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MORPHINE AND MUSCLE SPASM
1301 MORPHINE AND MUSCLE SPASM
SIR,-Mr Young (May 29, p. 1190), concludes that, in clini-
cally useful doses, morphine can produce spasm of striated muscle. His evidence for this is a 27-year-old Russian sailor, of whom no mention is made of any muscle spasm even after repeated injections, and a 24-year-old waiter after a single injection of morphine. Both patients experienced continued pain after morphine had been given. These limited observations would be better explamed by the action of morphine on intrabiliary pressure which is much increased after morphine administration. 1The increase in pain and apparent "spasm" of the rectus muscle in the second case would follow from this rise in intrabiliary pressure and also lead to epigastric tenderness-both symptoms being seen, although to a lesser degree, in acute cholecystitis due to a similar rise in pressure. Administration of diazepam would act both as a voluntary muscle relaxant and also may have some action in reducing the contraction of smooth muscle3 in the gallbladder, so reducing the pain and apparent "spasm" which is secondary to the high
intrabiliary pressure. This, I believe, is
plausible explanation
a more
of the facts
reported. Middlesex Hospital Medical School, London W1P 7PN
LAURENCE WALE
EAR-DROPS
SIR,-We support your view (April 24, p. 896) that "earbe prescribed", but feel there is a further hazard not commented on in your editorial-namely, antibiotic resistance associated with the topical use of antimicrobial agents. We have examined the sensitivity to gentamicin of Pseudomonas ceruginosa isolated in our laboratory from clinical specimens taken in three different hospitals. One hospital is a district general hospital (D.R.H.), the other two being specialised hospitals dealing with ear, nose, and throat and skin diseases. The sensitivity of the organisms to gentamicin, determined by
drops should seldom
GENTAMICIN RESISTANCE AMONG PS. AERUGINOSA ISOLATES IN THREE HOSPITALS to gentamicin of ceruginosa
17c sensitivity Ps.
Hospital
No. of isolates
Gentamicin
prescribed/mo.
—————,-——————.——————.——————-,——————
Fully sensitive
Moderately
Resistant
resistant
Cream/ ointment
(g)
Ear-drops (ml)
General
(D.R.H.) E.N.T.
Skin
1133 800 54
93.8 72.5 51.8
5.3 22.5 27.8
0.9
5.0 20.4
<30 150 810
<10 500 <10
the minimum inhibitory concentration (M.iC.), was graded as fully sensitive (M.!.c.<2 mg/1), moderately resistant (M.iC. 2-5 mg/1), or resistant (M.!.c.>5 mg/1). The results (see table) show a striking increase in resistance at the specialised hospitals as compared with D.R.H. Although cross-infection may be occurring, we believe this difference is due mainly to the topical use of gentamicin in eardrops (500 ml/month at the E.N.T. hospital). and creams and other topical applications (nearly a kilogram/month at the skin hospital). Such preparations are seldom used at D.R.H. The use or, some would say, abuse of antibiotics in topical preparations leading to problems of resistance has been recorded with several antibiotics4and must be a matter of 1. Huck, S., Stacher, G., Gogolák, G., Stumpf, C. Archs int. Pharmacodyn Ther. 1975, 218, 77. 2 Leeuwin, R. S., Djojodibroto, R. D., Groenewoud, E T. ibid. 1975, 217, 18 3. Hopton, D. S., Torrance, H. B. Gut, 1967, 8, 296. 4. Alder, V. G., Gillespie, W. A. Lancet, 1967, ii, 1062. 5. Lowbury, E. J. L., Cason, S. S., Jackson, D. M, Miller, R. W. S. ibid. 1962,
ii, 478.
all clinicians. We are perhaps fortunate that the patients from the specialised units are geographically segregated from the general surgical and medical patients who may require an antibiotic such as gentamicin for the treatment of life-threatenine infections. A. P. GILLETT Department of Microbiology, R. WISE Road Dudley Hospital, G. A. J. AYLIFFE Birmingham B18 7QH concern to
ATYPICAL MYCOBACTERIA AND STERILITY
S!R,—There have been few reports of isolation of mycobacteria, other than Mycobacterium tuberculosis, from endometrium. Even in India the diagnosis of tuberculous endometritis is based mostly if not entirely on histopathological evidences.I-5 Out of 88 endometrial curettage specimens from cases of primary and secondary sterility referred to us as "? tuberculous endometritis" over a period of two years the following Mycobacterium spp. were isolated: tuberculosis (human) 2, kansasii 2, fortuitum 2, and scrofulaceum 18; there were no isolations in 64 cases. The frequency of atypical mycobacteria from endometrial specimens seems to be rather high (25%). Isolations made of atypical mycobacteria from other clinical specimens such as gastric lavage (20.6%), sputum (27.5%), and urine (4%) were also significant. These endometrial specimens were from selected cases of sterility where all other tests, such as histopathology, had been negative. For isolation, the endometrial curettage specimens, received in sterile saline solution, were emulsified using a Ten Broeck tissue grinder. After inoculation into glucose broth, Robertson’s cooked meat medium, and Sabouraud’s glucose broth, the material was further concentrated by Petroff’s6 method for isolation of mycobacteria. From the final deposit smears were made and stained for acid-fast bacteria. The rest was cultured on L8wenstein-jensen medium in duplicate and incubated at 37°C for 8 weeks before being discarded as negative. Any growth8 seen, other than rapid growers, was tested as follows:7 colonial characteristics, cording, growth at 25OC, 37°C, and 44°C, photochromogenicity and scotochromogenecity, catalase, peroxidase, and amidase tests, nitrate reduction, niacin, ’Tween’ hydrolysis for 5 and 10 days, rabbit virulence, and guineapig inoculation. Practically all the specimens were derived from patients in the lower socioeconomic group (i.e., wives of fishermen and farmhands) who were constantly handling freshly caught fish or were in close contact with domestic animals, suggesting a possibility of zoonosis. The environment and the habits of the local population living in this tropical part may have something to do with this high incidence of atypical mycobacterial infection. These women generally bathe daily in the shallow waters of slow-flowing streams and stagnant back waters, and wash the parts after defecation and urination with the same water source.
