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A note on certain criticisms of hypertonic salines in the treatment of cholera
522
A N O T E ON C E R T A I N C R I T I C I S M S OF H Y P E R T O N I C S A L I N E S IN T H E T R E A T M E N T OF C H O L E R A . BY
SIR L E O N A R D ROGERS, M.D., F.R.C.P., F.R.C.S., F.R.S., I.M.S. (retd.)
The above criticism by TOMB and THOMSON* of the use of hypertonic salines in cholera consists in an attack, firstly on its theoretical basis, and secondly, and more important, on the facts recorded in its support. The latter is based on a fallacious comparison. It contrasts on the one hand the mortality of 32"6 per cent. which occurred under hypertonic salines in the early period of their use, before the method was fully worked out and in the very serious class of cases admitted to the Calcutta Medical College Hospital ; and on the other that in the villages of the coal fields, and, in the case of permanagnate data quoted, in Bombay villages. Now it is well known that, in most village outbreaks, many more fairly mild cases occur than do in a hospital series. The true comparison is between the same class of cases in the same hospital before and after the introduction of the hypertonic salines, and it is given as follows in the very Table from which these writers quote :--
Period.
Treatment.
Deaths.
Mortality (per cent.).
1,243
783
59'0
Cases.
1895-1905
Rectal and subcutaneous salines ...
1908-1909
Hypertonic intravenous salines . . . . . .
294
96
32"6
1910-1914
Hypertonic plus permanganates . . . . .
858
122
25"9
1915-1919
Hypertonic plus permanganates plus alkalies
1,429
298
20"8
...
Reduction of mortality by hypertonic salines alone ......... Reduction of mortality by hypertonic salines plus permanganates Reduction of mortality by hypertonic salines plus permanganates plus alkalies
45 per cent. 56 per cent, 65 per cent.
Thus, the hypertonic salines alone gave a reduction of mortality of 45 per cent., and my fully-developed system of treatment with the addition of permanganates and alkalies (the hypertonic salines being a most essential part) one of 65 per cent., so that deaths were reduced by almost two-thirds. t~ TOMB, J. WALTER and THOMSON, W. (1927). A Critical Enquiry into the Rationale of Intravenous Hypertonic Saline Injections in the Treatment of Cholera. These TRANSACTIONS, ~x, (8), 516.
CRITICISMS OF HYPERTONIC SALINES IN THE TREATMENT OF CHOLERA.
5~:~
The writers' ignoring of the above figures appears calculated to prejudice my methods seriously, by misleading any who are unacquainted with this conelusive evidence in their favour, to be found in the very Table from which they quote. Nor are the writers much more fortunate in their criticisms of the scientific basis of my methods, relatively unimportant as that is, now that its efficiency has been so amply proved by my minutely recorded hospital data. The latter, moreover, have been confirmed by extensive experience in the Campbell Hospital, Calcutta, in China, and elsewhere, and are shown in Table XXI of my work, which my critics also ignore. In the first place, as they mention, I found that cases with a high blood salt content did better than those with a low one ; a finding which alone justifies the use of hypertonie salines to produce this favourable high salt percentage. Secondly, and more important, they ignore the fact which that eminent bio-chemist, the late BENJAMINMOORE, F.R.S., pointed out in the discussion on Bayliss's gum solution, namely that the hypertonic salines are beneficial in cholera just because of the high salt content which they produce in the blood. This results in the chlorides combining with the cholera toxins, and leads to their excretion through the kidneys--by itself a sufficient justification for their use. They also ignore the fact that, in 1922, M. TSURUMI and T. TOVODA completely confirmed my original investigations, as regards the reduction of the salts, the alkalinity of blood, and the value of both the hypertonic and alkaline solutions. Accordingly, my twelve years' patient Calcutta investigations on the treatment of cholera (resulting in the reduction to almost one-third of its former rate, in eleven years, of the mortality of the same type of serious cases occurring in the same hospital) holds good both practically and theoretically. I have always recognized that to produce the best results these cases require skilled and constant medical and nursing attendance such as are only possible in hospitals ; but this does not alter the value of my full treatment under proper conditions.
