS: Psychology of Women, Vol. II,Motherhood, 1945, by Helen Deutsch. Manual for Coding Causes of Illness, 1944, U. S. Public Health Service. A History of Medicine, 1941, by Arturo Castiglioni. Medical Clinics of North America, Symposium on Specific Methods of Treatment! September, 1945, Boston Number. Surgical Clinics of North America, Symposium on Management of the Surgical! Patient, October, 1945, Nationwide Number. * BOOKLREVIEW LEAD POISONING: Cantarow and Trumper, Williams and Wilkins Co., 1944. In the three decades preceding World War II, consumption of lead in the United States was tripled, exposing over 50% of industrial workers. As evidence of the effec tiveness of hygienic measures, the severity of lead poisoning was reduced during the same period. However, lead intoxication is probably still the most important industrial illness| accounting for a large proportion of compensation costs—sufficient reason for the study of this problem by all who include industrial workers among their patients. In this book, the authors have gathered much of the best of modern thought on lead poisoning. Continuity is maintained through a confusion of somewhat opposed views by summaries of majority opinions and by the expressions of the authors' opinions gainel from their personal experience in large numbers of cases and in various industries. All aspects of the subject are discussed. The accepted standards of normal and toxic limits are stated, together with the necessary laboratory tests and their interpretation! The main sources of industrial intoxication are described. There is an excellent chapter on treatment, with particular emphasis on prevention. Altogether, it is an interesting and useful book. W. G. S. ABSTRACT "Unto One of the Least of These," Park, Orlando (Dept. of Zoology, North western University, Science, 102 : 389 (Oct. 19, 1945). This very brief article is one, we feel, which should come to the attention and I serious consideration of all men who think, and especially those who work in scientific I or related fields. The following quotations are printed here in the hope that many will j look up the original article in the Reading Room. Five minutes is ample time to read it. "Man's rise . . . has been progressively firmer and more conscious, and has brought j to bear a steadily increasing array of psychological, sociological and material weapons to complete the mastery of the earth. . . . Our plight is not so much a lack of ideas on imagination as it is a consequence of hormones out of sociological control. "Our brief past (Genus Homo) is crammed with a rhythniic succession of relative war and relative peace. . . . Man has amplified this basic competition (for food, shelter and mate) and is showing real progress in the destruction of his own kind. . . . Twd parallel tendencies emerge. These are to improve the methods of species destruction and ameliorate species longevity. ... In general, man is learning to kill, or hurt more people in less time, and patch them up more efficiently than ever before. . . . Suppose that we cannot stop killing one another in ever-increasing numbers? . . . another species or group of species will inherit the earth." We will discontinue the quotations here. The end of the story should not be anticipated. The answer "insects" will come first to the mind, but the zoologist's reservation! and concluding arguments are thought-provoking. D. E. H. C. Page 4 Vancouver Medical Association PSYCHOPATHIC PERSONALITY—THE USE OF THIS TERM IN THE CANADIAN ARMY OVERSEAS Major C. H. Gundry, R.C.A.M.C. (Read at a meeting of the Vancouver Medical Association, October 2, 1945) "Psychopathic Personality" has, it is to be feared, something of the quality of what A. P. Herbert calls "witch words"; these are words whose connotations are far more sinister than their defined meanings. In the coming years, physicians, in studying the histories of their patients, will often have to assess the significance of events that took place during a patient's life in one of the armed forces; and Psychopathic Personality was a diagnosis frequently employed in the Canadian Army Overseas. During the first six months of 1944, for instance, neuropsychiatric conditions accounted for approximately one-third of the medical down-grading carried out in the United Kingdom, and in about 44% of those cases the diagnosis was Psychopathic Personality. In ordinary civilian practice that term usually implies rather serious social problems and a grave prognosis. In army usage, on the other hand, it often means simply "military misfit." Consequently, when confronted with cases whose histories reveal that a diagnosis of Psychopathic Personality was made in the army, physicians should exorcise the evil spirit that ordinarily clings to the term and endeavour to understand what significance it could have had in relation to the constitution of their particular patient. They will find, commonly, that the military usage implies a very limited capacity for responsibility and for overcoming difficulties by persistence. The more spectacular behaviour ordinarily associated with the diagnosis will be infrequent. However, studying cases a little more thoroughly they will find that the milder military psychopath is similar in aetiology and development to the serious problems called Psychopathic Personality in civilian practice. The diagnostic concept "Psychopathic Personality" is confused by theoretical difficulties, and attended by practical complications. Theoretically it is a landscape shrouded in fog, in which we can see the outlines of a few features; the whole view is so obscured that different observers are sure to form varying mental pictures of the terrain. Practically it includes problems that put themselves forward inexorably in wartime armies. The social misfits, or, if one prefers, the extreme temperamental deviants, seem to seek military service with enthusiasm which presents a striking contrast to their failure to adapt themselves fo it. In their initial martial ardour their motives of restlessness and flight from responsibility are reinforced by the encouragement of friends-and relatives and magistrates expressed in the words—"The Army will make a man of you." That armies ever were successful in making good soldiers out of social misfits is a tradition of dubious validity. Certain it is that in the present day armies it was the men who were I stable and capable in civilian life who made the good soldiers. The many who failed to adapt themselves to the arbitrary ways of the Army presented problems with which it was difficult to deal, and often, after repeated periods of hospitalization and detention, they were finally disposed of as Psychopathic Personalities. This did not mean that the neuropsychiatrists were providing a way out for men who were unwilling to soldier, but rather that they were faced with the problem of classifying cases which the army had, in effect, already rejected. Psychopathic personalities are described by Henderson and Gillespie as persons who have been from childhood or early youth habitually abnormal in their emotional reactions. They constitute a rebellious mdividualistic group who fail to conform to their social milieu and whose emotional instability is largely determined by a state of psychological immaturity which prevents them from adapting to reality and profiting from Page 5 experience. A conference of a Board of Psychiatrists and Neurologists dealing with Canadian Pension Problems in 1936, describes psychopaths in these terms: "The Board isj of the opinion that a