By clever propaganda Hitler had convinced many people that he was a strong socialist. His aggression against Balkan countries had the passive backing of Western Europe, and what happened in the concentration camps was hidden from the public. He was careful not to alienate the Dutch from his cause because he considered them Arians. The ruthless extermination of any resistance in Germany and Eastern Europe was not happening on the same scale in Western Europe. Nevertheless, Nazification occurred, step by step and through persuasion. The council of the Royal Dutch College of Medicine in 1940 was socialistoriented and did not resist the Nazification of the medical profession. The resistance, therefore, had to come from individual doctors without the help of a central body. It was a spontaneous movement in the whole country, and that it was successful may be attributed to the traditional rejection in Holland of fanaticism and of any breach of individual freedom. University students were expected to develop a philosophy of life in an independent and objective way. We should not forget that the circumstances in Germany were incomparably more difficult for any resistance and that at least 3 million Arian Germans died in the concentration camps.
0O
S.. A
C.W. KOK, MD Chinook Medical Clinic P0 Box 5742, Postal Stn. "A" Calgary, Alta.
Vascular involvement in relapsing polychondritis To the editor: I was most interested to read the comments expressed by Dr. John Esdaile and his colleagues (Can Med Assoc J 116: 1019, 1977) regarding the multiple organ systems that can be involved in relapsing polychondritis (RP). As a dermatologist I have seen three cases of RP during my residency and clinical practice. I noted that each of the four patients described by Esdaile and his coauthors received prednisone with or without cyclophosphamide or azathioprine. Barranco, Minor and Solomon1 treated three patients who had ear and nose involvement consistent with RP with dapsone in doses of 50 mg/d to 100 mg bid. There was substantial involution of the inflammatory changes with this regimen. Dapsone is thought to operate through inhibition of lysosomal enzymes. These authors had previously shown resolution of hypervitaminosisA-induced chondritis in rabbits treated with this drug. Martin and associates' also had success with the use of dapsone in one patient with RP. 'Neither of these studies concentrated
AVEENO AYEQ9.Y BATH
QILATED BATH OATMEAL N
.b
O.N28¶eS3 L *
NETWT.#
.
AVEENO ..
AVEENO*
..
*O.
I
*@.
0.0006
0
0*
6
0@ .Se
-
S
-
-.
.5
0
S
CMA JOURNAL/JULY 23, 1977/VOL. 117 127
osed end-to-end to the distal 20 cm References of ileum.3 Shorter ileal segments, espe1. MANSON-BAHR PH: Synopsis of TrQpical Medcially when the total length of bowel icine, 4th ed, London, Cassell, 1963, p 171 2. PAYNE JH, DEWIND L, SCHWAB CE, et al: in the Scott procedure was less than 50 Surgical treatment of morbid obesity. Sixteen cm, were found to produce unacceptyears of experience. Arch Surg 106: 432, 1973 able diarrhea and malnutrition.3 A few Scorr HW, DEAN R, SHULL HJ, et al: New centimetres may have a profound ef- 3. considerations in use of jejunoileal bypass in patients with morbid obesity. Ann Surg 177: fect. Bile salts are normally reabsorbed 723, 1973 only in the terminal ileum. Short ileal 4. BUCHWALD H, SCHWARTZ MZ, VAstco RL: W.T. HODGE segments, therefore, permit excessive Surgical treatment of obesity. Adv Surg 7: Dermatologist 235, 1973 Credit Union Building depletion in the stool, of bile salts loss 5. MACLEAN LD: Intestinal bypass operations Vernon, BC for obesity: a review. Can .7 Surg 19: 387, of the bile-salt pool, fat malabsorption, 1976 increased diarrhea and steatorrhea, and, References finally, nutritional deficiencies. 1. BARRANCO VP, MINOR DB, SOLOMON H: Buchwald, Schwartz and Varco4 re- Tardive dyskinesia treated with Treatment of relapsing polychondritis with ported the only series in which very deanol acetamidobenzoate dapsone. Arch Dermatol 112 1286 1976 2. MARTIN J, ROENIOK HH, LYNCH W, et al: short ileal segments were preserved To the editor: Relapsing polychondritis treated with dapsone. I report a case of tardive Ibid, p 1272 without major nutritional complica- dyskinesia that developed after treattions. They anastomosed 45 cm of ment with haloperidol, in which therapy ileum. to 5 cm of jejunum end-to-end Complication of jejunoileal shunt The total length of the functioning with deanol acetamidobenzoate provided much relief. To the editor: The paper entitled "Phy- small bowel, however, was 50 cm, and A 77-year-old woman presented with sical and psychological complications the bypassed bowel was anastomosed to certainly almost from which severe, persistent tardive dyskinesia in the cecum, after intestinal bypass for obesity" by December 1976. She had continuous proDrs. R.C. Bowen and L. Shepel (Can some reflux and absorption resulted. trusive tongue movements and movements Finally, as MacLean5 pointed out in of Med Assoc J 116: 871, 1977) details lips and jaw muscles. She had also clinical features including