937 self-examination. A full bladder may be differentiated from other fluid collections such as a large ovarian cyst or loculated ascites. _
St. Richard’s Hospital, Chichester, West Sussex PO19 4SE
E. C. ASHBY
Therapeutic agents cannot reach the fungus which is protected by the keratin in which it grows. Several years ago I acquired onychomycosis of nails of the right thumb and both large toes caused by Trichophyton sp. I was given griseofulvin for a year, with clearing of the thumb nail but only slight improvement in the toenails. Although symptom-free I wanted to eliminate the fungus, so
following
TRYPTOPHAN IN PATIENTS ON CHRONIC HÆMODIALYSIS
SIR,-There is increasing evidence that
low free tryptodepression. In patients on chronic hsemodiatysis, depression and even dementia have been reported.2 Dementia might be a toxic encephalopathy due to trace elements such as copper, zinc, lead, cadmium and aluminium.3-6 But we believe that the psychiatric symptoms may result from a tryptophan deficiency. a
phan concentration is associated with
SERUM TRYPTOPHAN
([Hnol/1) BEFORE AND AFTER HÆMODIALYSIS
I devised the treatment. The nail is washed with soap and water and cleaned with alcohol. Then, with a sterile 18 or 20 gauge needle, five or six holes are drilled in the nail plate, in the form of a crescent about 2 mm distal to the lunula. Anaesthesia is not necessary. However, the introduction of the needle is felt when the nail bed is reached. Cultures may be made from the powder drilled up by the needle. The holes are enlarged by dipping a round toothpick in bichloroacetic acid and drilling through the hole in the nail. When the acid reaches the nail bed a burning sensation is felt. The area also blanches as the acid reaches the fungus in the keratin. Thereafter, an ointment composed of 3% precipitated sulphur, and 3% salicylic acid in petrolatum, is applied on the affected toes each morning. A week later, five or six new holes are drilled about 2 mm distal to and between the original ones, to obtain
greater distribution of the therapeutic agent. The treatment proved effective, presumably because the therapeutic agent could reach the fungus once the protective keratin barrier was breached. If necessary, more holes could be drilled, and further applications of acid or other antifungal agents could be given. If the nail is hard and very thick, a small dental electric drill could be used. The patient should be checked frequently in order to guard against complications such as infections and reactions to the acid.
a
Worcester
City Hospital,
JACOB BREM
Worcester, Massachusetts 01610, U.S.A.
IATROGENIC POLYDIPSIA
Using the method of Denckla and Dewey, we measured total serum-tryptophan before and after dialysis in 9 patients. Initially, it was not particularly low (reference values 40-100
pmol;1), but there was a significant decrease in concentration after dialysis in all patients (see table). The patients had a standardised protein intake (40g/day) supplemented with an essential amino acid preparation (’Aminess’), which was equivalent to a mean of 1-1 .mmol tryptophan/day. We do not know if the decrease in serum-tryptophan after dialysis would have been enough to induce depression and dementia if no extra tryptophan had been given. None of the 9 patients had signs of psychiatric disturbance, but this could be due either to the dietary supplementation or to the relatively short time of dialysis, or both. of Thoracic Medicine, Karolinska Hospital, S-10401 Stockholm, Sweden
Department
Department of Medicine, Karolinska Hospital Department of Clinical Chemistry, Serafirner Hospital, Stockholm
GUNNAR UNGE LARS-ERIC LINS ERIC HULTMAN
TREATING ONYCHOMYCOSIS
StR,-Treatment for onychomycosis is not satisfactory since surgical removal of the toenails and long courses of griseofulvin are usually required. Moreover, recurrences are frequent.’ 1.Coppen, A., Eccleston, E. C., Peet, M. Lancet, 1972,ii, 1415. 2.British Medical Journal. 1976, ii. 1213 3.Flendrig, J. A., Kruis, H., Das, H. A. Lancet, 1976, i, 1235. 4.Ulmer, D.D.New Engl. J.Med. 1976, 294, 218. 5.Platts, M. M., Moorhead, P. J., Gretch, P. Lancet, 1973, ii, 159. 6.Lyle,W.H.ibid.271. 7.Denckla, W. D., Dewey, H. K. J. lab. clin. Med. 1976, 69,160.