Psychopathic Personality should be defined as an inborn or con-.j genital one without intellectual defect or deterioration which habitually reacts in normal social environments in an anti-social way," etc. Eugene Kahn, the Professor of Psychiatry at Yale, has defined Psychopathic Personalities as those characterized by quantitivej peculiarities in the impulse, temperament, or character, stratum. These three definitions all reflect attempts to arrive at a cause for the problems presented by a group of individuals who are always present in society, but never comfortably adjusted to it. Some! of them are people whose stealing, lying, quarrelling, and maliciousness, seem fantastic! and without understandable motives. Often they are unfeeling and ungrateful, or their affections are treacherously unreliable. Some of them are subject to outbursts of destructive impulsiveness. They have been described, according to their outstanding characteristics, as excitable, impulsive, eccentric, psychopaths, as pathological liars and swindlers, kleptomaniacs, etc. Henderson and Gillespie simplify their classification into three groups: (1) Predominantly aggressive. (2) Predominantly inadequate or passive. (3) Predominantly creative. The theory that implies that these variegated borderline conditions are definitely inborn is not very helpful and smacks a good deal of the doctrine of original sin. In the development of a child's personality innate qualities and environmental influences become inseparably mixed, but it seems that some children are born with characteristics of impulse and temperament that render their early socialization difficult. Unwisely dealt with, these difficulties are aggravated. Psychopathic personalities are a group of people in a sort of "no man's land" between I medicine and law. The existence of such a clinical group is probably chiefly significant as an indicator of the inadequacy of our knowledge about the impulse level of human nature and qualities of emotional reactions. Human beings apparently differ from birth in such qualities as energy output, impulsiveness, changeability and persistence of mood, and interests. We know little about the inheritance or measurement of such characteris-l tics, and our knowledge of what makes most people behave as normally as they do§ ("What makes Sammy run?" as one bright author has recently put it), is inadequate.! Psychopaths are individuals who from childhood have displayed abnormalities on the level of impulse or emotional reaction with consequent extremely faulty socialization. They are little influenced by experience or punishment because they are immature in] their conception of reality and capacity to assume responsibility. The cause of the psychological immaturity referred to in Henderson and Gillespie's diagnosis is probably! insecure or unwholesome emotional relationships with parents, when children are very) young. Obviously the establishment of a natural affectionate child-parent relationship becomes "more difficult when a child's temperament varies widely from normal. Many! different types have been described, but in a general way they can be -divided into the aggressive and the inadequate. The following case history is a typical one of the aggressive psychopath: Pte. M., a man of 31, enlisted Sept. 19, 1939, when unemployed. He served 7 days detention for A.W.L. in the spring of 1940. In June, 1940, he went A.W.L. for 20 days and was i awarded only 20 days C.B. In August, 1940, upset by news from his bigamously mar4 ried wife, he took an army lorry and went on a jaunt around England, being arrested 201 days later. He was sentenced to one year in military prison and served 7 months. Two days after his return to the reinforcement unit he applied for leave and this not being granted went A.W.L. for 52 days. He was arrested in August, 1941, and sentenced toy one year in detention barracks. He broke out once and was away 7 days, receiving an additional 28 days detention. He was discharged from detention in the spring of 1942. After only 20 days in the Reinforcement Unit he went A.W.L. again and was sent tol Hospital for examination after apprehension, at the request of the officer defending him Page 6 jat court martial. He said he had gone back to duty with the intention of soldiering but pad been able to stick it only three months and then went A.WJ.L. again. He was jrearrested in August, 1943, and again admitted to hospital. In three years in the Army he had been A.W.L. 158 days and had received sentences aggregating 26 months. He had a history of impulsive, aggressive acts since childhood and had been severely punished, in childhood, by his father till he got big enough at the age of 16 to turn on the father and beat him. After that he had, in effect, been bribed by his father to stay iaway from home. In a suicidal attempt he had shot himself in the shoulder at the age jof 17. He had quarrelled with various employers and had revenged himself on some of jthem in malicious ways. He had had difficulties with two wives; his second marriage {was a bigamous one. Under observation this man was found to be active and co-operative as a rule. At [times he had short periods of depression. He was irritable and opinionated and placed a jvery exaggerated value on his own abilities. His intelligence was low average. He excused himself simply by saying that he had an uncontrollable temper, and showed no remorse; but he was very resentful because of what he considered unfair treatment. That is a fairly typical history of an aggressive psychopath although undoubtedly it is incomplete. There is not enough information about his development and training to indicate the cause of his poorly organized personality. He had never learned to accept [responsibility for his own actions and had been unimproved by punishment. From childhood he had been subject to violent emotional reactions and impulsive acts. He was unable to establish adult emotional relationships with other individuals to identify himself with groups, or to feel the significance of current group ideals. Pte. N, on the other hand, is an example of a type of inadequate psychopath who never did anyone much harm, unless it was the English girl who married him. He was 25, and came into Hospital after removal of a medial meniscus from one knee. He had a mjbst persistent, peculiar, and picturesque limp. He points the moral that as well as knowing what particular organic disturbance exists locally in a patient, it is well to consider what kind of a man the patient is. This man's history was simply one of life-long ineffectiveness. He was a Hobo, incapable of persistent effort or interest or affection. He began to wander away from home while going to High School, he never held a job for more than a month, and in 20 months in the Army had done nothing but fatigue duties, and had apparently been uniformly unsatisfactory at them. He was a very pleasant man, not devoid of an ironical sense of humor, regretting mildly that he could not develop an' interest in his wife or the army and was evidently of no account. He had no military crimes and no civilian ones as far as we know. In some ways he was like a case of simple schizophirenia, but'there was no indication that there had ever been a turning point in his development to suggest the onset of psychosis, and he had no confirmative schizophrenic symptoms. The contrasts and similarities between these two men illustrate some of the basic concepts in connection with this subject. Both have histories extending back to childhood, both show disorders of