Maniar and Vanbuckenhout9 from Brandon, Manitoba, have shown that a large number of M. kansasii, isolated from sputum and bronchial washings, could be traced to the "tap water" used in washing the glassware. We checked the tap water and distilled water used in our laboratory and found it 1. Haines, M. Lancet, 1951, i, 436. 2. Sutherland, A. M. Glasg. med. J. 1950, 31, 279. 3. Sutherland, A. M. J. Obstet. Gynœc. Br. Emp. 1956, 63, 161. 4. Sutherland, A. M. Am. J. Obstet. Gynec. 1960, 79, 486. 5. Bhargava, V., Madan, P. J. Obstet. Gynœc. India, 1969, 19, 376. 6. Cruickshank, R., Duguid, J. P., Marmion, B. P., Swain, R. H. N. in Medical Microbiology (edited by R. Cruickshank); vol. II, p. 390. Edinburgh, 1975. 7. Allen, B. W., Baker, F. J. Mycobacteria, p. 24. London, 1968. 8. Buchanan, R. E., Gibson, N. E. (editors). Bergey’s Manual of Determinative Bacteriology, p. 685. Baltimore, 1975. 9. Maniar, A. C., Vanbuckenhout, L. R. Can. J. publ. Hlth, 1976, 67, 59.
SIR,-Mr Young (May 29, p. 1190), concludes that, in clini-
cally useful doses, morphine can produce spasm of striated muscle. His evidence for this is a 27-year-old Russian sailor, of whom no mention is made of any muscle spasm even after repeated injections, and a 24-year-old waiter after a single injection of morphine. Both patients experienced continued pain after morphine had been given. These limited observations would be better explamed by the action of morphine on intrabiliary pressure which is much increased after morphine administration. 1The increase in pain and apparent "spasm" of the rectus muscle in the second case would follow from this rise in intrabiliary pressure and also lead to epigastric tenderness-both symptoms being seen, although to a lesser degree, in acute cholecystitis due to a similar rise in pressure. Administration of diazepam would act both as a voluntary muscle relaxant and also may have some action in reducing the contraction of smooth muscle3 in the gallbladder, so reducing the pain and apparent "spasm" which is secondary to the high
intrabiliary pressure. This, I believe, is
plausible explanation
a more
of the facts
reported. Middlesex Hospital Medical School, London W1P 7PN
LAURENCE WALE
EAR-DROPS
SIR,-We support your view (April 24, p. 896) that "earbe prescribed", but feel there is a further hazard not commented on in your editorial-namely, antibiotic resistance associated with the topical use of antimicrobial agents. We have examined the sensitivity to gentamicin of Pseudomonas ceruginosa isolated in our laboratory from clinical specimens taken in three different hospitals. One hospital is a district general hospital (D.R.H.), the other two being specialised hospitals dealing with ear, nose, and throat and skin diseases. The sensitivity of the organisms to gentamicin, determined by
drops should seldom
GENTAMICIN RESISTANCE AMONG PS. AERUGINOSA ISOLATES IN THREE HOSPITALS to gentamicin of ceruginosa
17c sensitivity Ps.
Hospital
No. of isolates
Gentamicin
prescribed/mo.
—————,-——————.——————.——————-,——————
Fully sensitive
Moderately
Resistant
resistant
Cream/ ointment
(g)
Ear-drops (ml)
General
(D.R.H.) E.N.T.
