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      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
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!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