impulse; the one shows lack of drive, the other a tendency to outbursts of destructive activity. Neither fits into society. Both show emotional abnormality, the one lack of emotional responses, the other outbursts of intense rage and resentment. Neither profits from experience, neither is capable of seriously criticizing himself, and neither has been of any use to the Army, but both are of normal intelligence. Presenting some contrast to these cases in which socialization was made difficult by marked deviation from normal in impulse and temperament, is another group which have been called chronic psychoneurotics sometimes, and sometimes temperamentally unstable. These were the "military misfits," who would probably never be called psychopathic personalities in civilian life. These cases usually came with neurotic symptoms as the presenting problem. They were classified with the psychopaths because their history showed so very clearly that they had been inadequate and unadaptable since childhood, unable to harden themselves to life and unable to criticize themselves maturely. All that the Army had done to aggravate their trouble was to separate them from their homes Page 7 I'l !l '■ w II 1 &\ m and f amilian circumstances, to impose restriction on them, and to deprive them ofl privacy. They were weak personalities who tended with slight frustration and deprivation of security to develop such symptoms as amnesia, vomiting, periods of confusion,] gross hysterical symptoms. Sometimes they were sent for examination because they] readily became fussed and erratic and could not absorb training in spite of adequate] intelligence. Cases which would conform to the descriptions of pathological liars, swindlers, klepH tomaniacs, and poorly socialized unduly sensitive and creative types, were infrequent u_< army practice, and when they did appear could be classified usually as inadequate, sometimes as aggressive, psychopaths. In some cases where abnormal sexual behaviour was the problem, a diagnosis of psychopathic personality with abnormal sexuality provided the most suitable category! within the scheme of classification which was in use. That was the case when no betted diagnosis could be justified. In many other cases the complaint of abnormal sexual behaviour would be found to be based on mental deficiency, psychosis, or psychoneurosisj When the Canadian Army was in action psychiatric casualties were all evacuated with the diagnosis of "Exhaustion." After treatment these cases were re-classified.! "Exhaustion" was obviously a temporary diagnosis. If cases did not make a good recovery, sufficient to make them fit for full combatant duties, after adequate treatment, they had to be classified according to the ordinary system of diagnoses. There is no psychiatric disease specifically related to war service. In a considerable proportion of cases] symptomatic recovery was good and the men became fit to be employed in lines of com munication areas without regaining enough control of their anxiety to fit them for com-j batant duties again. When casualties who had developed "exhaustion" symptoms unde relatively slight stress made a good symptomatic recovery and continued to be fit for duties in the rear, but failed to regain enough self-confidence to make them good pros-j pects for combatant duties, psychopathic personality of the inadequate type was the onl diagnostic group into which they could be put. The situation was that they had proved] inadequate to the demands of a situation which an average soldier was expected to endureJ In connection with the use of the diagnosis of psychopathic personality in the armyj there are special considerations. The army does not tolerate as wide a variety of indi-I vidualistic behaviour as a civilian community; the army confronts men who are, so to speak, at best wobbly, with frustrations and deprivations, and takes away the props! which have supported their weak egos. T. E. Lawrence says: \ . . the soldier assigned! his owner the twenty-four hours' use of his body and the sole conduct of his mind and! passions. A convict had license to hate the rule which confined him and all humanity! outside, if he were greedy enough in hate; but the sulking soldier was a bad soldier; indeed, no soldier. His affections must be hired pieces on the chessboard of the king.' It requires a fair degree of maturity and an ability to identify himself with his brothers! in bondage, at least, if not, better, with their cause, to enable a man to become a good soldier. Those were the primary defects of the "military psychopath." Page 8 THE TRANSPLANTATION OF SKIN By Lieut. Colonel Stuart D. Gordon, R.CA.M.C. Read at the Vancouver Medical Association Summer School, 1945 Introduction The transplantation of skin is one of the oldest operations in surgery. This is true, q{ course, of the attached graft: free grafts have been used clinically for the past 75 years only. It is my purpose today to discuss the various types of grafts in use today, together with one or two of the more recent advances in the technique of skin grafting. Pedicle Skin Grafts The first written account of the use of a pedicle skin graft is to be found in the Hindu holy books—the Ayur-Vedas—describing the making of an ear lobule from cervical skin some 3000 years before Christ. Celsus in Roman times described many local tissue shifts—the simplest form of a pedicle graft. Local tissue shifts may take the form of a straight advancement, a rotation flap or a V Y advancement. The straight advancement is the least satisfactory of the three; the rotation flap the most useful. Rotation flaps are most valuable when transferring skin on flat, or relatively flat, surfaces. It is more difficult to use well on the rounded upper and lower limbs. If the incision outlining the flap is five times the length the distance the tip of the flap has to go the entire raw area can usually be closed after under-cutting the edges. V Y advancements are useful in closing small defects on limbs. A simpler form of this tissue shift is the relaxation incision placed parallel to, and on each side of, the defect to be closed. The V Y shift places the relaxation incision on one side only. The next pedicle I wish to discuss is the Z plastic and a most useful manoeuvre it is. It can be used in any scar line which by contraction is interfering with motion. Each Z plastic increases the length of the contraction band, and so improves function. Flexion contracture of finger, of the neck, of any joint—provided the line of contraction is narrow—cen be lessened or relieved by this shift. Several Z plastics may be done on the line of contracture: the more or less vertical incision of the Z being in the line of the contracture, the other two at about 60 to it. The tips of the flaps should be rounded rather than pointed. A direct pedicle graft, as we have already stated, is a very ancienti type of graft: Hindus of the Tilemaker caste used a flap of forehead skin to repair nasal defects—a fact which we acknowledge today when we speak of Indian rhinoplasty. Tagliacozzi" in the 16th century, used a direct pedicle graft from arm to nose; a procedure still called the Italian rhinoplasty. The direct pedicle graft is a.very useful form. It is the commonest graft used in rhinoplasty: it is used to repair soft tissue losses of the fore- arm by the direct transference of skin from abdominal wall. If the defect is on the anterior surface of the fore-arm a more comfortable position is sometimes obtained by transferring skin from the lumbar region. The cross leg flap is