headaches, his excellent review, most surgeons who involuntary movements of both legs. poor memory, depression, burning sen- use the jejunoileostomy procedure give She was first treated for hypomania in sation in the gums and teeth, and hy- their patients multivitamin preparations November 1969 with methotrimeprazine, perkeratotic, hyperpigmented, scaling postoperatively. Arrangements must be 25 mg tid for 6 weeks. Hypomania reand cracking skin, all of which, it was made at discharge for indefinite follow- curred six times between June 1970 and stated, were alleviated by replacement up by the surgeon or a reliable physi- November 1976. During these relapses she therapy with vitamins B12, C and D, cian. We maintain surveillance of our was treated with haloperidol, 3 to 6 mg/d folic acid, calcium, magnesium, iron 27 patients, in whom no significant orally for 6 to 8 weeks. During her relapse in July 1975 she took promazine hydrocomplications have occurred. and potassium. chloride, 100 to 200 mg/d for about 10 These clinical features are not in- MICHAEL A. ALEXANDER, MB, B5, FRCS[C] weeks; haloperidol was not prescribed. frequently seen in tropical areas in paMERVYN DFTTEL, MD, FRC5[C], FAC5, FIcs On Jan. 20, 1977 therapy with diazeof surgery tients with severe malnutrition or cer- St. Joseph's Hospital and Department pam, 5 mg tid, and promazine hydroUniversity of Toronto Toronto, Ont. tain small-bowel malabsorption synchloride, 50 mg tid, was begun to control the dyskinesia. Her condition remained dromes.1 Although a number of factors may be responsible, the main deficien- To the editor: We appreciate the com- unchanged. On Feb. 4 deanol acetamidocies appear to be of vitamin B1 (result- ments of Drs. Alexander and Deitel. benzoate, 100 mg bid, was prescribed; the ing in a form of Wernicke's encephalo- They are correct about the vitamin dosage was increased to 100 mg qid over the next 7 days. The dyskinesia improved pathy), of riboflavin and nicotinic acid therapy in our patient. She did receive greatly on the 4th day of treatment: the (resulting in pellagra with dementia, a multiple vitamin B preparation with limb movements disappeared and the oroand therapy, the start of replacement diarrhea and dermatitis) and of vitamin vitamin A 3 days before discharge. facial movements became minimal. She A (resulting in vision problems and was able to walk by Feb. 18. At present Payne and colleagues2 reported two she is taking 200 mg tid of the drug and xerodermatosis). Although not stated in the paper, it is likely that, as part of deaths, and Scott and associates3 one it is well tolerated. the nutritional repletion of the patient instance of complications from possible The movements in tardive dyskinesia described, multivitamin preparations emotional causes. We hope that our seem to be caused by dopaminergic for cause one possible case indicated containing vitamins A and B complex overactivity in the striatonigral system, were also given; these would more like- such emotional reactions to bypass sur- with a relative reduction of cholinergic gery. ly explain the patient's improvement. function. Deanol acetamidobenzoate, an comment a do have follow-up We More important, however, is that acetylcholine precursor, restores the severe nutritional deficiency problems on our patient, who was placed in con- acetylcholine-dopamine balance. My Seven a reliable physician. could have developed from the surgical tact with case and others1'2 give grounds for cauprocedure. It was stated that 40 cm of months after discharge she has pre- tious optimism that this drug may have jejunum was anastomosed to 4 to 6 cm sented with physical and psychological a role in the treatment of tardive dysof ileum. Measurements are critical, complaints similar to those described kinesia. especially of the ileum, and after many in the case report. The Minnesota MulINDRAJIT RAY, MD, DPM (ENG), years of clinical trials two procedures tiphasic Personality Inventory and cogMRC PSYCH (ENG), FRCP[C] for jejunoileostomy in patients with nitive findings are also similar. She had Senior psychiatrist is and her supplements discontinued Department of Public Health morbid obesity, in which short ileal Union Hospital segments are preserved, are now the again under investigation and treatMoose Jaw, Sask. ment. most accepted. In the Payne procedure References the proximal 35 cm of jejunum is anasR.C. BOwEN, MD, CM, FRCP[C] tomosed end-to-side to the distal 10 cm L. SHEPEL, PH D 1. MILLER EM: Deanol: a solution for tardive Department of psychiatry dyskinesia. N Engi .7 Med 291: 796, 1974 of ileum.2 In the Scott procedure the 2. CASE DE, DENNY D: Dimethylaminoethanol University Hospital in tardive diskinesia. Ibid, p 797 Saskatoon, Sask. proximal 30 cm of jejunum is anastomon the vascular involvement or arthritis associated with RP and neither referred to the benefits of dapsone in patients with such involvement. However, consideration should be given to the use of this drug for treatment of RP in view of its effectiveness in patients with ear and nose inflammation.