Skin
1133 800 54
93.8 72.5 51.8
5.3 22.5 27.8
0.9
5.0 20.4
<30 150 810
<10 500 <10
the minimum inhibitory concentration (M.iC.), was graded as fully sensitive (M.!.c.<2 mg/1), moderately resistant (M.iC. 2-5 mg/1), or resistant (M.!.c.>5 mg/1). The results (see table) show a striking increase in resistance at the specialised hospitals as compared with D.R.H. Although cross-infection may be occurring, we believe this difference is due mainly to the topical use of gentamicin in eardrops (500 ml/month at the E.N.T. hospital). and creams and other topical applications (nearly a kilogram/month at the skin hospital). Such preparations are seldom used at D.R.H. The use or, some would say, abuse of antibiotics in topical preparations leading to problems of resistance has been recorded with several antibiotics4and must be a matter of 1. Huck, S., Stacher, G., Gogolák, G., Stumpf, C. Archs int. Pharmacodyn Ther. 1975, 218, 77. 2 Leeuwin, R. S., Djojodibroto, R. D., Groenewoud, E T. ibid. 1975, 217, 18 3. Hopton, D. S., Torrance, H. B. Gut, 1967, 8, 296. 4. Alder, V. G., Gillespie, W. A. Lancet, 1967, ii, 1062. 5. Lowbury, E. J. L., Cason, S. S., Jackson, D. M, Miller, R. W. S. ibid. 1962,
ii, 478.
all clinicians. We are perhaps fortunate that the patients from the specialised units are geographically segregated from the general surgical and medical patients who may require an antibiotic such as gentamicin for the treatment of life-threatenine infections. A. P. GILLETT Department of Microbiology, R. WISE Road Dudley Hospital, G. A. J. AYLIFFE Birmingham B18 7QH concern to
ATYPICAL MYCOBACTERIA AND STERILITY
S!R,—There have been few reports of isolation of mycobacteria, other than Mycobacterium tuberculosis, from endometrium. Even in India the diagnosis of tuberculous endometritis is based mostly if not entirely on histopathological evidences.I-5 Out of 88 endometrial curettage specimens from cases of primary and secondary sterility referred to us as "? tuberculous endometritis" over a period of two years the following Mycobacterium spp. were isolated: tuberculosis (human) 2, kansasii 2, fortuitum 2, and scrofulaceum 18; there were no isolations in 64 cases. The frequency of atypical mycobacteria from endometrial specimens seems to be rather high (25%). Isolations made of atypical mycobacteria from other clinical specimens such as gastric lavage (20.6%), sputum (27.5%), and urine (4%) were also significant. These endometrial specimens were from selected cases of sterility where all other tests, such as histopathology, had been negative. For isolation, the endometrial curettage specimens, received in sterile saline solution, were emulsified using a Ten Broeck tissue grinder. After inoculation into glucose broth, Robertson’s cooked meat medium, and Sabouraud’s glucose broth, the material was further concentrated by Petroff’s6 method for isolation of mycobacteria. From the final deposit smears were made and stained for acid-fast bacteria. The rest was cultured on L8wenstein-jensen medium in duplicate and incubated at 37°C for 8 weeks before being discarded as negative. Any growth8 seen, other than rapid growers, was tested as follows:7 colonial characteristics, cording, growth at 25OC, 37°C, and 44°C, photochromogenicity and scotochromogenecity, catalase, peroxidase, and amidase tests, nitrate reduction, niacin, ’Tween’ hydrolysis for 5 and 10 days, rabbit virulence, and guineapig inoculation. Practically all the specimens were derived from patients in the lower socioeconomic group (i.e., wives of fishermen and farmhands) who were constantly handling freshly caught fish or were in close contact with domestic animals, suggesting a possibility of zoonosis. The environment and the habits of the local population living in this tropical part may have something to do with this high incidence of atypical mycobacterial infection. These women generally bathe daily in the shallow waters of slow-flowing streams and stagnant back waters, and wash the parts after defecation and urination with the same water source.
Maniar and Vanbuckenhout9 from Brandon, Manitoba, have shown that a large number of M. kansasii, isolated from sputum and bronchial washings, could be traced to the "tap water" used in washing the glassware. We checked the tap water and distilled water used in our laboratory and found it 1. Haines, M. Lancet, 1951, i, 436. 2. Sutherland, A. M. Glasg. med. J. 1950, 31, 279. 3. Sutherland, A. M. J. Obstet. Gynœc. Br. Emp. 1956, 63, 161. 4. Sutherland, A. M. Am. J. Obstet. Gynec. 1960, 79, 486. 5. Bhargava, V., Madan, P. J. Obstet. Gynœc. India, 1969, 19, 376. 6. Cruickshank, R., Duguid, J. P., Marmion, B. P., Swain, R. H. N. in Medical Microbiology (edited by R. Cruickshank); vol. II, p. 390. Edinburgh, 1975. 7. Allen, B. W., Baker, F. J. Mycobacteria, p. 24. London, 1968. 8. Buchanan, R. E., Gibson, N. E. (editors). Bergey’s Manual of Determinative Bacteriology, p. 685. Baltimore, 1975. 9. Maniar, A. C., Vanbuckenhout, L. R. Can. J. publ. Hlth, 1976, 67, 59.