Thomas Graham Balfour 1813 - 1891

Thomas Graham Balfour 1813 - 1891 MD FRS 1859 - 1873 was a Scottish physician noted for his work with medical statistics, and a member of  Florence Nightingale’s inner circle. (1st) Head of the (new) Statistical Branch of the Army Medical Service, 1873 Surgeon General, President of the Royal Statistical Society. Fellow of Royal College of Physicians of London, President of the Royal Statistical Society, Surgeon to the Duke of York’s Asylum Chelsea, and in 1887 Thomas Graham Balfour was appointed honorary physician to Queen Victoria.

Balfour’s clinical trial of belladonna to prevent scarlet fever resulted in his comment: ”Had I given the remedy to all the boys, I should probably have attributed it to the cessation of the epidemic.”

Balfour was a colleague of Florence Nightingale, Sidney Herbert,

From http://www.jameslindlibrary.org/illustrating/records/quoted-in-west-c-lectures-on-the-diseases-of-infancy-and-childh/articles ‘… Thomas Graham Balfour’s 1854 clinical trial of belladonna given to prevent scarlet fever appears to have been his only published example of clinical research, his main achievements being his key role in the compilation and analysis of naval and military statistics work which was subsequently reflected in his presidency of the Royal Statistical Society.

Balfour was recognised as exceptional during his involvement in assembling and analysing the military statistics that had accumulated since the Waterloo campaign. A letter to the War Office just after Balfour’s 27th birthday by his superior officer, Major Alexander Tulloch, reads:

“I am happy to have this opportunity of expressing to the Secretary at War my sense of the value of this officer’s services, not only in regard to this investigation but in the preparation of the voluminous documents from which the Statistical Reports have been framed, & in which he has constantly afforded me his assistance without any other remuneration than the regimental pay of his rank”.

Seven years later, (then Colonel) Alexander Tulloch wrote to the Minister at War seeking funding for Balfour to conduct further analyses of statistics on incapacity and mortality among army pensioners:

“…I am not aware of any other of his standing in the Service who combines the requisite degree of Medical and Statistical knowledge… Medical Men are, generally, the last persons in the world to be trusted in matters of figures, and I had too much experience of the difficulty of dealing with them when I commenced this undertaking, ever to trust to indiscriminate assistance again from that profession”.

The following year (1848), Balfour was appointed surgeon at the Royal Military Asylum for soldiers’ orphans at Chelsea, and it was here that he conducted his controlled trial to assess whether belladonna prevented scarlet fever (scarlatina)…’

From http://www.jameslindlibrary.org/illustrating/records/quoted-in-west-c-lectures-on-the-diseases-of-infancy-and-childh/articles ‘… Thomas Graham Balfour’s 1854 report of a clinical trial of belladonna given to prevent scarlet fever appears to have been his only published example of clinical research, his main achievements being his key role in the compilation and analysis of naval and military statistics (Balfour 1845; 1872; 1880), work which was subsequently reflected in his presidency of the Royal Statistical Society (Balfour 1889).

Balfour was recognised as exceptional during his involvement in assembling and analysing the military statistics that had accumulated since the Waterloo campaign. A letter to the War Office just after Balfour’s 27th birthday by his superior officer, Major Alexander Tulloch, reads:

“I am happy to have this opportunity of expressing to the Secretary at War my sense of the value of this officer’s services, not only in regard to this investigation but in the preparation of the voluminous documents from which the Statistical Reports have been framed, & in which he has constantly afforded me his assistance without any other remuneration than the regimental pay of his rank.” (Major Alexander Tulloch 1840).

Seven years later, (then Colonel Alexander Tulloch) wrote to the Minister at War seeking funding for Balfour to conduct further analyses of statistics on incapacity and mortality among army pensioners:

“…I am not aware of any other of his standing in the Service who combines the requisite degree of Medical and Statistical knowledge… Medical Men are, generally, the last persons in the world to be trusted in matters of figures, and I had too much experience of the difficulty of dealing with them when I commenced this undertaking, ever to trust to indiscriminate assistance again from that profession.” (Colonel Alexander Tulloch 1847)

The following year (1848), Balfour was appointed surgeon at the Royal Military Asylum for soldiers’ orphans at Chelsea, and it was here that he conducted his controlled trial to assess whether belladonna prevented scarlet fever (scarlatina). A searching review of the evidence bearing on this question was published by James Warburton Begbie the year after Balfour’s controlled trial, and helps to set the study in context (James Warburton Begbie 1855).