another example of the $_rect pedicle graft. A more satisfactory end result, particularly in working men, will be obtained if the donor site is the thigh. The greater the area of the recipient site covered by the graft, the less, up to a point the time the two areas need to be fastened together. If about two-thirds of the recipient area, for example, is covered at the primary operation, the attachment may be divided about the fourteenth day with safety. It is wise to cover the donor area either by free graft, if the area is large, or by local rotation flaps if small. Indirect pedicle grafts are of two types: although I wish to describe a third which I have been using during the past five months. The indirect flap which is transferred to its new site after obtaining a new blood supply to one portion is not often used today. A flap of cervical skin sutured to the hand and then swung into position is an example. It is difficult to close the raw area entirely and thus considerable fibrosis develops—or may develop—in the graft. Page 9 The development of the tube pedicle by Gillies in England and Filatoff in Russia,] to a large extent, did away with the indirect flap operation. A tube pedicle is the most I satisfactory way of transferring large amounts of skin and subcutaneous tissue in use today. Skin may be tubed over the neck to form the helix of an ear: over the acro-i miothoracic region for facial repair: over the arm for the repair of small nasal defects; over the abdomen, for use almost anywhere, and over the back, for repair of cervical j defects. As originally described the graft was swung end for end, at three week intervals,! until the recipient site was reached. This has since been modified by making the first: attachment to the wrist in cases where more than one shift is required. After its blood supply has developed sufficiently at this site—usually in three weeks—the tube can be i placed at any site within reach of the hand. One interesting fact that came to light! in a recent investigation of ours was that the lower end of an abdominal tube had the better blood supply. Therefore if the tube is to be lengthened it is probably safer to place the tube so that the upper end is the one to be lengthened J_nd also the better end to be shifted, first, whenever possible. The safe rule in making tubes is to make the length 2J4 times the width. The donor site should be closed either by approximation or by free graft. In attempt to get way from cross leg grafts,, which are uncomfortable, and which, particularly in elderly patients, may cause some trouble with joints, I have" been using a form of indirect pedicle graft which we call the Caterpillar graft. A flap of skin, in line with the defect, and a little over twice as long as the distance to be covered is marked out. The two longitudinal edges of the flap are incised and the flap undercut. A sheet of cellophane is placed between the flap and its bed and the incisions are then closed. Ten days later the end of the flap farthest from the defect is divided under local and then sutured. After another ten days the flap is raised, suffijciently folded on itself to allow the lower end to cover the defect when opened l£ter, and the remainder sutured into the lower part of the raw areas. This part of the. graft has to pick up enough blood supply to carry the entire flap eventually so it is important that it is not too small. It is also important that the two original incisions iare not brought too near the defect because at this stage all the blood supply of the flap ft from this end. The raw area is covered with a free graft. In another ten days the lower end of the flap is divided and sutured. Finally after ten more days the lower end of the flap is raised, the folded portion straightened out, and'the defect is covered. The manoeuvre takes some time, but all the stages are relatively small, the. discomfort is minimal; and there is no possibility of causing stiff or painful joints. The graft is actually an indirect advancement flap. The two main groups of free grafts are the full and the partial thickness grafts.' for example—the percentage of takes is less. They should only be used to cover a clean fresh wound; never a granulating one. One of the best examples of the use of free full thickness skin is the repair of lower eyelids by post auricular skin. A specialized form of this type is the use of hair bearing skin (from scalp) to repair eyebrows; or (from neck) to repair an upper lip. Split grafts, razor grafts and Thiersch grafts are really interchangeable terms: a dermatome graft, while also a split graft, is of uniform thickness and perhaps should not be called by any other name. Split grafts are the most widely used form of free skin grafting. They can be used on any raw surface, provided it is free of streptococci. Split grafts, cut into small squares, are frequently used to cover large and infected ulcers. Spacing the grafts makes sure that secretion will readily escape and therefore not float the graft off its bed. This method of use has come to be known as stamp grafting. Reverdin or pinch grafts were the first of the free grafts to be used clinically. They consist of small bits of skin picked up on the point of a needle and cut free with a scalpel. Thus they are thick in the middle land thin out at the edges. Placed four to the square inch as a rule they show a high percentage of take. Their chief use is Page 10 to cover an area in preparation for the use of a better type of graft: thick dermatome or free full thickness. There are two definite drawbacks to their uses; poor appearance of the healed graft, and, if the area to be grafted is extensive, the donor area is ruined as a source of supply for further grafts. In my opinion this type of free graft has outlived its clinical usefulness. Refrigeration Martin, of Paris, in 1873, experimentally showed that, under proper conditions, skin could be kept for long periods and still be viable. Best results were obtained when the grafts were "preserved in hermetically sealed tubes at low temperatures." In 1937 working with rabbits I was able to keep free grafts alive for four weeks in saline kept at 1 C. One human case was done, the skin being kept for three weeks, and then applied. I saw her in December, 1944, because of a small ulcer in the graft which followed injury. Webster has pointed out that refrigerated grafts may be of special value in grafting the young, debilitated or extensively burned. Either homo- or iso- grafts may be used. When the time comes that we can successfully transplant homografts permanently we shall, no doubt, have skin banks in our hospitals, but until that time comes the question of refrigeration of free skin grafts is largely an academic one. Fibrin Glueing of Grafts Sano, in 1943, published her technique for sticking grafts to their new beds. Plasma and white cell extract were used. Her original technique has been considerably modified. We did a large number of free grafts using stored blood of universal type as our source of supply of glue. Later it was suggested that as the fibrin content of wet blood gradually falls dried plasma should be used instead. More recently we have been using plasma from universal donor stored blood and commercial thrombin. I Just how valuable this contribution is remains to be seen. The method is somewhat wasteful of skin since the degree of glueing obtained will not allow much stretching of the graft. On the other hand operating time is shortened because of the quicker fixation time. It is possible that such glueing leads