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IS PNEUMONIA INCREASING? by EWALD TOMANEIC and EDWIN B

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IS PNEUMONIA INCREASING? by EWALD TOMANEIC and EDWIN B PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES Volume 10 MAY 15, 1924 Number 5 IS PNEUMONIA INCREASING? By EWALD TOMANEIC AND EDWIN B. WILSON' HARVARD SCHOOL OF PUBLIC HSALTH, BosToN Read before the Academy April 30, 1924 It is probably impossible to answer the question: Is pneumonia in- creasing? The diagnosis is uncertain; an eminent authority writing to us states that whether a physician reports on a death certificate lobar pneumonia, bronchopneumonia, influenza or bronchitis must rest in many cases on his whim. But if we deal with large numbers it may be contended that the whimsy (chance?) fluctuations should average out and leave the mass statistics accurate-true if the fluctuations are really by chance and exempt from that form4tion and modification of mass habits which is observed in many organic fields. To throw some light on the situation a number of curves will be shown and discussed; the details of the numer- ical values must be reserved for publication when more space is available. SPECIFlC NMTE smr /AV-Am Pfleumo ia,ai iuu1 Sutalesfa. furrebm Ama a ragtftt"itates. .30 ____ _____u 40 4 "Is ,s, , ,,, , \ -- -%.- W IMA4 JL -~ ~ ~i I- Nisx/Wo st AMO4- FIGURE 2 Figure 1 shows on arith-log paper the course of the mortality due to bronchopneumonia, to lobar and undefined pneumonia and to pneumonia Downloaded by guest on September 26, 2021 162 STATISTICS: TOMANEK A ND WILSON PROC. N. A. S. all forms in the U. S. registration area, 1900-1920 inclusive. Like almost all pneumonia curves for the period including 1918 these show the peaks due to influenza, moderate for bronchopneumonia but very marked for lobar and undefined pneumonia and also for pneumonia all forms. Apart from these peaks the death rate from pneumonia other than broncho- pneumonia is clearly declining, sharply for lobar and undefined pneumonia, but moderately for pneumonia all forms in which bronchopneumonia with its steady increase is included. The registration area was rapidly expanding from 1900-1920 from ten states with a population of 31 million to about three quarters of all our states and 87 millions of our population. Figure 2 shows the course of mortality when the statistics are confined to the ten original states. In these, pneumonia all forms is holding about constant (abstraction being made of the influenza year), bronchopneumonia is increasing rapidly, lobar and undefined pneumonia are declining slowly, bronchitis is dropping fast. The marked differences between the course of mortality in the regis- tration area with its greatly widening limits and in the original ten states shows the necessity of holding the geographical limits fast if inferences are to be valid. In figures 3 and 4 are given the age specific mortality rates from respira- tory diseases and pneumonia all forms in the ten original states. Thus not only are changes of geographical area disallowed but fluctuations in the age distribution of the population are held under control. Mortality A16 SPfCfilC NTHR4TE fespoir6to,ow-~~~~~~~~~~~~~~~foCiwases 4 S Cl CD llP T rea wial fgistAwtiee States P emwi. All Forms 'a's"&nsI tke riomd 19001920 /at&elOOVlReg,trfnat i, S&,, , , r~~~~7-oe 4 MOX k 500 ~~~~~60-69 .1 ,Soo 4--4 4 let ~~~~~~-AtXV_ A 20< 200 -oo ,=. s JO _ ,_ N WC 30 l-I 1# 'lll 'lll 'lll 900 1905 me INS 'AS-9/o /Me 9w twoA1- FIGURE 3 FIGURE 4 from respiratory diseases is apparently slowly falling off in all age groups except for the indications that in the groups 10-19 and 20-39 which were Downloaded by guest on September 26, 2021 VoL. 10, 1924 STATISTICS: TOMANEK A ND WILSON 163 hit very hard by the influenza the post-influenza rate has not come back to its pre-influenza figure. Persons over 60 had a lower respiratory and pneumonia mortality in 1918 than in the previous year. The curves for pneumonia are on the whole practically horizontal and indicate no increase or decrease in the mortality from all forms of pneumonia. Figures 5 and 6 give a similar analysis for acute and for chronic bron- chitis. For the former the mortality has been cut in two and for the A&eSPECi/r EATH WATE AWCSPtC/flCDtAH WAE fl fro," Clujnc B&ohitis aAcute in&rchitisthe Ten rign feij&stta5tes TenOr;l i tS tates Owil thehfSd 19-1bt 100 - 200 Xe _ o.DIIIen te Ib,Xrie 19042 a- I2 Z < > e05 ; >A Vw 1905 nGU0 915 AM 19vo IW5 Ns5 -So FIGURE, 5 FIGURE 6 latter somewhat better than cut in two in 21 years. For chronic bron- chitis the decline is at about the same rate in all age groups. For acute bronchitis the situation is somewhat mixed, the rates of decline vary and there is even a slight increase in the most advanced ages. With broncho- pneumonia theie is a marked increase at each age (fig. 7). Whether in reality these rates of increase or decrease