- Email: [email protected]
ANAPHYLAXIS AFTER GENTAMYCIN
455 ABDOMINAL PAIN OF SPINAL ORIGIN
MICROORGANISMS IN AIR OF COTTON MILLS
Diamond and Dr Roberts (July 23, p. 195), one might recall that eradication of a local pain by local injection does not
SiR,-With reference to your editorial, and the letters by Dr
SiR,-The observation by Dr Lockwood and Dr Attwell (July 2, p. 45) that thermophilic actinomycetes, especially Thermoactinomyces vulgaris, occur in the air of cotton mills
necessarily mean that its source has been demonstrated.2-4 As a physiotherapist, I am surprised that an anesthetist should believe that it does, or use it as a basic tenet of diagnosis in musculoskeletal problems. Reference of pain and tenderness to lower abdomen and groin,’-’ and palpable unilateral spasm of the iliopsoas muscle near McBurney’s point,8-10 are common in sacroiliac joint problems. For example, a patient I have treated had low-back and groin symptoms persisting since a gynaecological operation two years previously. Postures for surgery in women are not above suspicion in causing sacroiliac conditions. 10 The patient had the abdominal site of her "entrapment neuropathy" injected, with relief of the pain. The pain returned, accompanied by severe tenderness of the site. The pain and tenderness could then be eradicated on the spot by localised unilateral movement, not a vigorous manipulative thrust, of the hypermobile sacroiliac joint on that side. In my experience "the need for a routine and deliberate
needs to be put into the context of the total microflora of the air and the different processes of cotton spinning before conclusions may be drawn as to its relevance to byssinosis. As part of a survey initiated by the Health and Safety Executive, I have been sampling the air at different sites in a modern cotton mill (mill 1) periodically for more than two years. Additional samples have been taken in an older mill (mill 2). My results suggest that although T. vulgaris can sometimes be common in the air and other actinomycetes can be equally abundant, they are usually outnumbered by mesophilic bacteria.I Two methods of sampling have been used: a cascade impactor2 to give a microscopic assessment of the total spore and dust content of the air, and an Andersen sampler3 to enable identification of the predominant fungi, actinomycetes, and bacteria and to establish the relative abundance of different species. Fungi were isolated on malt-extract agar containing streptomycin and penicillin, and actinomycetes and bacteria were isolated on half-strength nutrient or tryptone/soya/casein
search for tenderness localised to the anterior abdominal wall" (Dr Roberts) is balanced by the need for a careful vertebral examination which includes spinal and paraspinal palpation. The standard of examination of the spine is not as high as it might be, nor is referred tenderness as appreciated as it should be. Perhaps entrapment neuropathy at the abdominal wall in patients who also exhibit spinal problems should not be diagnosed until the vertebral column, and thoracic and pelvic joints have been comprehensively examined; rattling through the spinal movements, testing for neurological signs and taking anteroposterior and lateral X-rays does not constitute a comprehensive examination. Department of Rheumatology and Rehabilitation, Norfolk and Norwich Hospital, Norwich, Norfolk NOR 53A
G. P. GRIEVE
ANAPHYLAXIS AFTER GENTAMYCIN
SIR,-A 66-year-old woman, with a history of ureteric carcinoma treated by nephroureterectomy followed by irradiation, was admitted for severe intractable perineal pain, necrosis of the urethral tissue at the external meatus, and a mild urinary-tract infection. She began to have rigors with a temperature around 39°C, and the probable diagnosis was septicxmia from her urinary tract; she was treated with intravenous gentamicin. Within a minute of the start of the first dose of 80 mg, the patient collapsed with a tachycardia, low blood-pressure, and apnoea. Anaphylaxis was suspected and she was given hydrocortisone 100 mg intravenously after which she made a rapid recovery. Adrenaline was not given because the patient had an exceedingly poor cardiac state, and it was felt that adrenaline might be hazardous. She has shown no subsequent signs that could explain her collapse. General
Hospital,
Birmingham
B4 6NH
F.
J. HALL
1. Lancet, 1977,i, 1190. 2. Melzack, R. The Puzzle of Pain. Harmondsworth, 1973. 3. Samson Wright’s Applied Physiology; p. 381. London, 1973. 4. MacNab,I. Backache, Toronto, 1973. 5. Norman, G. F. Am. J. Surg. 1968, 116, 54. 6. Norman, G. F., May, A. West. J. Surg. 1956, 64, 461. 7. Laban, M. M., Meerschaert, J. R. Archs phys. Med. Rehabil. 8. Lewit, K., Knobloch, V., Faktorova, Z. Man. Med. 1970, 4, 79. 9. Lewit, K., Wolff, H. D. ibid. 1970, 6, 150 10. Bankart, A. S. B. Manipulative Surgery. London, 1932.