to a quicker revascularization of the graft; but that remains to be proven. The control of oozing by the use of the technique is of value. a 1 s _- AMERICAN ASSOCIATION FOR THE STUDY OF GOITRE Announcement of Van Meter Prize Award The American Association for the Study of Goitre again offers the Van Meter Prize Award of three hundred dollars and two honourable mentions for the best essays submitted concerning original work on problems relating to the thyroid gland. The award will be made at the annual meeting of the Association which will be held in Chicago, Illinois, in April or May, 1946, providing essays of sufficient merit are presented in competition. The competing essays may cover either clinical or research investigations; should not exceed three thousand words in length; must be presented in English; and a typewritten double spaced copy sent to the Corresponding Secretary, Dr. T. C. Davison, 207 Doctors Building, Atlanta 3, Georgia, not later than February 20th, 1946. The Committee, who will review the manuscripts, is composed of men well qualified to judge the merits of the competing essays. A place will be reserved on the programme of the annual meeting for presentation of the Prize Award Essay by the author if it is possible for him to attend. The essay will be published in the annual Proceedings of the Association. This will not prevent its further publication, however, in any Journal selected by the author. Page 11 VcuixuMtue/i QeneAal ctto&pdiaJ, Section FUNGOUS INFECTIONS OF THE SKIN D. E. H. Cleveland, M.D. It is not possible to deal in a complete manner with all mycotic skin infections in the course of a brief clinical presentation. I shall therefore confine my remarks to the commonest superficial infections as we meet them in British Columbia. Tinea Corporis (Tinea Circinata or Rignworm of the Glabrous Skin): This is seen most commonly in women and children. It is contracted from human or animal sources, cats almost exclusively in the latter case. Cats, as conclusively shown by Davidson and his associates in Winnipeg, may act as carriers without showing clinical signs of infection. The lesions appear chiefly on exposed surfaces: face, neck, sterno-clavicular region and limbs. The first appearance is a pink, slightly raised, rounded patch, dime-sized or smaller. As it enlarges it tends to clear centrally, becoming circulate. Scaliness is scanty, chiefly about the margin, where the scales often cover minute papulo-vesicles. Lesions are usually muliple, often coalescing to form gyrate outlines. Itching is variable, and may be negligible. It is easy to find mycelial hyphae and spores in scales macerated in 30% KOH examined under the low-power objective with light well stopped down. Treatment: Fresh Tincture of lodin, preferably diluted with nine parts of water, rubbed on twice daily, will clear up most lesions in a week. Full-strength Tincture of lodin is commonly used, but is more apt to cause dermatitis, especially as the iodin in the family medicine-cabinet is apt to be old and concentrated by evaporation, and is applied with unnecessary vigor and frequency. A simple ointment containing 3 % salicylic acid and 5% ammoniated mercury is also efficacious, but should not be preceded or followed closely by iodin. A dermatitis, sometimes severe and generalized-, is pretty sure to result from this combination. A quick and efficacious remedy in the very early stages is to spray the lesion with ethyl chloride until it is well frosted. One such treatment often clears the patch in three or four days. Tinea Capitis (Scalp Ringworm): Children before puberty exposed to ringworm of the glabrous skin or scalp in others, j or to cats which are carriers or infected, will develop not only ringworm of the glabrous skin, but also may have their scalps infected. Bare patches appear covered by dry grayish powdery scale. The hairs are either broken off short, or where the follicle is deeply infected will fall out. After puberty the scalp is immune to most varieties of fungus, thus ringworm of the scalp is not seen in adults in western America. Sometimes small pustules appear in the patch, or a tender red elevation studded with pustules may develop. This is called kerion, and is not due to secondary pyogenic infection but only to a more intense inflammatory reaction produced by the fungus. There is an important feature of scalp ringworm as found on the Pacific Coast which must be considered here. About eight species of fungus account for practically all scalp ringworm. Of these the majority of cases are accounted for by two varieties only. The prevalence of one or other of these two species varies strikingly with the geographic distribution1 One of these, Microsporon Audouini (sometimes referred to as the "human type"), is found everywhere in America, as far as investigation up to the present has shown, except on the Pacific Coast of America, and possibly in Cuba and the West Indies. It is very resistant to treatment, and in nearly every case mechanical removal of infected hairs from the scalp is necessary. Owing to its convenience and comparative safety, the Page 12 i method in most common use is X-ray epilation. By this means all hair, healthy and infected alike, is removed. When hair is removed from the scalp in this way, since X-rays are not lethal to fungus, the patient remains infected during the three weeks which intervene between the application of X-rays and the falling out of the hair. Topical medication with fungistatic or fungicidal drugs is necessary as well since some infection always remains on the skin of the scalp, and with the most careful technique a few infected hairs also may remain behind. Ringworm caused by the other of the two prevailing species, Microsporon Lanosum (sometimes referred to as the "animal type"), apparently accounts for all scalp ringworm on the Pacific Coast. It sometimes undergoes spontaneous recovery in a few months, and with rare exceptions is remediable in four to twelve weeks by use of topical applications alone. It is evident, therefore, that X-ray epilation is almost never necessary for treatment of ringworm as encountered in British Columbia. It is easy to recognize scalp ringworm when hairless gray patches, or pustular denuded patches are found. The few broken stumps can readily be lifted out and examined in 30% KOH under low-power. The hairs will be seen surrounded by the characteristic mosaic masses of spores like clumps of frog-spawn. Mycelial filaments are rarely seen. Where the rest of the scalp is covered with hair very minute patches may be missed on ordinary inspection. New patches may start with a single infected hair and it is impossible to detect such inefective foci by ordinary means. In short it is easier to say where ringworm is present than where it is not. It is nevertheless a matter of extreme importance to recognize at once every infective focus, otherwise valuable time will be wasted in treating the readily visible patches while others are left to develop unseen. Also after treatment has been employed with apparent success it is for similar reasons impossible to be sure that every trace of infection has been eradicated. Yet in many cities, states or provinces this is what every physician attending a case of scalp ringworm is required to do* when he gives the patient a note to the school health authorities permitting the child to return to school. There is only one method by which every infected hair present can be detected at once, and thus only one criterion by which a patient can without delay be pronounced cured