[Reprinted from the British Homoeopathic Journal, Oct. 1931.].
Someone has said that there is no more inexact science than that of statistics, and particularly in medicine the value of statistics has been freely criticised, but it is doubtful if there is any alternative.
At first sight pneumonia seems to be an ideal disease in which to demonstrate the value of any particular line of treatment, but it is not so. An acute disease with a natural tendency, under frequent conditions, to terminate by crisis occurring at periods varying from the third, even the second day, to the seventh or the eleventh days, or longer, instead of being an ideal condition for purposes of argument, infact, lends itself to almost every fallacy in reasoning when discussing the beneficial effects of active medical interference.
Pneumonia in general seems to show little or no signs of becoming less common. Figures available for periods of years as widely separated as 1838-42, and 1906-26, show little difference in frequency per million of the population.
If statistics are to be considered of use one must decide which measurements are to be accepted in estimating the value of any particular line of treatment (1).
SHALL IT BE CASE MORTALITY?.
When large series of cases taken over a number of years are considered, the case mortality in uncomplicated lobar pneumonia is said to be 20 per cent. It is, of course, essential that lobar pneumonia should be separated from broncho-pneumonia, and, if possible, from post-influenza pneumonias.
Smaller groups of cases show variations in case mortality from year to year in the same institutions, e.g., the following are the figures from the Edinburgh Royal Infirmary over two seven year periods. Each column indicated per cent for the year:.
1891-2 to 1897-98….25.3 24.4 24.1 33.8 23.8 39.5 35.7
1921-2 to 1927-28….28.2 24.6 25.5 22.3 29.1 33.9 33.0.
On the other hand, long runs of cases without a single death are quoted in the literature, and it is generally considered that undue credit is often given in such case to the particular line of treatment given.
Galbraith, e.g., had 50 consecutive cases without a death (2). The extreme variability in the severity of the cases also renders the information derived from case mortality figures of little value. The use of controls is a more scientific procedure, but again the element of chance cannot be eliminated in that the more serious cases might be in the preponderance in either group. Constitution, previous health, alcoholic habit, age, sex, etc., are all unequal factors, and particularly is age of importance, for as life advances, so do the chances of recovery from lobar pneumonia diminish.
Figures of old series of cases treated by discarded methods are again proof of the weakness of case mortality figures, e.g.:.
In 1,040 cases treated by venesection during 1840-47, the case mortality was only 11.54 per cent.
In 1,576 cases treated without venesection during 1848-55, the case mortality was 10.2.
Other figures are 20 per cent mortality in a series treated with tartar emetic and 7.4 per cent in a series treated expectantly (3).
This wide range in the case mortality figures shows how little value can be placed upon them for purposes of comparing results.
DURATION OF THE DISEASE.
The duration of the disease offers another measurement much more accurate and probably less fallacious, but here again one must remember that recovery in pneumonia is often spontaneous.
The duration of the pyrexia even in untreated cases varies from case to case.
Defervescence occurs from the sixth to the tenth day in 60 per cent of cases, but is of shorter duration in 15 to 20 per cent, and is extended in 20 per cent.
Nearly all tables show a peak on the fifth day greater than on the sixth.
Cases of well authenticated “one day” and “two-day” pneumonias are recorded where no specific form of treatment was used (4).
These are, of course, infrequent, and only odd cases are quoted, ranging from 1898 to 1925. (If such cases are more frequent in our hands, then they must be published.).
One remarkable series of ten one-day pneumonias in one ward is recorded and accepted.
To turn now to methods of shortening the duration of the disease, so-called abortive methods of treatment, one must first consider.
[This is for comparison only and not given as homoeopathic treatment.].
The figures of Wynn (5), of Birmingham, are staggering.
In 100 consecutive cases:.
Of those inoculated on the first day of the disease in 80 per cent the temperature became normal in 24 hours.
Of those inoculated on the second day of the disease, in 57 per cent the temperature became normal in 24 hours.
Of those inoculated on the third day of the disease, in 71 per cent the temperature became normal in 48 hours.
After the third day results are said to be poor, and this corresponds with the statement made by Dr. Kyle recently that, in his opinion, any crisis after the third day was natural and not to be ascribed to treatment.
Wynns figures are not quite unique, and the value of vaccine therapy in pneumonia has been confirmed by many other workers though with less startling success, probably because most of the series have been hospital cases, and it is generally acknowledged that the majority of hospital cases are admitted after the third day.
[This is for comparison only and not given as homoeopathic treatment].
There is no doubt that the serum treatment of pneumonia can offer similar results, particularly when administered early. With the reduction in cost of the preparation of the specific sera, it is likely that the serum treatment of pneumonia will become a routine in orthodox hands.
Pneumococci have been divided by the pathologist into roughly four groups (6):.
Type I, corresponding to 33.6 per cent of all cases, is said to be the causal organism in the pneumonia of young people in which the onset is abrupt, with chill, pain in the chest, rusty sputum, etc., and tending to resolve by crisis. Mortality is in the region of 20 per cent.
Type II, corresponding to 19.1 per cent of all cases, is the most virulent of all and has a mortality of 42 per cent.
Type III, is a common germ in people with a history of old respiratory infection. The onset is usually more gradual, and rusty sputum is rare. It attacks people in the second half of life, and chiefly those with some chronic constitutional disease. The mortality is high, 41 per cent. In cases without systemic disease it is low, 8 per cent, in cases with systemic weakness high, 64 per cent. Thus, in previously healthy adults, the mortality is very low.
Type IV is the most common infective agent in pneumonias, secondary to preceding respiratory infection. The onset is gradual and recovery by lysis. The mortality is 29 per cent.
These percentages are calculated from a series of 2,000 cases.
In those with positive blood-cultures the mortality was 83 per cent. Where the blood-cultures were negative the mortality was only 18.7 per cent.
The actual number of colonies grown is now being used as an index of the severity of the infection.
Recent reports of serum treatment in this country prove that, given early, the disease may be aborted in 24 hours after its administration (7). This seemed to be true up to fourth day of the disease.
OTHER METHODS EXCLUDING HOMOEOPATHY.
Similar claims have been made for the use of nuclein (8), which is supposed to be capable of producing a leucocytosis per se, and for S.U.P., but adequate figures have not yet been given to justify this claim, and in fact there have been definite adverse accounts of the value of both (9).
Treatment by homoeopathic methods can, and does, very definitely abort the course of pneumonia.
As will be inferred from the foregoing, the duration of the disease has been accepted as a reasonable measure of the success or otherwise of treatment in pneumonia.
It must be shown that by the use of such methods the course of the disease is definitely shortened; that the period of defervescence does occur earlier than would otherwise be expected.
When dealing with large numbers of cases the frequency curve of the duration of the disease shows a remarkable uniformity.
When a plea, therefore, is made on behalf of a new remedy, it is considered necessary to draw up a frequency table in percentages showing the days on which the cases became afebrile.
If there is a definite move towards the left, then the contention may be considered justified.
Unfortunately, the published figures dealing with the treatment of pneumonia homoeopathically are few.
One small series (10) recently published has been examined as suggested:.
Of the 19 cases-
1 terminated on the third day……………………5 per cent
2 terminated on the fourth day………………….10 per cent
1 terminated on the fifth day……………………5 per cent
7 terminated on the sixth day…………………..35 per cent
5 terminated on the seventh day…………………25.7 per cent
3 terminated on the eighth day………………….15 per cent.