1975, 56, 548.
agars containing cycloheximide.4 The samples at mill 1 revealed a fairly consistent pattern, with most air-borne dust close to where bales of cotton were
being opened, decreasing at subsequent stages of processing. Up to I _ 1 X 107 particles/m3 air were found at bale opening of which 2.2 x 105 were fungus spores and 1-4x10’* hyphal fragments, 1.2x106 were "actinomycete spores + bacteria", 8-3x10 were cotton fibres, and 8-8x10* were unidentified dust particles. Counts varied between one sampling occasion and another, depending on cotton quality and mill hygiene, but were usually of the same order of magnitude. The single set of samples from mill 2 showed similar total counts to mill 1 but dust particles were much less numerous while fungus spores and "actinomycete spores + bacteria" were, respectively, three and two times more numerous. On most occasions, and at most sites, gram-negative chromogenic bacteria were by far the most numerous category of microorganism isolated, yielding up to 114 000 colonies/m3 air. However, numbers of bacteria were smaller and Bacillus species more abundant at mill 2 than at mill 1. Fungus colonies were less than half as numerous as bacteria during the early stages of processing and the proportion decreased as processing progressed. Many species of fungi were isolated, with Penicillium spp., Cladosporium spp., Aspe.rgillus niger, and A. versicolor the most common, sometimes with A. ochraceus, A. nidulans, and Rhizopus sp. Actinomycetes were isolated frequently but usually in small numbers and included- Micropolyspora faeni (probably the most important cause of farmer’s T. vulgaris, Nocardiopsis (Actinomadura) dassonvillei, Streptomyces griseus, S. albus, Saccharomonospora viridis, and Thermomonospora sp. T. vulgaris and M. faeni occurred, respectively, in 26% and 32% of air samples, but each was numerous on only one occasion; T. vulgaris at bale opening and blowing sites in mill 1 when more than 15 000 to 35 000 colonies/m3 air were grown and M. fceni at mill 2 which yielded more than 40 000 colonies/m3 air at bale opening. Of a group of T. vulgaris isolates tested for melanin production on C.Y.C./tyrosine medium,6 42% were melanin positive. Samples of cotton taken from bales at the same time as air was sampled in the mill showed that these were the source of most organisms isolated. T. vulgaris was present in 84% of samples and M. fceni in 36%, although numbers were seldom large.
lungS),
1. Lacey, J. Rep. Rothamsted exp. Stn. 1977, part 1, p. 255. 2. May, K. R. J. sci. Instrum. 1945, 22, 187. 3. Andersen, A. A. J. Bact. 1958, 76, 471. 4. Lacey, J., Dutkiewicz, J. J. appl. Bact. 1976, 41, 315. 5. Pepys, J., Jenkins, P. A., Festenstein, G. N., Gregory, P. H., Skinner, F. A. Lancet, 1963, ii, 607. 6. Cross, T., Unsworth, B. A. ibid. 1976, i, 959.
Lacey,
M.
E.,
MICROORGANISMS IN AIR OF COTTON MILLS
Diamond and Dr Roberts (July 23, p. 195), one might recall that eradication of a local pain by local injection does not
SiR,-With reference to your editorial, and the letters by Dr
SiR,-The observation by Dr Lockwood and Dr Attwell (July 2, p. 45) that thermophilic actinomycetes, especially Thermoactinomyces vulgaris, occur in the air of cotton mills
necessarily mean that its source has been demonstrated.2-4 As a physiotherapist, I am surprised that an anesthetist should believe that it does, or use it as a basic tenet of diagnosis in musculoskeletal problems. Reference of pain and tenderness to lower abdomen and groin,’-’ and palpable unilateral spasm of the iliopsoas muscle near McBurney’s point,8-10 are common in sacroiliac joint problems. For example, a patient I have treated had low-back and groin symptoms persisting since a gynaecological operation two years previously. Postures for surgery in women are not above suspicion in causing sacroiliac conditions. 10 The patient had the abdominal site of her "entrapment neuropathy" injected, with relief of the pain. The pain returned, accompanied by severe tenderness of the site. The pain and tenderness could then be eradicated on the spot by localised unilateral movement, not a vigorous manipulative thrust, of the hypermobile sacroiliac joint on that side. In my experience "the need for a routine and deliberate
needs to be put into the context of the total microflora of the air and the different processes of cotton spinning before conclusions may be drawn as to its relevance to byssinosis. As part of a survey initiated by the Health and Safety Executive, I have been sampling the air at different sites in a modern cotton mill (mill 1) periodically for more than two years. Additional samples have been taken in an older mill (mill 2). My results suggest that although T. vulgaris can sometimes be common in the air and other actinomycetes can be equally abundant, they are usually outnumbered by mesophilic bacteria.I Two methods of sampling have been used: a cascade impactor2 to give a microscopic assessment of the total spore and dust content of the air, and an Andersen sampler3 to enable identification of the predominant fungi, actinomycetes, and bacteria and to establish the relative abundance of different species. Fungi were isolated on malt-extract agar containing streptomycin and penicillin, and actinomycetes and bacteria were isolated on half-strength nutrient or tryptone/soya/casein
search for tenderness localised to the anterior abdominal wall" (Dr Roberts) is balanced by the need for a careful vertebral examination which includes spinal and paraspinal palpation. The standard of examination of the spine is not as high as it might be, nor is referred tenderness as appreciated as it should be. Perhaps entrapment neuropathy at the abdominal wall in patients who also exhibit spinal problems should not be diagnosed until the vertebral column, and thoracic and pelvic joints have been comprehensively examined; rattling through the spinal movements, testing for neurological signs and taking anteroposterior and lateral X-rays does not constitute a comprehensive examination. Department of Rheumatology and Rehabilitation, Norfolk and Norwich Hospital, Norwich, Norfolk NOR 53A
G. P. GRIEVE
ANAPHYLAXIS AFTER GENTAMYCIN
SIR,-A 66-year-old woman, with a history of ureteric carcinoma treated by nephroureterectomy followed by irradiation, was admitted for severe intractable perineal pain, necrosis of the urethral tissue at the external meatus, and a mild urinary-tract infection. She began to have rigors with a temperature around 39°C, and the probable diagnosis was septicxmia from her urinary tract; she was treated with intravenous gentamicin. Within a minute of the start of the first dose of 80 mg, the patient collapsed with a tachycardia, low blood-pressure, and apnoea. Anaphylaxis was suspected and she was given hydrocortisone 100 mg intravenously after which she made a rapid recovery. Adrenaline was not given because the patient had an exceedingly poor cardiac state, and it was felt that adrenaline might be hazardous. She has shown no subsequent signs that could explain her collapse. General
Hospital,
Birmingham
B4 6NH
F.