Half a century earlier, Samuel Hahnemann, the founder of homeopathic medicine, had published a pamphlet recommending homeopathic belladonna as a prophylactic against scarlet fever. Samuel Hahnemann’s designation of this “divine remedy as a preservative” led others to adopt it, and not only homeopaths.

For example, Christoph Wilhelm von Hufeland, who has been described as the greatest German clinician of the late 18th century (Habrich 1991) and founded a respected and still extant medical journal in Göttingen, reported in an article published in The Lancet in 1829 that:

“I. The proper use of belladonna has, in most cases, prevented infection, even in those instances where, by the continual intercourse with patients labouring under scarlet fever, the predisposition towards it was greatly increased. “II. Numerous observations have shown that, by the general use of belladonna, epidemics of scarlet fever have actually been arrested. “III. In those few instances where the use of belladonna was insufficient to prevent infection, the disease has been invariably slight. “IV. There are exceptions to the above three points, but their number is extremely small.”

The evidence for these and similar inferences was examined and challenged by James Warburton Begbie, who refers to “the interesting experiments of Dr. Balfour”, which had been recorded, between quotation marks, in the 3rd edition of a book of lectures on the diseases of infancy and childhood published the previous year by Charles West, founder of the Great Ormond Street Hospital (Charles West 1854).

Balfour’s account of his trial must rate as one of the most succinct and careful accounts of a clinical experiment ever written:

“There were 151 boys of whom I had tolerably satisfactory evidence that they had not had scarlatina; I divided them in two sections, taking them alternately from the list, to prevent the imputation of selection.

“To the first section (76) I gave belladonna; to the second (75) I gave none; the result was that two in each section were attacked by the disease. The numbers are too small to justify deductions as to the prophylactic power of belladonna, but the observation is good, because it shows how apt we are to be misled by imperfect observation.

“Had I given the remedy to all the boys, I should probably have attributed to it the cessation of the epidemic”.

In these four sentences, Balfour addresses the application of eligibility criteria, control of allocation bias, the problem of Type 2 statistical errors (that is, false negatives), and the dangers of reliance on uncontrolled case series as a basis for causal inferences about the effects of treatment.

Balfour’s caution in referring to the numbers of cases being “too small to justify deductions as to the prophylactic power of belladonna” is especially noteworthy.

Indeed, the celebrated medical statistician William Guy was rather less cautious when, in his Croonian Lectures on The numerical method, and its application to the science and art of medicine (William Guy 1860), he used Balfour’s experiment to illustrate that “Average Values derived from Small Numbers of Facts are sufficient to refute rash Assertions… based on wild and fanciful Hypotheses.”

“I think you will agree with me”, he wrote, “that a perfectly gratuitous assertion, advanced in support of a very fanciful hypothesis, has met at Dr. Balfour’s hands with much more respectful treatment than it deserves, and that the facts adduced are amply sufficient under the circumstances of the case.” (William Guy 1860)

Balfour’s controlled trial is one of three controlled evaluations of the effects of belladonna in scarlet fever considered in James Warburton Begbie’s 1855 review of the evidence. In an evaluation that appears to have been contemporary with Balfour’s, Andrew Wood reported his experience in Heriot’s Hospital as follows:

“The plan I proposed to myself was this - viz.: whenever scarlatina appeared in any particular ward, and not till then, I immediately made inquiry, and having ascertained the boys who had previously had the fever, these I left out of the question.

“I then divided the remainder into two nearly equal sections: to one I gave one eighth of a grain of belladonna, twice a day: to the other, no belladonna was given.

“This experiment was continued for several weeks, and the reason why it was then discontinued was simply this - that a fatal case occurred in the person of a boy (J.B.) who had been taking the belladonna for nearly four weeks. Taking alarm, I resolved to discontinue the experiment.” (cited in James Warburton Begbie 1855, p 93)

In an earlier evaluation reported by Bayle (1830), Dusterberg is reported as follows:

“Pour mieux faire ressortir l’effet de la belladonne et en écarter celui du hazard, j’ai choisi dans chaque famille un enfant, lequel fut excepté de cet mode de traitement. Or, tous les enfants auxquels l’usage du préservatif était demeuré interdit, furent attaqués de la contagion.” (cited in James Warburton Begbie 1855, p 85)

Dusterberg’s experience using belladonna during three consecutive epidemics of scarlet fever led him to conclude that it was “as effective as vaccination”.