A N O T E ON C E R T A I N C R I T I C I S M S OF H Y P E R T O N I C S A L I N E S IN T H E T R E A T M E N T OF C H O L E R A . BY
SIR L E O N A R D ROGERS, M.D., F.R.C.P., F.R.C.S., F.R.S., I.M.S. (retd.)
The above criticism by TOMB and THOMSON* of the use of hypertonic salines in cholera consists in an attack, firstly on its theoretical basis, and secondly, and more important, on the facts recorded in its support. The latter is based on a fallacious comparison. It contrasts on the one hand the mortality of 32"6 per cent. which occurred under hypertonic salines in the early period of their use, before the method was fully worked out and in the very serious class of cases admitted to the Calcutta Medical College Hospital ; and on the other that in the villages of the coal fields, and, in the case of permanagnate data quoted, in Bombay villages. Now it is well known that, in most village outbreaks, many more fairly mild cases occur than do in a hospital series. The true comparison is between the same class of cases in the same hospital before and after the introduction of the hypertonic salines, and it is given as follows in the very Table from which these writers quote :--
Period.
Treatment.
Deaths.
Mortality (per cent.).
1,243
783
59'0
Cases.
1895-1905
Rectal and subcutaneous salines ...
1908-1909
Hypertonic intravenous salines . . . . . .
294
96
32"6
1910-1914
Hypertonic plus permanganates . . . . .
858
122
25"9
1915-1919
Hypertonic plus permanganates plus alkalies
1,429
298
20"8
...
Reduction of mortality by hypertonic salines alone ......... Reduction of mortality by hypertonic salines plus permanganates Reduction of mortality by hypertonic salines plus permanganates plus alkalies
45 per cent. 56 per cent, 65 per cent.
Thus, the hypertonic salines alone gave a reduction of mortality of 45 per cent., and my fully-developed system of treatment with the addition of permanganates and alkalies (the hypertonic salines being a most essential part) one of 65 per cent., so that deaths were reduced by almost two-thirds. t~ TOMB, J. WALTER and THOMSON, W. (1927). A Critical Enquiry into the Rationale of Intravenous Hypertonic Saline Injections in the Treatment of Cholera. These TRANSACTIONS, ~x, (8), 516.
CRITICISMS OF HYPERTONIC SALINES IN THE TREATMENT OF CHOLERA.
5~:~
The writers' ignoring of the above figures appears calculated to prejudice my methods seriously, by misleading any who are unacquainted with this conelusive evidence in their favour, to be found in the very Table from which they quote. Nor are the writers much more fortunate in their criticisms of the scientific basis of my methods, relatively unimportant as that is, now that its efficiency has been so amply proved by my minutely recorded hospital data. The latter, moreover, have been confirmed by extensive experience in the Campbell Hospital, Calcutta, in China, and elsewhere, and are shown in Table XXI of my work, which my critics also ignore. In the first place, as they mention, I found that cases with a high blood salt content did better than those with a low one ; a finding which alone justifies the use of hypertonie salines to produce this favourable high salt percentage. Secondly, and more important, they ignore the fact which that eminent bio-chemist, the late BENJAMINMOORE, F.R.S., pointed out in the discussion on Bayliss's gum solution, namely that the hypertonic salines are beneficial in cholera just because of the high salt content which they produce in the blood. This results in the chlorides combining with the cholera toxins, and leads to their excretion through the kidneys--by itself a sufficient justification for their use. They also ignore the fact that, in 1922, M. TSURUMI and T. TOVODA completely confirmed my original investigations, as regards the reduction of the salts, the alkalinity of blood, and the value of both the hypertonic and alkaline solutions. Accordingly, my twelve years' patient Calcutta investigations on the treatment of cholera (resulting in the reduction to almost one-third of its former rate, in eleven years, of the mortality of the same type of serious cases occurring in the same hospital) holds good both practically and theoretically. I have always recognized that to produce the best results these cases require skilled and constant medical and nursing attendance such as are only possible in hospitals ; but this does not alter the value of my full treatment under proper conditions.