and freed from isolation precautions. Ignorance or neglect of this fact is undoubtedly a factor accounting for the increasing prevalence of scalp ringworm among children in schools. It is a matter of definite knowledge that for years many children have been returned to school and other association with their fellows, pronounced cured by their doctors, who in fact are still infective. Except in the case of a few rare varieties of fungus which do not concern us here, hairs infected with fungus have the property of fluorescing brilliantly with a characteristic blue-green colour when ultra-violet rays of a certain wave-length fall upon them. These rays which can be filtered out of the ultra-violet spectrum by Wood glasss, which contains nickel oxide, and are thus called "Wood light" or more fancifully "black light," cause every infected hair to stand out brightly against the unilluminated background, when examined in a dark room. Researches carried out in the Vancouver General Hospital laboratories first established the fact that hairs which thus fluoresce in Wood light will give positive ringworm cultures on suitable media, and will also infect experimental animals2. Treatment of scalp ringworm must therefore be preceded by Wood light examination, progress checked from time to time by such examination, and the patient must be "Wood light negative" before isolation precautions are relaxed. Treatment: That employed successfully by the writer for the past eighteen years consists of daily shampooing with Tincture of Green Soap, rubbing in from 5% to 10% ammoniated mercury in soft paraffin over the scalp nightly and on alternate mornings, and on intervening mornings rubbing 5% mercurochrome solution into all visibly infected patches. The average time required for cure is eight or nine weeks, although cases are sometimes cured within four weeks. It is necssary to keep the hair of the entire scalp Page 13 f li fe clipped very short during treatment, and a cap which can be boiled and is snug-fittingl should be worn and changed daily. Dermatophytosis (Ringworm of the Toes; "Athlete's Foot."): This is usually encountered in the subacute or chronic form as whitish, sodden, macerated patches and desquamating epithelium in the outer one or two interdigital spaces of the foot. This commonly extends to the plantar surface of the proximal phalanges of the toes and the foot. There may be groups of small deep vesicles like birdshot under the toes, and larger patches under the longitudinal plantar arch. These tend to aggregate and desquamate, producing scaly patches on the sole and inner side of the foot, the epithelium at the margin being lifted, with its free edges towards the centre of the patch. Similar lesions often are seen about the malleoli. The pink epithelium following desquamation between and under the toes is more or less moist according to the acuity of the inflammation. Fissuring between and under the toes is common, and opens the ground to secondary pyogenic infection. In acute stages there will be oedema and much moisture. Itching is always present in varying degree. Differential Diagnosis is important, as there is far too prevalent a habit of pronouncing every inflammatory condition of the toes and feet to be "athlete's foot," with consequent waste of time spent in misdirected and futile treatment. The following three not uncommon conditions are often confused with dermatophytosis: (1) Contact Dermatitis due to chemicals in shoe-leather or lining-rnaterial. This usually appears first on the doprsum of the toes, especially the great toe, the dorsum and sides of the feet. When interdigital clefts are involved it is their dorsal and not their plantar portions which are affected. (2) Pustular Bacterid. A disease of unknown cause, appearing as groups of flat, superficial, non-elevated pustules on the plantar and lateral surfaces of the foot, especially about the longitudinal arch and heel. Desquamation leaves a dry pink surface, and small brown macules mark the site of each dried-up pustule. Itching is usually slight. (3) Pyodermia. This may be primary or secondary to one of the two preceding. The eruption is predominantly pustular; often there are blebs with purulent contents. Any or all toes, and any part of their surface may be affected, but it is usually about the nails, tips and dorsal surfaces. Lymphangitis and femoral adenitis are common complications. Dermatophytosis may be produced by one of several species of fungus. The source of infection is usually a floor-surface, especially when damp, as in bathrooms, dressing- rooms, concrete margins of pools, etc. The role of the soil is most important; the epidermis must be in a receptive and susceptible condition. Hard, dry, horny skin is relatively immune, while soft, sweat-sodden skin, alkaline by reason of the stale sweat, offers ideal conditions for invasion and growth of fungus. Domestic and conjugal infections are of negligible frequency. Prophylaxis is an individual problem. The feet should be kept dry and clean by frequent washing with soap and water. The socks and shoes should be changed frequently and rubber footgear avoided. Persons predisposed to sweaty feet should use a drying powder, such as a mixture of equal parts of magnesium carbonate, boric acid, zinc oxide and starch. Treatment: (a) Acute. Stay off the feet until acute symptoms subside. Bathe feet twenty to thirty minutes twice daily in warm freshly prepared 1-4000 potassium permanganate solution. Follow with a bland ointment, e.g. 10% Naftalan or Naftex with 12.5% each of zinc oxide and starch in a base of soft paraffin. (b) Subacute. The following routine is recommended: 1. 1-4000 potassium permanganate foot-bath morning and night, fifteen minutes. 2. Calamine lotion containing 1% phenol and 0.5% menthol kept applied during the day. 3. Soap and warm water wash at night before the permanganate bath. Page 14 4. Ointment of 3% salicylic acid and 6% benzoic acide with 0.1% crystalline iodine in Eucerin base (modified half-strength Whitfield formula) rubbed in after the permanganate bath at bed-time. 5. Freshly boiled white cotton socks put on after morning treatment, worn day and night, to be changed following morning. (c) Chronic. Same routine, except the permanganate bath may be omitted. If there is very much hyperkeratosis the salicylic and benzoic acids in the ointment may be increased to 6% and 12% respectively. The following powder ("Navy Powder") is applied with friction after the morning soap and water bath: Salicylic acid 5%, Menthol 2%, Powdered Camphor, 8%, Boric acid 50% in Starch. < If cotton socks cannot be worn, the woollen socks worn, and if possible the shoes also, should be sterilized daily as follows: Place a glass caster-cup in a shoe box with a good- fitting lid. Fill the hollow of the caster-cup with commercial formalin. Place socks (and shoes) in the box and keep box closed for at least eight hours. Air the footgear for twenty-four hours before wearing. Treatment as for the chronic stage should be continued until symptom-free for one month at least. Failure to be thorough in details of treatment and prophylactic routine and too early discontinuance of treatment is the reason why the disease is so commonly regarded as incurable. This notion is false and should be combatted. Tinea Cruris (Ringworm of the Groin; Eczema Marginatum): Usually this is secondary to foot-infection with the same fungus. The eruption is distinguished by a sharply-defined area of erythema, and scaling triangular outline as viewed from in front, the base being at the mons, the