CMA JOURNAL/JULY 23, 1977/VOL. 117 129
0O
S.. A
C.W. KOK, MD Chinook Medical Clinic P0 Box 5742, Postal Stn. "A" Calgary, Alta.
Vascular involvement in relapsing polychondritis To the editor: I was most interested to read the comments expressed by Dr. John Esdaile and his colleagues (Can Med Assoc J 116: 1019, 1977) regarding the multiple organ systems that can be involved in relapsing polychondritis (RP). As a dermatologist I have seen three cases of RP during my residency and clinical practice. I noted that each of the four patients described by Esdaile and his coauthors received prednisone with or without cyclophosphamide or azathioprine. Barranco, Minor and Solomon1 treated three patients who had ear and nose involvement consistent with RP with dapsone in doses of 50 mg/d to 100 mg bid. There was substantial involution of the inflammatory changes with this regimen. Dapsone is thought to operate through inhibition of lysosomal enzymes. These authors had previously shown resolution of hypervitaminosisA-induced chondritis in rabbits treated with this drug. Martin and associates' also had success with the use of dapsone in one patient with RP. 'Neither of these studies concentrated
AVEENO AYEQ9.Y BATH
QILATED BATH OATMEAL N
.b
O.N28¶eS3 L *
NETWT.#
.
AVEENO ..
AVEENO*
..
*O.
I
*@.
0.0006
0
0*
6
0@ .Se
-
S
-
-.
.5
0
S
CMA JOURNAL/JULY 23, 1977/VOL. 117 127
osed end-to-end to the distal 20 cm References of ileum.3 Shorter ileal segments, espe1. MANSON-BAHR PH: Synopsis of TrQpical Medcially when the total length of bowel icine, 4th ed, London, Cassell, 1963, p 171 2. PAYNE JH, DEWIND L, SCHWAB CE, et al: in the Scott procedure was less than 50 Surgical treatment of morbid obesity. Sixteen cm, were found to produce unacceptyears of experience. Arch Surg 106: 432, 1973 able diarrhea and malnutrition.3 A few Scorr HW, DEAN R, SHULL HJ, et al: New centimetres may have a profound ef- 3. considerations in use of jejunoileal bypass in patients with morbid obesity. Ann Surg 177: fect. Bile salts are normally reabsorbed 723, 1973 only in the terminal ileum. Short ileal 4. BUCHWALD H, SCHWARTZ MZ, VAstco RL: W.T. HODGE segments, therefore, permit excessive Surgical treatment of obesity. Adv Surg 7: Dermatologist 235, 1973 Credit Union Building depletion in the stool, of bile salts loss 5. MACLEAN LD: Intestinal bypass operations Vernon, BC for obesity: a review. Can .7 Surg 19: 387, of the bile-salt pool, fat malabsorption, 1976 increased diarrhea and steatorrhea, and, References finally, nutritional deficiencies. 1. BARRANCO VP, MINOR DB, SOLOMON H: Buchwald, Schwartz and Varco4 re- Tardive dyskinesia treated with Treatment of relapsing polychondritis with ported the only series in which very deanol acetamidobenzoate dapsone. Arch Dermatol 112 1286 1976 2. MARTIN J, ROENIOK HH, LYNCH W, et al: short ileal segments were preserved To the editor: Relapsing polychondritis treated with dapsone. I report a case of tardive Ibid, p 1272 without major nutritional complica- dyskinesia that developed after treattions. They anastomosed 45 cm of ment with haloperidol, in which therapy ileum. to 5 cm of jejunum end-to-end Complication of jejunoileal shunt The total length of the functioning with deanol acetamidobenzoate provided much relief. To the editor: The paper entitled "Phy- small bowel, however, was 50 cm, and A 77-year-old woman presented with sical and psychological complications the bypassed bowel was anastomosed to certainly almost from which severe, persistent tardive dyskinesia in the cecum, after intestinal bypass for obesity" by December 1976. She had continuous proDrs. R.C. Bowen and L. Shepel (Can some reflux and absorption resulted. trusive tongue movements and movements Finally, as MacLean5 pointed out in of Med Assoc J 116: 871, 1977) details lips and jaw muscles. She had also clinical features including headaches, his excellent review, most surgeons who involuntary movements of both legs. poor memory, depression, burning sen- use the jejunoileostomy procedure give She was first treated for hypomania in sation in the gums and teeth, and hy- their patients multivitamin preparations November 1969 with methotrimeprazine, perkeratotic, hyperpigmented, scaling postoperatively. Arrangements must be 25 mg tid for 6 weeks. Hypomania reand cracking skin, all of which, it was made at discharge for indefinite follow- curred six times between June 1970 and stated, were alleviated by replacement up by the surgeon or a reliable physi- November 