768 be interpreted cautiously. Nevertheless, our patient’s illness did worsen fulminantly after rubeola immunisation. Measles vaccine and gammaglobulin have been administered to patients with S.S.P.E.,2.3 but we know of no other patients with S.S.P.E. being similarly affected by rubeola immunisation. Departments of Neurological Surgery W. EDWIN DODSON and Neurology and Pediatrics, JOSEPH PASTERNAK School of Medicine, Washington University to
St. Louis, Missouri 63110, U.S.A.
JOHN L. TROTTER
INTERNATIONAL RESEARCH LABORATORY IN BANGLADESH
SiR,—The scientific directors of the Cholera Research
Laboratory (March 18, p. 602) state that the C.R.L. had had a "modus operandi which is now acknowledged as imperfect". An understanding of these imperfections is important if we are to understand why many people in Bangladesh (myself included) feel that efforts to reform the C.R.L. have so far been inadequate, however well intentioned. Experiments have been done at the C.R.L. which have paid little regard to the rights and needs of the subjects of the research and which have been done without informed consent. The following experiments would not, in my opinion, have been passed by ethics committees elsewhere:
(a) Radioactive materials were given to cholera patients. (b) Tubes were passed through the entire intestinal tract from mouth to anus to measure "transmural electric potential" in cholera patients. (c) Biopsies were taken from the jejunum and other parts of the
mother in hospital the nature of the oral fluid she is feeding her sick child, and there are still no firm plans for training fieldworkers in the study area to use oral fluids. No effort has been made to develop practical sanitary measures to prevent the spread of cholera even though the disease is probably highly susceptible to environmental control. The intravenous fluid production plant is a good example of useful cooperation with a local institution (the Institute of Public Health), but it is the only one. The scientific programme has been of high quality, intellectually, but it needs to be kept in perspective. The principles of the treatment of cholera by intravenous fluids were well established before the C.R.L. opened. Oral sugar and salt has been used for decades: it was studied scientifically in 19531 and rediscovered in 1968.2 The "Dacca formula" may even have obstructed progress for a time since patients in shock or vomiting need intravenous fluids while those who are not probably do just as well with sucrose and table salt. The main contributions of the C.R.L. have been careful vaccine trials,3 some important observations of natural determinants of fertility,4.5 and many physiological studies of diarrhcea patients which are of little practical significance. An international centre for diarrhoea disease research with a broader mandate and a commitment to service could contribute to the health of the people of Bangladesh, but this cannot happen if present realities are ignored, as in the letter from Dr Mosley and his colleagues. The present programme and the posture in negotiations with the government of Bangladesh reflect a similar lack of appreciation of the existence of serious a
to
problems. Cholera Research
Laboratory,
COLIN MCCORD
Dacca, Bangladesh
intestine.
(d) Proper treatment was withheld from patients in coma and suspected to have acute hypoglycxmia in order to test a hypothesis; glucagon was given instead of intravenous glucose to see whether glycogen stores were depleted. Liver glycogen was depleted and one patient died who might have survived with prompt administration of glucose. (e) Catheters were passed through the heart and into the pulmonary artery to study the haemodynamic effects of cholera and of different kinds of fluid replacement. (f) When it was observed that there was a high incidence of cholera in villages downstream from the Cholera Hospital at Matlab, the first reaction was not to improve the sanitary problem, but to use these villages as a place to test whether installation of tubewells would prevent cholera. The experiment was a failure. Subsequently, measures were introduced to prevent contamination of the water by the hospital. months ago an ethical review system which appears any in the world was set up, but since there was an ethical review committee at the time the experiments in question were done, the critics are not convinced that the review process will work properly without radical changes in the organisation and objectives of the laboratory. The change to a significant role for Bangladeshi scientists in C.R.L. has been so rapid that it is unconvincing. True, about half the scientific workers are now Bangladeshi and about 85% of major papers in 1976-77 had Bangladeshi principal authors, but before 1976 all senior scientific posts were held by expatriates and 90% of all publications in international journals had expatriates as senior authors. (4 Bangladeshi scientists began to play larger roles in the mid-1970s, sometimes despite opposition from the administration.) At present eight out of thirty-one approved research protocols have Bangladeshi prinas
Eight good
as
cipal investigators. The C.R.L.’s record of service to the people of Bangladesh is dismal. More than half the 500 000 people treated at the hospitals were outpatients, and it seems unlikely that 20% (100 000) would have died without treatment. No-one teaches 2.