angles in either groin and in the midline below the external genitalia. This area is often prolonged posteriorly over the perinaeum and may include the anal region. The margin is usually marked by minute papulo-vesicles covered with scales. The entire area may be more or less scaly and is usually dry, but may be acutely inflamed with exudation and maceration. It must be distinguished from ordinary intertrigo due to moisture and friction and imperfect hygiene, in which the eruption is diffuse with ill-defined border; also from contact dermatitis from clothing, medications, plants, etc., in which the symptoms are more acute with oedema of the external genitalia as a pronounced feature. Treatment. Do not overlook a careful examination and necessary attention to the feet. The patient may not mention them, and may even deny the presence of trouble there when the infection is sub-acute or chronic. The general procedure is approximately the same as for the feet: soap and water and permanganate bathing, phenolized calamine lotion (omit menthol) by day, and the weaker Whitfield formula already given for night use. Freshly boiled cotton shorts should be donned each morning, to be worn during the next twenty-four hours. Mycotic Paronychia and Onychomycosis (Ringworm of the Nails): This is commonly due to infection with yeasts and the picture is characteristic. The proximal nail-fold is thickened, red and tender, having the crescentic shape of a Vienna roll, standing well away from the nail-plate. The nail-matrix is commonly damaged, resulting in deformity of the nail-plate, usually a transverse rumpling. The lustre of the nail is usually retained except when its substance is invaded by fungus, when it assumes a dull yellowish, friable character. The eruption is commonly seen in housewives whose hands are constantly in warm dish-water or laundry-water. In women with short fat fingers, especially in Jewish women, the paronychia is commonly accompanied by a moist intertrigo from the same cause between the fingers. Treatment. The hands should be kept out of water except for the personal toilet. Where the colour is not seriously objected to, 2% gentian violet solution should be applied to all affected parts daily. An ointment of 1 % potassium permanganate in soft paraffin is less objectionable, although it will stain. Otherwise the weaker Whitfield formula is rubbed in and worked under the nail-fold morning and night. An ointment of Page 15 i I I- § I- I 3% salicylic acid and 5% ammoniated mercury in Eucerin is satisfactory if dark discolouration of the nail-plate is not objected to. The infected nails should be softened by rubbing in soft soap and covering with a finger-cot or adhesive overnight on alternate nights, the ointment being applied on the intervening nights. After each softening thej nail should be scraped with a piece of broken bottle-glass until it is thin. X-ray treat-1 ment is of great value and often indispensable. Tinea Barbae (Ringworm of the Beard): This is uncommon here in comparison with the pyogenic infection of the beard I (sycosis barbae; "barber's itch"). It is seen almost exclusively in those who have frequent close contact with cattle and sheep. The lesions have an exuberant, fungoid character, like kerion in a child's scalp. Beard-hairs infected not only break off, but fall out readily. The fungus responsible for most beard-infections in this country does not produce fluorescence of infected hairs thus the Wood light is seldom of value in diagnosis. Treatment. X-ray treatment gives good results, but as most of these patients come from rural districts and cannot obtain this form of treatment from those competent to administer it at the necessary intervals it is fortunate that a carefully observed medical routine will give satisfactory results in most cases. (1) After preliminary thorough softening of the beard for two or three days with constant dressings of oil (olive, almond or peanut), it is thoroughly washed with Tincture of Green Soap. (2) Shave, not too closely and using abundant lathering. (3) Bathe with hot boric solution and open all pustules with a flamed needle. (4) Bathe for several minutes in 15% sodium thiosulphate solution. (5) Dry for fifteen minutes and bathe again with hot water. (6) Rub in ointment of 25% sulphur and 0.1% mercuric sulphid in soft paraffin, gently. (7) Following niorning repeat soap and water bathing followed by the sodium thiosulphate as before and dust with borated talc. (8) Continue this routine daily until only reddened follicles remain and no pustules appear, when the ointment may be stopped. The powder is continued untilj cured. Tinea Versicolor: This is an eruption of light to dark fawn macules or blotches on the chest wall,i which tend to coalesce until the greater part of the anterior and posterior aspects of the thorax are uniformly covered with a sheet of this colour. It is sometimes confused with tanning, or even with the pigmentation of Addison's disease. On stretching and scraping the skin lightly a fine branny scale is raised in which Microsporon Furfur is easily found by the usual technic. Subjective symptoms are negligible. The condition is seen commonly in those who work hard and sweat freely, bathing and changing their clothing infrequently. Treatment. Thorough scrubbing daily with ordinary toilet soap and warm water, and daily changing of clothing, which must be thoroughly laundered and hot-pressed, is often sufficient. A simple and effective local treatment, which should, however, be accompanied by the foregoing measures, is to sponge the affected area once or twice daily with 25% sodium thiosulphate solution, and before it is quite dry to rub it over with domestic vinegar diluted with an equal quantity of warm water. REFERENCES: Lewis, Geo. M., and Hopper, Mary E., An Introduction to Medical Mycology. Chicago: Year Book Publishers, p. 48, 1943, Ed. 2. Cleveland, D. E. H., Infectivity of Fluorescent Hairs in Scalp Ringworm. Canadian Medical Association Journal, 40 :280, Oct. 1943. Page 16 OFFICES FOR DOCTORS RETURNING FROM SERVICE Enquiries are now being received from returned medical officers who wish to avail themselves of the opportunity of sharing office space with a returned man will you please fill out this form and return it to the office of the Registrar, 203 Medical-Dental Building, Vancouver, B. C: I AM WILLING TO SHARE MY OFFICE WITH A RETURNING VETERAN. Office address Tel. No ___. I desire a physician whose specialty is ! Hours office will be available at a.m -p.m. I have the following employees whose services I would be willing to share (R.N., Secretary, Technician, etc.) I have the following apparatus I would be willing to share (X-ray, short wave, clinical laboratory, etc.) . = I have telephone service which I would be willing to share I do not wish to share the services of employees apparatus Telephone service. 1 I desire $ per month for rental and services listed above. it If NOTICE—RE RETURNING MEDICAL OFFICERS VICTORIA MEDICAL SOCIETY The Victoria Medical Society requests all medical men, at present in the armed forces, who were formerly living in Victoria to communicate with the Society as soon as possible. Information is wanted concerning their requirements of Office space and their plans for returning to civil practice, so that the Society may assist in securing the desired accommodation. Please act promptly. At present accommodation is very difficult to obtain. Page 17 II •••••••••"•••••••••••* tours CASES OF VENEREAL DISEASE INFECTION REPORTED BY PROVINCIAL HEALTH DEPARTMENTS TO THE DOMINION BUREAU OF STATISTICS, 1944 f gonorrhoea syphilis ratio Gonorrhoea/Syphilis* Prince Edward Island 20 35 0.6 Nova Scotia ] 1,663 496 3.3 New Brunswick 913 573 1.6 Quebec j 3,936 6,539 0.6 Ontario 7,317 5,225 1.4 Manitoba '. I 1,737 663 2.6 Saskatchewan 1,123 360 3.1 Alberta 1 1,348 750 1.8 British Columbia 2,976 1,270 2.3 CANADA 21,033 . 