1976. During these relapses she therapy with vitamins B12, C and D, cian. We maintain surveillance of our was treated with haloperidol, 3 to 6 mg/d folic acid, calcium, magnesium, iron 27 patients, in whom no significant orally for 6 to 8 weeks. During her relapse in July 1975 she took promazine hydrocomplications have occurred. and potassium. chloride, 100 to 200 mg/d for about 10 These clinical features are not in- MICHAEL A. ALEXANDER, MB, B5, FRCS[C] weeks; haloperidol was not prescribed. frequently seen in tropical areas in paMERVYN DFTTEL, MD, FRC5[C], FAC5, FIcs On Jan. 20, 1977 therapy with diazeof surgery tients with severe malnutrition or cer- St. Joseph's Hospital and Department pam, 5 mg tid, and promazine hydroUniversity of Toronto Toronto, Ont. tain small-bowel malabsorption synchloride, 50 mg tid, was begun to control the dyskinesia. Her condition remained dromes.1 Although a number of factors may be responsible, the main deficien- To the editor: We appreciate the com- unchanged. On Feb. 4 deanol acetamidocies appear to be of vitamin B1 (result- ments of Drs. Alexander and Deitel. benzoate, 100 mg bid, was prescribed; the ing in a form of Wernicke's encephalo- They are correct about the vitamin dosage was increased to 100 mg qid over the next 7 days. The dyskinesia improved pathy), of riboflavin and nicotinic acid therapy in our patient. She did receive greatly on the 4th day of treatment: the (resulting in pellagra with dementia, a multiple vitamin B preparation with limb movements disappeared and the oroand therapy, the start of replacement diarrhea and dermatitis) and of vitamin vitamin A 3 days before discharge. facial movements became minimal. She A (resulting in vision problems and was able to walk by Feb. 18. At present Payne and colleagues2 reported two she is taking 200 mg tid of the drug and xerodermatosis). Although not stated in the paper, it is likely that, as part of deaths, and Scott and associates3 one it is well tolerated. the nutritional repletion of the patient instance of complications from possible The movements in tardive dyskinesia described, multivitamin preparations emotional causes. We hope that our seem to be caused by dopaminergic for cause one possible case indicated containing vitamins A and B complex overactivity in the striatonigral system, were also given; these would more like- such emotional reactions to bypass sur- with a relative reduction of cholinergic gery. ly explain the patient's improvement. function. Deanol acetamidobenzoate, an comment a do have follow-up We More important, however, is that acetylcholine precursor, restores the severe nutritional deficiency problems on our patient, who was placed in con- acetylcholine-dopamine balance. My Seven a reliable physician. could have developed from the surgical tact with case and others1'2 give grounds for cauprocedure. It was stated that 40 cm of months after discharge she has pre- tious optimism that this drug may have jejunum was anastomosed to 4 to 6 cm sented with physical and psychological a role in the treatment of tardive dysof ileum. Measurements are critical, complaints similar to those described kinesia. especially of the ileum, and after many in the case report. The Minnesota MulINDRAJIT RAY, MD, DPM (ENG), years of clinical trials two procedures tiphasic Personality Inventory and cogMRC PSYCH (ENG), FRCP[C] for jejunoileostomy in patients with nitive findings are also similar. She had Senior psychiatrist is and her supplements discontinued Department of Public Health morbid obesity, in which short ileal Union Hospital segments are preserved, are now the again under investigation and treatMoose Jaw, Sask. ment. most accepted. In the Payne procedure References the proximal 35 cm of jejunum is anasR.C. BOwEN, MD, CM, FRCP[C] tomosed end-to-side to the distal 10 cm L. SHEPEL, PH D 1. MILLER EM: Deanol: a solution for tardive Department of psychiatry dyskinesia. N Engi .7 Med 291: 796, 1974 of ileum.2 In the Scott procedure the 2. CASE DE, DENNY D: Dimethylaminoethanol University Hospital in tardive diskinesia. Ibid, p 797 Saskatoon, Sask. proximal 30 cm of jejunum is anastomon the vascular involvement or arthritis associated with RP and neither referred to the benefits of dapsone in patients with such involvement. However, consideration should be given to the use of this drug for treatment of RP in view of its effectiveness in patients with ear and nose inflammation.
CMA JOURNAL/JULY 23, 1977/VOL. 117 129