3.
Jabbour, J. T., Duenas, A. A., Modlin, J. ibid. 1975, 32, 496. Agnarsdottir, G. in Recent Advance in Clinical Virology (edited by Waterson); p. 21. New York, 1977.
A. P.
VIBRATION-ASSISTED BLADDER EMPTYING IN MULTIPLE SCLEROSIS
SIR,-Having read Nathan’s letter on emptying the paralysed bladder,6 we decided to try the use of a vibrator in eight patients with multiple sclerosis and four patients who were paraplegic after spinal-cord injuries above Dl0. These patients had been applying manual pressure or repeated tapping above the pubis to empty their bladders. For 4 weeks frequency of micturition and urine volume per micturition were recorded. Bladder residue was determined twice a week. Urine cultures were done four times a week. Three mt.s. patients and two paraplegic patients had chronic bladder infections; the urine of the remaining patients was sterile. Lowenstein culture was negative in all cases. Bladder stones or anatomical distortions were excluded by intravenous
pyelography. No vibrator
used during the first fortnight. During the between umbilicus and pubis was vibration following fortnight used four or six times a day. The vibrator had a frequency of 110 Hz and a mechanical output of 0 - 2-0.3mm. Throughout the test period medication was kept constant. In the M.S. patients the frequency of micturition tended to fall when the vibrator was used while the volume per micturition rose (see table). In some patients micturition during the second half of the night ceased and they slept better. Most remarkable was the reduction in residual urine volume (see table). An undesirable effect was secondary diarrhoea in three M.S. patients; this was transient in two but vibration-assisted bladder emptying had to be suspended for 5 days in one patient. We are now investigating the influence of vibration on was
rectal dysfunction in M.s. 1. 2. 3. 4. 5. 6.
patients.
Chatterjee, H. N. Lancet, 1953, ii, 1063. Nalin, D. R., and others ibid. 1968, ii, 370. Mosley, W. H., and others Bull. Wld Hlth Org. 1969, 40, 187. Chen, L. C., and others Popa Stud. 1974, 28, 277. Mosley, W. H., and others J. biosoc. Sci. 1977, suppl. 4, p. 93. Nathan, P. Lancet, 1977, i, 377.
St. Louis, Missouri 63110, U.S.A.
JOHN L. TROTTER
INTERNATIONAL RESEARCH LABORATORY IN BANGLADESH
SiR,—The scientific directors of the Cholera Research
Laboratory (March 18, p. 602) state that the C.R.L. had had a "modus operandi which is now acknowledged as imperfect". An understanding of these imperfections is important if we are to understand why many people in Bangladesh (myself included) feel that efforts to reform the C.R.L. have so far been inadequate, however well intentioned. Experiments have been done at the C.R.L. which have paid little regard to the rights and needs of the subjects of the research and which have been done without informed consent. The following experiments would not, in my opinion, have been passed by ethics committees elsewhere:
(a) Radioactive materials were given to cholera patients. (b) Tubes were passed through the entire intestinal tract from mouth to anus to measure "transmural electric potential" in cholera patients. (c) Biopsies were taken from the jejunum and other parts of the
mother in hospital the nature of the oral fluid she is feeding her sick child, and there are still no firm plans for training fieldworkers in the study area to use oral fluids. No effort has been made to develop practical sanitary measures to prevent the spread of cholera even though the disease is probably highly susceptible to environmental control. The intravenous fluid production plant is a good example of useful cooperation with a local institution (the Institute of Public Health), but it is the only one. The scientific programme has been of high quality, intellectually, but it needs to be kept in perspective. The principles of the treatment of cholera by intravenous fluids were well established before the C.R.L. opened. Oral sugar and salt has been used for decades: it was studied scientifically in 19531 and rediscovered in 1968.2 The "Dacca formula" may even have obstructed progress for a time since patients in shock or vomiting need intravenous fluids while those who are not probably do just as well with sucrose and table salt. The main contributions of the C.R.L. have been careful vaccine trials,3 some important observations of natural determinants of fertility,4.5 and many physiological studies of diarrhcea patients which are of little practical significance. An international centre for diarrhoea disease research with a broader mandate and a commitment to service could contribute to the health of the people of Bangladesh, but this cannot happen if present realities are ignored, as in the letter from Dr Mosley and his colleagues. The present programme and the posture in negotiations with the government of Bangladesh reflect a similar lack of appreciation of the existence of serious a
to
problems. Cholera Research
Laboratory,
COLIN MCCORD
Dacca, Bangladesh
intestine.