15,911 1.3 In 1944, 21,033 cases of gonorrhoea and 15,911 cases of syphilis were reported by provincial health departments to the Donfinion Bureau of Statistics. The ratio of gonorrhoea to total syphiilis was, therefore, 1.3 to 1. The experience of the three Armed Forces in Canada from 1940 to 1944 reveals thatf the ratio of gonorrhoea to total syphilis in Canada for that period was approximately 6 to 1. It is apparent, therefore, that the reporting of gonorrhoea by physicians in Canada is very inadequate. There is reason to suspect that syphilis is not being reported! completely. We know definitely that 15,911 cases of syphilis came to attention. Admitting that^ the ratio of gonorrhoea to syphilis was 6 to 1, it is estimated that in 1944 there were at least 90,000 cases of gonorrhoea in Canada. Of these, only 21,033 were reported by physicians. The incidence rate of syphilis in Canada is exceedingly high. In 1944 the syphilisf rate for Canada was 135 per 100,000 per annum. In 1942, the syphiHs rate for Sweden was 7 per 100,000 per annum, the rate for Denmark was 23 per 100,000 per annum and the rate for Norway was 38 per 100,000 per annum. These are three countries which have maintained reliable venereal disease statistics over* a period of years. CONGENITAL SYPHILIS The diagnosis of congenital syphilis should be applied only to cases showing definite! evidence of the existence, or former existence, of the characteristic changes of congenital j syphilis. The congenital origin of syphilis is not to be assumed merely because the time and circumstances of the infection cannot be ascertained and there is no scar of a primary lesion. Page 18 MULTIPLE CONTACTS The clinical history of the patient should be kept in mind by the physician in his enquiry for alleged contacts' to a venereal infection. A patient may have had several contacts within the incubation period of his infection, any one or all of whom may have been, or have become infected at the time of the sexual exposure. It is important that all such contacts are examined to ensure that none remain an undetected health menace. As a guide in this matter, the incubation period of gonorrhoea is stated to average 3 to 9 days, but may, in certain instances, be as short as 2 days or as long as 14 days. The incubation period of syphilis is commonly 3 to 4 weeks, but may be as long as 3 months. REGULARITY OF SYPHILIS TREATMENT It cannot be too strongly emphasized that regularity of syphilis treatment without long or short-time variations or lapses is critically important to both infection control and cure. Congratulations are extended to Capt. and Mrs. W. H. White on the birth of a daughter. Capt. White, formerly of Penticton, has just returned from service overseas. * *t ■<. »t *_ Major and Mrs. G. M. Kirkpatrick of Vancouver and Dr. and Mrs. Wallace Coburn of Vancouver are receiving congratulations on the birth of sons. Colonel J. F. Haszard, formerly of Kimberley, has received his discharge from the R.C.AJM.C, following service overseas. Lieut.-Col. G. A. Bird, formerly of Victoria, is now out of the Army, and associated with the Department of Veterans' Affairs in Vancouver. Lieut.-Col. Roy Huggard of Vancouver, following service overseas, has received his discharge from the R.C.A.M.C., and is resuming practice in Vancouver. Lieut.-Col. J. U. Coleman has resumed practice in Duncan, following his discharge from the R.C.A.M.C. 5j* ^ -fr *fr Major R. Scott-Moncrieflf of Victoria, who served overseas, has received his discharge, and.has returned to civilian practice in Victoria. Major W. W. Simpson of Vancouver is now out of the R.C.A.M.C, and on the staff of Shaughnessy Hospital. Major J. Moscovich of Vancouver has received his discharge from the Army. Squadron Leader D. S. Munroe, R.C.A.F., returned to Vancouver recently, following service overseas. While in England, Dr. Munroe passed the examination of the Royal College of Physicians, and is now a member of that body, entitled to the letters M.R.C.P. Page 19 ; i. Capt. F. E. Saunders of Vancouver has returned to civilian life, following service in the R.C.A.M.C. * * 55- * Surgeon Lieut.-Commander Murdo McRitchie, formerly in practice at Fernie, is now out of the Naval Medical Services. Surgeon Lieutenant R. M. Jameson has returned to Vancouver from the West Indies, where he was taking a course. Major W. C. Mooney has received his discharge from the R.C.A.M.C. and will continue his work with the Division of Venereal Disease Control. Major R. W. Patten, formerly of Chilliwack, is now out of the Army, and has resumed practice in Chilliwack. * * * * Capt. D. J. FitzOsborne recently returned to Vancouver with the Seaforth Highlanders of Canada. * * * * Capt. A. M. Inglis, R.C.A.M.C, has returned to civilian practice at Gibsons Landing.; Flight Lieut. V. W. Pepper of New Westminster has received his discharge from the Air Force. *r *P Flight-Lieut. W. R. Brewster received his discharge from the R.CA.F., and is in practice again in New Westminster. __ *_ nT *F Capt. N. B. Hall, recently discharged from the R.C.A.M.C, has returned to Campbell River to practise there. *»* . •_• *p "S* Capt. N. H. Jones, formerly of Port Alberni, has been transferred from the R.C A.M.C to the Air Force, overseas. » -,* »»- -»- -»- Dr. R. W. Garner of Port Alberni has returned from a short holiday in Seattle' and Vancouver. * * * * The annual Fall meeting of the Upper Island Medical Association was held on November 7th at Parksville. Following the general business session, a very useful and instructive address was given by Lieut.-Colonel Roy Huggard on "Various Aspects of War Surgery." This large subject was covered very ably by the speaker. * * * * Doctors J. S. Daly and D. J. M. Crawford of Trail have returned from Portland, Oregon, where they attended post-graduate classes. _ _ # * Dr. Ethlyn Trapp of Vancouver will be in the Eastern States until February, 1946. During her absence Dr. Andrew Turnbull will take care of her practice of radium and deep X-ray therapy. Page 20
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The Vancouver Medical Association Bulletin: October, 1945 Vancouver Medical Association Oct 31, 1945
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Title | The Vancouver Medical Association Bulletin: October, 1945 |
Creator |
Vancouver Medical Association |
Publisher | Vancouver, B.C. : McBeath Spedding Limited |
Date | 1945-10 |
Date Issued | 1945-10 |
Subject |
Medicine--Periodicals. |
Genre |
Periodicals |
Type |
Text |
FileFormat | image/jpeg |
Language | English |
Identifier | W1 .VA625 VMA_Bulletin1945_10 |
Collection |
History of Nursing in Pacific Canada |
Source | Original Format: University of British Columbia. Library. Woodward Library Memorial Room |
Date Available | 2015-01-29 |
Provider | Vancouver : University of British Columbia Library |
Rights | Images provided for research and reference use only. Permission to publish, copy, or otherwise use these images must be obtained from the University of British Columbia Library. |
CatalogueRecord | http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642 |
DOI | 10.14288/1.0214323 |
AggregatedSourceRepository | CONTENTdm |
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