Quarter of a century later, James Warburton Begbie comments on this notion as follows:

“The truth is, in regard to scarlet fever, as well as many other infectious diseases, that an amount of capriciousness so evidently attends their progress, indeed, if we might so speak, regulates their progress, as to make it a very difficult matter to decide if, at any time, or in any degree, their occurrence is at all affected or moderated by external circumstances; and if this be true, as undoubtedly it is, how far more difficult must it be to decide if the exhibition of any prophylactic means does good.

“Vaccination in its effects made itself at once recognised, and the contrast between the ravages of small pox at the commencement of this century, and the almost entire immunity from that disease in an epidemic form, which now prevails, are facts so plainly recognisable, and so appreciable, as in the instance of that disease entirely to remove the difficulty referred to.

It is altogether otherwise with scarlatina; notwithstanding the introduction of belladonna, and its extensive employment, both in this country and abroad, as a prophylactic against scarlet fever, we are not aware that the mortality in either has been reduced; a circumstance which itself militates very strongly both against the prophylactic and the remedial efficacy of belladonna.” (James Warburton Begbie 1855, pp 98-99)

James Warburton Begbie concludes:

“It is our opinion that experience has altogether failed to recommend the employment of belladonna, and that we should now be prepared to abandon the practice, as not only insufficient but absurd.” (James Warburton Begbie 1855, p 101)

James Warburton Begbie’s mid 19th century opinion did not prevent continued use of and research into belladonna as a means of preventing scarlet fever well into the 20th century (Dean 2001).

Acknowledgements: We are grateful to Dr Michael Emmans Dean for comments on an earlier draft of this commentary.

Thomas Graham Balfour must have been aware of medicine from an early age as his Edinburgh family – the Balfours of Pilrig – had several medical connections.

His great grandfather was the influential Scottish Enlightenment neurologist Robert Whytt, and his cousin, George William Balfour, became an eminent cardiologist and President of Royal College of Physicians of Edinburgh.

Balfour studied medicine at Edinburgh University where he was taught by William Pulteny Alison and Robert Christison. After graduating MD in 1834, he joined the army and went on to become Surgeon General, a Fellow of Royal College of Physicians of London, a President of the Royal Statistical Society and a Honorary Physician to the Queen.

Thomas Graham Balfour was appointed surgeon to the Duke of York’s Asylum, Chelsea, in 1848. While he was there, there was an epidemic of scarlet fever and Dr Balfour used this opportunity to test the claim that homeopathic belladonna offered protection from the disease.

The report of his experiment appears in the chapter on scarlet fever in the 1854 edition of Lectures on the Diseases of Infancy and Childhood, a popular book authored by Charles West, founder of the Hospital for Sick Children in Great Ormond Street.

Balfour’s account must rate as one of the most succinct and careful accounts of a clinical experiment ever written.

Thomas Graham Balfour’s 1854 clinical trial of belladonna given to prevent scarlet fever appears to have been his only published example of clinical research, his main achievements being his key role in the compilation and analysis of naval and military statistics work which was subsequently reflected in his presidency of the Royal Statistical Society.

Balfour was recognised as exceptional during his involvement in assembling and analysing the military statistics that had accumulated since the Waterloo campaign.

The following year (1848), Balfour was appointed surgeon at the Royal Military Asylum for soldiers’ orphans at Chelsea, and it was here that he conducted his controlled trial to assess whether belladonna prevented scarlet fever (scarlatina)…

References

Balfour TG (1845). Comparison of the sickness, mortality and prevailing diseases among seamen and soldiers, as shown by the naval and military statistical reports. Journal of the Statistical Society of London 8:77-86.

Balfour TG (1854). Quoted in Charles West Diseases of Infancy and Childhood, 3rd edition. London: Longman, Brown, Green and Longmans, p 600.