J. HALL
1. Lancet, 1977,i, 1190. 2. Melzack, R. The Puzzle of Pain. Harmondsworth, 1973. 3. Samson Wright’s Applied Physiology; p. 381. London, 1973. 4. MacNab,I. Backache, Toronto, 1973. 5. Norman, G. F. Am. J. Surg. 1968, 116, 54. 6. Norman, G. F., May, A. West. J. Surg. 1956, 64, 461. 7. Laban, M. M., Meerschaert, J. R. Archs phys. Med. Rehabil. 8. Lewit, K., Knobloch, V., Faktorova, Z. Man. Med. 1970, 4, 79. 9. Lewit, K., Wolff, H. D. ibid. 1970, 6, 150 10. Bankart, A. S. B. Manipulative Surgery. London, 1932.
1975, 56, 548.
agars containing cycloheximide.4 The samples at mill 1 revealed a fairly consistent pattern, with most air-borne dust close to where bales of cotton were
being opened, decreasing at subsequent stages of processing. Up to I _ 1 X 107 particles/m3 air were found at bale opening of which 2.2 x 105 were fungus spores and 1-4x10’* hyphal fragments, 1.2x106 were "actinomycete spores + bacteria", 8-3x10 were cotton fibres, and 8-8x10* were unidentified dust particles. Counts varied between one sampling occasion and another, depending on cotton quality and mill hygiene, but were usually of the same order of magnitude. The single set of samples from mill 2 showed similar total counts to mill 1 but dust particles were much less numerous while fungus spores and "actinomycete spores + bacteria" were, respectively, three and two times more numerous. On most occasions, and at most sites, gram-negative chromogenic bacteria were by far the most numerous category of microorganism isolated, yielding up to 114 000 colonies/m3 air. However, numbers of bacteria were smaller and Bacillus species more abundant at mill 2 than at mill 1. Fungus colonies were less than half as numerous as bacteria during the early stages of processing and the proportion decreased as processing progressed. Many species of fungi were isolated, with Penicillium spp., Cladosporium spp., Aspe.rgillus niger, and A. versicolor the most common, sometimes with A. ochraceus, A. nidulans, and Rhizopus sp. Actinomycetes were isolated frequently but usually in small numbers and included- Micropolyspora faeni (probably the most important cause of farmer’s T. vulgaris, Nocardiopsis (Actinomadura) dassonvillei, Streptomyces griseus, S. albus, Saccharomonospora viridis, and Thermomonospora sp. T. vulgaris and M. faeni occurred, respectively, in 26% and 32% of air samples, but each was numerous on only one occasion; T. vulgaris at bale opening and blowing sites in mill 1 when more than 15 000 to 35 000 colonies/m3 air were grown and M. fceni at mill 2 which yielded more than 40 000 colonies/m3 air at bale opening. Of a group of T. vulgaris isolates tested for melanin production on C.Y.C./tyrosine medium,6 42% were melanin positive. Samples of cotton taken from bales at the same time as air was sampled in the mill showed that these were the source of most organisms isolated. T. vulgaris was present in 84% of samples and M. fceni in 36%, although numbers were seldom large.
lungS),
1. Lacey, J. Rep. Rothamsted exp. Stn. 1977, part 1, p. 255. 2. May, K. R. J. sci. Instrum. 1945, 22, 187. 3. Andersen, A. A. J. Bact. 1958, 76, 471. 4. Lacey, J., Dutkiewicz, J. J. appl. Bact. 1976, 41, 315. 5. Pepys, J., Jenkins, P. A., Festenstein, G. N., Gregory, P. H., Skinner, F. A. Lancet, 1963, ii, 607. 6. Cross, T., Unsworth, B. A. ibid. 1976, i, 959.
Lacey,
M.
E.,