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In fact, within a few weeks after the beginning of the experiments, no doubt
was left in the minds of the experimenters that the treatment was effective, although
the results were, at the time, anything but favourable from a statistical point of
view.
And last, but not least, I cannot omit to say that the statistical method in its
application to human beings is repulsive to the physician who does not look upon
patients as mere objects of experiment, but as sui similis when he is called upon
to help and to cure.
We come now to explain the principles followed in the selection of cases.
The first principle was to select for treatment cases which were admitted in
the first days of disease ; for it is obvious that, in a disease which leads usually to
death within four days, early treatment give the only chance of recovery.
It has been said that this principle brings about the selection of cases which
have the greatest chance of natural recovery. To this I can give the answer of Dr.
Simonds quoted in his report on the patients treated by him at Karachi with Roux
serum, that it is a "gross error."
Experience and statistics show that in hospitals the highest mortality is just
amongst the patients admitted in the first days of disease. Thus, this principle
leads, on the contrary, to the selection of patients the mortality in whom is higher
than the average.
Considering further, that, on the one hand, more than 30 per cent. of the patients
admitted in the large hospitals are evidently moribund and beyond any possibility of
recovery, dying within 24 hours and even less after admission, and that, on the other
hand, about 20 per cent. recover under ordinary treatment, it was thought best to try
to exclude both categories from the serum treatment. The first, because it could not
reasonably be expected that any treatment could be effective in patients already
showing signs of approaching death ; the second, for mere economy and in order to
meet beforehand the objection that the treated patients would have recovered with-
out specific treatment. In itself there is naturally no reason to exclude the latter :
in such patients the recovery may be hastened and sequelæ prevented. It would,
moreover, he unsafe to rely on nature unaided, when the mortality is one of 80 per cent.
It was usually easy to exclude patients recovering by nature from the treat-
ment.
Experience and statistics show again that in hospitals the majority of recover-
ies by nature takes place in patients admitted in the later stages of the disease,
when the battle for life has already been fought and won outside the hospital.
Greater difficulty was, however, experienced in excluding the small number of
patients brought to the hospital in the first days of disease, who might have recovered
by themselves, and there is no doubt that some such cases came under treatment in
consequence of the impossibility of recognising them as such.
But the greatest difficulty was encountered in excluding cases beyond hope of
recovery. Unexpected sudden changes, never for the better but always for the worse,
are so common in plague, that even the most experienced fail in predicting the
course of the disease. So it happened rather often, that death followed some hours
after the commencement of the treatment, thus demonstrating the error in prognosis.
It may appear to the superficial observer that the exclusion of moribund cases
must have influenced favourably the results of the serum treatment. This is by no
means the case. The place of the excluded moribnnds was taken by other patients,