Balfour TG (1872). Comparative health of seamen and soldiers, as shown by the naval and military statistical reports. Journal of the Statistical Society of London 35:1-24.

Balfour TG (1880). Vital statistics of cavalry horses. Journal of the Statistical Society of London 43:251-274.

Balfour TG (1889). Opening address, Session 1889  -90. Journal of the Royal Statistical Society 52:517-534.

Bayle ALJ (1830). Travaux thérapeutique sur la belladonne. Tome Seconde de Bibliothèque de Thérapeutique, Paris.

James Warburton Begbie (1855). On the use of belladonna in scarlatina. The British and Foreign Medico Chirurgical Review or Quarterly Journal of Practical Medicine and Surgery XV:77-101.

Dean ME (2001). The trials of homeopathy: a critical historical account of the origins, structure and development of Samuel Hahnemann__’s scientific therapeutics, and two systematic reviews of homeopathic clinical trials, 1821-1953 and 1940-1998. DPhil Thesis, University of York.

William Guy (1860). Croonian Lectures on the numerical method, and its application to the science and art of medicine. BMJ 186:553-555.

Habrich C (1991). Characteristic features of eighteenth century therapeutics in German. In: Bynum WF, Nutton V (eds). Essays in the history of therapeutics. Amsterdam: Rodopi:39-49.

Samuel Hahnemann (1801). Heilung und Verhütung des Scharlachfiebers. Originally published at Gotha.

Hufeland M (1929). On the prophylactic powers of belladonna against scarlet fever. _The Lancet_, 2 May.

Major Alexander Tulloch (1840). Letter to War Office, 20 March 1840. Public Record Office W.O. 43/701, Folio 212.

Colonel Alexander Tulloch (1847). Letter to War Office, 19 November 1847. Public Record Office W.O. 43/701, Folio 216.

Charles West (1854). Diseases of Infancy and Childhood, 3rd edition. London: Longman, Brown, Green and Longmans.

From http://en.wikipedia.org/wiki/Thomas_Graham_Balfour ‘… Balfour was born in Edinburgh on 18 March 1813. He was son of John Balfour, a merchant of Leith, and his wife Helen, daughter of Thomas Buchanan of Ardoch. He was great-grandson of James Balfour, professor of moral philosophy at Edinburgh in 1754, and of Robert Whytt, a celebrated medical writer and professor of physiology at Edinburgh. He graduated M.D. at Edinburgh in 1834; FRS, 1859; Surgeon-General, Honorary Physician to Queen Victoria and compiler of the first four volumes ofStatistics of the British Army. __The Statistics of the British Army were reputed to be the most accurate and complete of their sort throughout Europe. __From 1840 to 1848, he served as assistant surgeon in the Grenadier Guards. In 1857 he was appointed secretary to Sidney Herbert’s committee on the sanitary state of the army, and in 1859 he became deputy inspector-general in charge of the new statistical branch of the army medical department, a post which he held for fourteen years. He was elected F.R.S. on 3 June 1858, and in 1860 a fellow of the Royal College of Physicians of London. __He along with Dr John Sutherland were secretaries to the Sanitary Section of the International Statistical Congress in 1860, which was attended by Adolphe Quetelet, and to which Florence Nightingale submitted a paper. __In 1887 he was appointed honorary physician to the queen. He was placed on half-pay as surgeon-general in 1876, and in his forty years of service had done much to improve the sanitary condition of the forces. He was President of the Royal Statistical Society 1888-9 shortly after it had changed from the Statistical Society of London. He married in 1856 Georgina, daughter of George Prentice of Armagh, and had one son, Sir Graham Balfour. He died at Coombe Lodge, Wimbledon, on 17 Jan. 1891…’ 

Thomas Graham Balfour’s portrait is in The National Portrait Gallery.

Balfour also wrote Tackling bias in assessing the effects of health care interventions, Lectures on the Diseases of Infancy and Childhood,

Of interest:

Arthur James Balfour 1st Earl of Balfour, KG, OM, PC 1848 - 1930 was a British Conservative politician and statesman, and the Prime Minister from 1902 to 1905,

As Foreign Secretary, Arthur James Balfour authored the Balfour Declaration of 1917, which supported the establishment of a Jewish homeland in Palestine.