are of biological or clinical im- portance, whether they may be due to some progressive change in the dis- eases, or whether they are due to shifting diagnosis, or how the rates of change should best be divided up and assessed in part to the one and in part to the other cause is very difficult to say. In 1910 the group lobar and undefined pneumonia was subdivided and Downloaded by guest on September 26, 2021 164 STATISTICS: TOMANEK AND WILSON PROC. N. A. S.. for 11 years we may trace separately the course of mortality due to lobar and undefined pneumonia as shown in figures 8 and 9. The two groups taken together (fig. 2) exhibited a practically constant mortality in this A¢&SPrCIfIC OEM1Mr Brwpneumania hw &ic/iini R.gisowtStatea lfo-9 0 - FIGURE 7 period (exception being made of the influenza year 1918); but takren indi- vidually we see that undefined pneumonia which started in 1910 with a rate at least as high as lobar has declined with remarkable precipitancy to about one-eighth of its original value while lobar~pneumonia has as steadily climbed in 1920 to about double its mortality in 1910, the effect being particularly marked in thie large age group 20-39. TEN~ORIGINAL R18GISTRATION STAinS 1900-1920 DISEASE MEAN RATE iS. D. TREND DISTURDANCY k p All respiratory 196. =5. -2.6~ .4 10% 11.4 6% PneumoniaA.rP. 152.5 ~2. - .4**3 6% 9.1 6% Pneumonia L. andU. 105.5 ~3.6 -2.1 .4 14%o 9.9 9% Bronchopneumonia 47. =12.3 +1.7=~.13 23%~ 3.2 7% Bronchitis 26.7 ~1.8 -1.3~.1 31% 3.4 9% * The column headed R gives the standard deviation of the residuals after the elim- ination of the trend, and that headed p gives the coefficient of disturbancy measured after the trend is out. In all calculations the excessive rates in 1918 have been dis- carded or adjusted. Considering the supposed considerable effect of the weather on the incidence of and morbidity from these diseases, the reduced coefficients of dis- turbancy p are perhaps surprisingly small. Downloaded by guest on September 26, 2021 VoL. 10, 1924 STATISTICS: TOMANEK AND WILSON 165 We have similar figures for each of the ten original states but shall pass them by. The numerical values for the means, standard deviations, trends, coefficients of disturbancy, etc., are also available. But here we shall offer these values only for the ten states continued. AGf.W(CF/CDIATHPAT A6t1CIfCATHAT (wOM (perim IDODGOCPop. HeAre Ld;r Pmwuenia iref In Ik /OOti atinSxtes kAle/ o "Ig g" mista OurelnthceAwo! k& /0 ta1io Pined _0 0- ----192 500 4. Jo# - a1. k i1. 4- 20 ~ ~ I a k I 1. FIGURE 8 IllI 1I1 I FIGURE, 9 The general inference from this table which is based on a reasonably uniform population over a considerable period of time is that the mor- tality as reported for all respiratory diseases, for lobar and undefined pneu- monia, and for bronchitis is decreasing with a statistically significant trend, whereas bronchopneumonia is increasing and pneumonia all forms is hold- ing steady. Considering, however, the behavior of lobar and undefined pneumonia individually, the difficulties of diagnosis, the many diseases for which pneumonia is the term-iinal phase and others (particularly the heart group) which may complicate and terminate pneumonia, taking further into account the fact that the period 1900-1920 was one of rising prices with rising standards of living and that the economic situation may not always be so favorable, and remembering that the year 1918 (which has to be adjusted in a 21-year series but would have to be taken more fully into account in 50-year series) undoubtedly had a considerable ex- cess of real pneumonia, all that we think it safe at present to infer is that pneumonia is neither increasing or decreasing, that the human organism Downloaded by guest on September 26, 2021 166 MATHEMATICS: G. A. MILLER PROC. N. A. S. is reasonably in equilibrium with its environment with respect to this disease. This paper is a brief account of a small part of a large statistical investigation in the epidemiological situation relative to pneumonia begun by Dr. Tomanek, Fellow of the International Health Board, under Dr. M. J. Rosenau and continued in association with me. A sudden call to the Health Section of the League of Nations forced Dr. Tomanek to leave to me the composition of this work which is so largely his. E. B. W. PRIME POWER SUBSTITUTION GROUPS WHOSE CONJUGATE CYCLES ARE COMMUTATIVE G. A. MILLER DEPARTMUNT OF MATHMATICS, UNIVZRSITY OF ILLINOIS Communicated April 4, 1924 From the fact that the number of letters in every set of conjugate cycles of a substitution group is equal to the order of this group when each such cycle is counted for every substitution in which it appears it may be in- ferred that the further study of the properties of sets of conjugate cycles would be desirable.' One of the simplest cases presents itself when it is assumed that all the cycles in every set of conjugate.
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