[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.
At first sight these figures may not appear striking, but when plotted against the standard figures they do show that the move to the left which is indicative of improved results.
LONDON HOMOEOPATHIC HOSPITAL STATISTICS.
I have extracted from the hospital records the notes of 87 cases of lobar pneumonia between the years of 1920-29. I cannot claim that these are all the cases of pneumonia treated during that period, but they include all the cases under the direct care of three physicians and as many single cases as could be traced in the records of the various assistant physicians.
Unfortunately the records are not yet fully indexed, and so one had to go through all the records for that period.
Excluding moribund cases there were seventeen deaths 19.5 per cent mortality, a very average figure.
1 case had crisis on the second day of the disease.
1 case had crisis on the third day of the disease.
4 cases had crisis on the fourth day of the disease.
7 cases had crisis on the fifth day of the disease.
13 cases had crisis on the sixth day of the disease.
15 cases had crisis on the seventh day of the disease.
8 cases had crisis on the eighth day of the disease.
5 cases had crisis on the ninth day of the disease.
16 cases had crisis on the tenth onward.
Calculated on a percentage of cases by a certain day the figures are as follows. For a comparison and as a basis for the curve, the figures of other large series of cases are shown as well as those of Rorke previously noted (11).
Day…………. 2 3 4 5 6 7 8 9
L.H.H……….. 1.1 1.1 4.6 8.0 15.0 17.2 9.2 –
Rorke……….. 0 5.0 10.0 5.0 35.0 25.0 15.0 –
266…………. 0 1.5 4.7 14.2 12.4 16.9 11.6 –
829…………. 0.5 3.0 5.9 11.3 10.3 18.2 12.9 -.
It will be seen that the hospital figures are only average and there is no move to the left so apparent in those of Rorke. It is to be noted that the majority of cases were not admitted earlier than the third day, and it is the opinion of some that this is more common in our hospital than in others.
From a consideration of the hospital records I would urge:.
1. That an accurate account of the onset be obtained and that the date rather than the day of the week be noted for the convenience of those who may in later years be studying the records.
Particular attention should be paid to the onset by chill, or pain, or cough, as denoting different and chronological stages of the disease.
2. That as far as possible pneumonias be treated as “star” cases and the opinion of the physician be sought on the day of the admission.
3. That reasons for the administration of the particular remedy be given.
4. That the case be typed according to modern bacteriological methods.
It might be possible to verify the opinion that, e.g., Bryonia is a remedy for illness of slow onset and therefore for Types III and IV rather than for Type I.
5. That blood-cultures be made and the severity of the disease compared with the number of colonies noted.
In conclusion, might I say that there are those who think we claim too much. One orthodox colleague has asked me to get you to publish your results in pneumonia, if they are as good as you claim them to be. I know that we can abort the disease, but the orthodox school are not interested in opinions. They will have figures. I have tried to show that adopting their own criteria of success Rorkes figures are good but, knowing how important it is to get the cases early, I feel that there must be a large number of cases in private practice unrecorded which would be overwhelmingly convincing if collected.
Please let us have them for publication.