Arthur James Balfour intended to marry his cousin May Lyttleton, but she died young from typhus in 1875 and as a result, Balfour never married.  May Lyttleton used homeopathy (Sheila Fletcher, Victorian girls: Lord Lyttelton’s daughters, (Hambledon Press, 1 Jul 1997)) - her father was George William Lyttleton was married to William Gladstone’s sister in law.

George William Balfour ?1814 - ?1883

In 1846, an allopathic doctor, George William Balfour of Edinburgh, studied for three months with Friedrich Wilhelm Karl Fleischman at the Vienna Homeopathic Hospital, on the insistence of John Forbes, to observe the homeopathic treatment of his patients, and who made extensive reports of his findings there to John Forbes. (_Report on the Homeopathic Treatment of Acute Diseases in Dr. Fleischmann’s Hospital, Vienna, during the months of May, June and july 1846_) (John Forbes Homeopathy, allopathy and ‘young physic.’ British and Foreign Medical Review 21:225-265 1846).

George William Balfour had extensive correspondence with James Young Simpson on his research into homeopathy.

Blayney T Balfour and Mrs. Balfour were contributors to the Chapman Memorial Fund in 1866.

Evelyn Barbara Balfour 1899-1990 daughter of Gerald William Balfour and niece of Alfred James Balfour, was a proponent of “organic agriculture” and a founder of the Soil Association in England…

Evelyn Balfour wrote The Living Soil: Evidence of the Importance to Human Health of Soil Vitality, with Special Reference to National Planning.

Lady Eve Balfour (Arthur Balfour’s niece) was the founder of the Soil Association. In 1939 she was given a couple of farms by a sympathetic landlord to launch Haughley experimental farms:

“The Haughley farms followed the German Anthroposophical farms of the 1930s (influenced by Rudolph Steiner) in their composition and experimental method, although the bio dynamic element in organic farming was generally played down.

“However the ecological vision was the same; Alwin Seifert’s bio dynamic paper and appeals to the German Ministry of Agriculture in 1936 stressed much the same belief in mulching, non ploughing farming methods, the same opposition to single crops and weed eradication.”

Evelyn Balfour was an English farmer, educator, organic farming pioneer, and a founding figure in the organic movement. She was one of the first women to study agriculture at an English university, graduating from the University of Reading.

The daughter of the second Earl of Balfour, she began farming in 1920, in Haughley Green, Suffolk, England. In 1939, with her friend and neighbor Ryan Nelson (and Alice Debenham), she launched the Haughley Experiment, the first long-term, side by side scientific comparison of organic and chemical based farming.

In 1943, she published the organics classic, The Living Soil, a book combining her research with the initial findings at Haughley. In 1946, she co-founded and became the first president of the Soil Association, an international organization promoting sustainable agriculture (and the main organic farming association in the UK today). She continued to farm, write and lecture for the rest of her life.

William Leslie Balfour 1898 - 1983, was a British orthodox physician, a graduate of Edinburgh University, who converted to homeopathy, and he practiced homeopathy until his death aged 85.

William Leslie Balfour wrote Homeopathy and Wet Beds, published in the Journal of the British Homeopathic Association in July/ August 1969:

Harassed, trauchled mothers hate a succession of wet beds, and dread going each morning to see if the children have sprung a leak. However frayed their tempers get at the constant washing, yet they are faintly buoyed up by the knowledge that, in time, the flooding will stop, which it does in most instances.

There are, of course, hopeless cases where some mental defect continues the enuresis. I think it is supremely sad that so many of these tired and harassed mothers daily switch on their washing machines ignorant of the fact that their cruel bondage could be lifted.

Those who do escape through the genius of Samuel Hahnemann find that their joy is well diluted not only by regret but also by exasperation that they need not have gone through the daily ritual of washing and purification. A few powders have transformed things.

I need not stress the handicap of enuresis, which greatly limits the places to which children can be taken. One very fine missionary told me that she dreaded doing deputation work, as her little girl was certain to cause a flood nearly every night. The child got two powders of Kreosotum in January 1960, and the cure is perfect and permanent.

Not every cure is so instantaneous, and we may have to hunt for a good time before striking the curative medicine. Children have very few distinctive symptoms. The great majority of children grow out of the trouble, but not all. I have had big, strapping girls brought to me as they longed to go to camp, and dare not, because they dreaded the mockery which they would surely get.