SIR,-We describe here sive
water
and
was
a
patient with
a
variant
of compul-
drinking induced by medical advice for the treatment of nephrolithiasis. A 44-year-old post-office worker presented with complaints of excessive thirst and polyuria. 4 years previously, he had had renal colic and had been advised by his physician to increase his fluid intake. Since then he had been drinking water frequently throughout the day. Recently he had had polyuria which interfered with his daily activities, especially while on military reserve duty. During the month before admission, he was drinking every 20 min, micturating with similar frequency unable to work or travel because of his embarrassand dependence on a water supply and adjacent closet. He had nocturia several times. There were no physical findings. The osmolalities of blood and urine were 286 and 87 mosmol/kg H2O, respectively. Blood creatinine, glucose, potassium, and calcium levels were normal. During his admission the patient carefully recorded every fluid intake and urine output. He drank 9 litres by day and 2.8 litres by night and passed comparable quantities of urine. During water deprivation for 14 h, the patient’s urine output decreased and the concentration of his urine rose to 649 mosmol/kg H2O. This was also therapeutic, convincing him of his ability to moderate his fluid intake. He was advised to reduce his drinking to 2.0 litres/day. He remains well after follow-up for 9 months and is working full-time. When a patient has polydipsia and polyuria but normal renal function and glucose.and electrolyte levels, he may have diabetes insipidus or a compulsion to drink water. In this case, the latter seems more likely. The patient did not show the psychological disturbance usual in compulsive water drinking,’1 although the careful records he kept of his fluid balance sug-
ment
1. Barlow, E.
D., de Wardener, H. E. Q. Jl. Med. 1959. 28, 235.
St. Richard’s Hospital, Chichester, West Sussex PO19 4SE
E. C. ASHBY
Therapeutic agents cannot reach the fungus which is protected by the keratin in which it grows. Several years ago I acquired onychomycosis of nails of the right thumb and both large toes caused by Trichophyton sp. I was given griseofulvin for a year, with clearing of the thumb nail but only slight improvement in the toenails. Although symptom-free I wanted to eliminate the fungus, so
following
TRYPTOPHAN IN PATIENTS ON CHRONIC HÆMODIALYSIS
SIR,-There is increasing evidence that
low free tryptodepression. In patients on chronic hsemodiatysis, depression and even dementia have been reported.2 Dementia might be a toxic encephalopathy due to trace elements such as copper, zinc, lead, cadmium and aluminium.3-6 But we believe that the psychiatric symptoms may result from a tryptophan deficiency. a
phan concentration is associated with
SERUM TRYPTOPHAN
([Hnol/1) BEFORE AND AFTER HÆMODIALYSIS
I devised the treatment. The nail is washed with soap and water and cleaned with alcohol. Then, with a sterile 18 or 20 gauge needle, five or six holes are drilled in the nail plate, in the form of a crescent about 2 mm distal to the lunula. Anaesthesia is not necessary. However, the introduction of the needle is felt when the nail bed is reached. Cultures may be made from the powder drilled up by the needle. The holes are enlarged by dipping a round toothpick in bichloroacetic acid and drilling through the hole in the nail. When the acid reaches the nail bed a burning sensation is felt. The area also blanches as the acid reaches the fungus in the keratin. Thereafter, an ointment composed of 3% precipitated sulphur, and 3% salicylic acid in petrolatum, is applied on the affected toes each morning. A week later, five or six new holes are drilled about 2 mm distal to and between the original ones, to obtain
greater distribution of the therapeutic agent. The treatment proved effective, presumably because the therapeutic agent could reach the fungus once the protective keratin barrier was breached. If necessary, more holes could be drilled, and further applications of acid or other antifungal agents could be given. If the nail is hard and very thick, a small dental electric drill could be used. The patient should be checked frequently in order to guard against complications such as infections and reactions to the acid.
a
Worcester
City Hospital,
JACOB BREM
Worcester, Massachusetts 01610, U.S.A.