(d) Proper treatment was withheld from patients in coma and suspected to have acute hypoglycxmia in order to test a hypothesis; glucagon was given instead of intravenous glucose to see whether glycogen stores were depleted. Liver glycogen was depleted and one patient died who might have survived with prompt administration of glucose. (e) Catheters were passed through the heart and into the pulmonary artery to study the haemodynamic effects of cholera and of different kinds of fluid replacement. (f) When it was observed that there was a high incidence of cholera in villages downstream from the Cholera Hospital at Matlab, the first reaction was not to improve the sanitary problem, but to use these villages as a place to test whether installation of tubewells would prevent cholera. The experiment was a failure. Subsequently, measures were introduced to prevent contamination of the water by the hospital. months ago an ethical review system which appears any in the world was set up, but since there was an ethical review committee at the time the experiments in question were done, the critics are not convinced that the review process will work properly without radical changes in the organisation and objectives of the laboratory. The change to a significant role for Bangladeshi scientists in C.R.L. has been so rapid that it is unconvincing. True, about half the scientific workers are now Bangladeshi and about 85% of major papers in 1976-77 had Bangladeshi principal authors, but before 1976 all senior scientific posts were held by expatriates and 90% of all publications in international journals had expatriates as senior authors. (4 Bangladeshi scientists began to play larger roles in the mid-1970s, sometimes despite opposition from the administration.) At present eight out of thirty-one approved research protocols have Bangladeshi prinas
Eight good
as
cipal investigators. The C.R.L.’s record of service to the people of Bangladesh is dismal. More than half the 500 000 people treated at the hospitals were outpatients, and it seems unlikely that 20% (100 000) would have died without treatment. No-one teaches 2.
3.
Jabbour, J. T., Duenas, A. A., Modlin, J. ibid. 1975, 32, 496. Agnarsdottir, G. in Recent Advance in Clinical Virology (edited by Waterson); p. 21. New York, 1977.
A. P.
VIBRATION-ASSISTED BLADDER EMPTYING IN MULTIPLE SCLEROSIS
SIR,-Having read Nathan’s letter on emptying the paralysed bladder,6 we decided to try the use of a vibrator in eight patients with multiple sclerosis and four patients who were paraplegic after spinal-cord injuries above Dl0. These patients had been applying manual pressure or repeated tapping above the pubis to empty their bladders. For 4 weeks frequency of micturition and urine volume per micturition were recorded. Bladder residue was determined twice a week. Urine cultures were done four times a week. Three mt.s. patients and two paraplegic patients had chronic bladder infections; the urine of the remaining patients was sterile. Lowenstein culture was negative in all cases. Bladder stones or anatomical distortions were excluded by intravenous
pyelography. No vibrator
used during the first fortnight. During the between umbilicus and pubis was vibration following fortnight used four or six times a day. The vibrator had a frequency of 110 Hz and a mechanical output of 0 - 2-0.3mm. Throughout the test period medication was kept constant. In the M.S. patients the frequency of micturition tended to fall when the vibrator was used while the volume per micturition rose (see table). In some patients micturition during the second half of the night ceased and they slept better. Most remarkable was the reduction in residual urine volume (see table). An undesirable effect was secondary diarrhoea in three M.S. patients; this was transient in two but vibration-assisted bladder emptying had to be suspended for 5 days in one patient. We are now investigating the influence of vibration on was
rectal dysfunction in M.s. 1. 2. 3. 4. 5. 6.
patients.
Chatterjee, H. N. Lancet, 1953, ii, 1063. Nalin, D. R., and others ibid. 1968, ii, 370. Mosley, W. H., and others Bull. Wld Hlth Org. 1969, 40, 187. Chen, L. C., and others Popa Stud. 1974, 28, 277. Mosley, W. H., and others J. biosoc. Sci. 1977, suppl. 4, p. 93. Nathan, P. Lancet, 1977, i, 377.