Children may be angels in the eyes of their parents, but their cruelty is quite savage. I was written to by a young man of 23 who was doing his naval service, and who responded immediately to one powder of Calcarea carbonica. The surgeon on his boat was very kind, but I thought of the time he would have had in the Kaiser’s war!

The word “strapping” reminded me of a schoolfellow of mine, whose mother hailed from the neighbourhood of the Granite City. There was a substratum of granite in her nature, as she literally thrashed the boy each time there was a flood. Her treatment was successful, but she would doubtless have been sent to penal servitude for five years nowadays. The boy grew up tough and died very gallantly at the Battle of the Loos which a few of my readers will remember.

Unexpected enuresis can cause offence, and lasting hatred, when a visitor springs a leak. When two girls were in holiday rooms, the landlady was moved with choler and the innocent one deliberately took the blame, and, of course, her name still suffers.

Comfort in numbers At boarding schools, there are usually quite a number of pupils who are afflicted and things are not so hard. I have treated children at boarding schools where homeopathy was accepted, and medicines could be sent directly to the youngsters.

At other establishments, the matron or the doctor must know the name of the medicines, and in some cases treatment can only be given during the holidays, or at weekends when they are home. Sometimes, all the children in a quite large family have enuresis.

At first sight, this would appear to be of signal help in finding the family medicine, but this is not necessarily the case. “Different ships have different customs,” as the sea cook said, and brothers and sisters can need completely different medicines.

Two sisters, very like in appearance, had asthma and the medicine which cured one would not look at her sister. I have noticed on several occasions that when a whole family is afflicted, the reports can be somewhat perfunctory. I suppose the poor, tired mum just cannot bring herself to write long reports.

Help for the ageing Elderly folks, and some not so elderly, seem to grow into bed wetting. A homeopathic colleague of mine, dead these many years, began to be afflicted in his fifties, and felt it very keenly when the holiday packing had to include necessary protective sheets.

He contacted me and I suggested the stately delphinium, which was wrong. The choice of the remedy was not wrong, but I should not have told him. He was a Kentian of the Kentians and wrote immediately, and a trifle indignantly, that he was not a Staphisagria patient, as he could not fit himself into the framework of James Tyler Kent’s picture. However, I sent him other doses, but forbore to say what they were, and his waterworks assuredly benefited.

He referred a patient to me, who had been a lay homeopath for many years, and told me that he refused to take any medicine unless he was first told the name thereof. When I mildly told him that my front door could serve as an exit for patients as well as admitting them, he cooled down considerably and we eventually signed a peace treaty. After his waterworks had improved, I told him to thank the delphinium and he had the grace to admit that he had never so much as heard of Staphisagria.

It is a wonderful and rewarding thing to be able to keep enfeebled and aged patients dry, and often clean as well. They may have had a stroke, or their machinery is running down. I remember one very nice lady, an ex-teacher, who was comparatively young when she had a stroke. By ringing the changes on three drugs, she was kept dry and clean.

Of course, there are accidents at times and the body will get used to one medicine, and then we call upon another. In a number of cases, the brain is dulled and the body is just disintegrating, and only the high potencies will really penetrate.

Opium CM has done wonders at times, and the lower potencies are just a waste of time and worse. One gentle and aged lady would react for many months to Conium, and then the body would like a change.

In other cases, the mind is still as clear as a bell. One strong-minded lady in sight of 90, is very grateful for the dry bed which Causticum has given her. Another lady always reacts well to Arnica in a most miraculous fashion.

It is, however, depressing to hear about so many cases in elderly folks, whom we cannot treat. One retired doctor who lived alone horrified even the Sanitary Squad who came to shift his belongings. What he wanted was Conium.

The elderly and aged just get worse and worse, unless they, or their relatives, are introduced to homeopathy. There are over 100 drugs given for the treatment of enuresis and there is no point in even mentioning them.

Sometimes, a patient who has had previous homeopathy gravitates to me, and I know that there is no use in trying the well-known drugs. I can gaze at the long list and may feel almost tempted to follow the example of a domestic retainer of ours, who had a reputation in the picking of winners. Like Samson, she hung on to her secret for a long time before disclosing it. She looked at the long list of horses, closed her eyes and dabbed with a pin!