IATROGENIC POLYDIPSIA
Using the method of Denckla and Dewey, we measured total serum-tryptophan before and after dialysis in 9 patients. Initially, it was not particularly low (reference values 40-100
pmol;1), but there was a significant decrease in concentration after dialysis in all patients (see table). The patients had a standardised protein intake (40g/day) supplemented with an essential amino acid preparation (’Aminess’), which was equivalent to a mean of 1-1 .mmol tryptophan/day. We do not know if the decrease in serum-tryptophan after dialysis would have been enough to induce depression and dementia if no extra tryptophan had been given. None of the 9 patients had signs of psychiatric disturbance, but this could be due either to the dietary supplementation or to the relatively short time of dialysis, or both. of Thoracic Medicine, Karolinska Hospital, S-10401 Stockholm, Sweden
Department
Department of Medicine, Karolinska Hospital Department of Clinical Chemistry, Serafirner Hospital, Stockholm
GUNNAR UNGE LARS-ERIC LINS ERIC HULTMAN
TREATING ONYCHOMYCOSIS
StR,-Treatment for onychomycosis is not satisfactory since surgical removal of the toenails and long courses of griseofulvin are usually required. Moreover, recurrences are frequent.’ 1.Coppen, A., Eccleston, E. C., Peet, M. Lancet, 1972,ii, 1415. 2.British Medical Journal. 1976, ii. 1213 3.Flendrig, J. A., Kruis, H., Das, H. A. Lancet, 1976, i, 1235. 4.Ulmer, D.D.New Engl. J.Med. 1976, 294, 218. 5.Platts, M. M., Moorhead, P. J., Gretch, P. Lancet, 1973, ii, 159. 6.Lyle,W.H.ibid.271. 7.Denckla, W. D., Dewey, H. K. J. lab. clin. Med. 1976, 69,160.
SIR,-We describe here sive
water
and
was
a
patient with
a
variant
of compul-
drinking induced by medical advice for the treatment of nephrolithiasis. A 44-year-old post-office worker presented with complaints of excessive thirst and polyuria. 4 years previously, he had had renal colic and had been advised by his physician to increase his fluid intake. Since then he had been drinking water frequently throughout the day. Recently he had had polyuria which interfered with his daily activities, especially while on military reserve duty. During the month before admission, he was drinking every 20 min, micturating with similar frequency unable to work or travel because of his embarrassand dependence on a water supply and adjacent closet. He had nocturia several times. There were no physical findings. The osmolalities of blood and urine were 286 and 87 mosmol/kg H2O, respectively. Blood creatinine, glucose, potassium, and calcium levels were normal. During his admission the patient carefully recorded every fluid intake and urine output. He drank 9 litres by day and 2.8 litres by night and passed comparable quantities of urine. During water deprivation for 14 h, the patient’s urine output decreased and the concentration of his urine rose to 649 mosmol/kg H2O. This was also therapeutic, convincing him of his ability to moderate his fluid intake. He was advised to reduce his drinking to 2.0 litres/day. He remains well after follow-up for 9 months and is working full-time. When a patient has polydipsia and polyuria but normal renal function and glucose.and electrolyte levels, he may have diabetes insipidus or a compulsion to drink water. In this case, the latter seems more likely. The patient did not show the psychological disturbance usual in compulsive water drinking,’1 although the careful records he kept of his fluid balance sug-
ment
1. Barlow, E.
D., de Wardener, H. E. Q. Jl. Med. 1959. 28, 235.
