History and evidence-based medicine: lessons from the history of somatic treatments from the 1900s to the 1950s.

This paper examines the early history of biological treatments for severe mental illness. Focusing on the period of the 1900s to the 1950s, I assess the everyday use of somatic therapies and the science that justified these practices. My assessment is based upon patient records from state hospitals and the contemporaneous scientific literature. I analyze the following somatic interventions: hydrotherapy, sterilization, malaria fever therapy, shock therapies, and lobotomy. Though these treatments were introduced before the method of randomized controlled trials, they were based upon legitimate contemporary science (two were Nobel Prize-winning interventions). Furthermore, the physicians who used these interventions believed that they effectively treated their psychiatric patients. This history illustrates that what determines acceptable science and clinical practice was and, most likely will, continue to be dependent upon time and place. I conclude with how this history sheds light on present-day, evidence-based medicine.

Organizational characteristics of solid-organ donor hospitals and nondonor hospitals.

CONTEXT: Efforts to increase organ donation include serious attempts in hospital settings, where unrealized donation potential exists. Research on hospital donation must include understanding organizational as well as patient-specific influences on the donation process. OBJECTIVE: To identify organizational characteristics that distinguish hospitals producing organ donations from those that do not, and to estimate the number of nondonor hospitals with donor potential. DESIGN: Data from the American Hospital Association's 1992 annual survey of hospitals were matched to Organ Procurement and Transplantation Network information from the United Network for Organ Sharing regarding the number of solid-organ donors in 1992. Hospitals with donation capability were identified, based on bed size and factors necessary to produce successful donor maintenance and organ recovery. Based on statistical analyses, organizational characteristics distinguishing donor hospitals from nondonor hospitals were identified. We also compared the number of donors and the number of donor hospitals in 1992 and 1996. SETTING: United States. RESULTS: Among all hospitals affiliated with the American Hospital Association (n = 5607), 1214 (22%) were identified as donor hospitals (> or = 1 donation in 1992). Of 2333 hospitals with procurement capability, 1268 (54%) produced no donors in 1992. Based on a multiple logistic regression model, donor hospitals differed from nondonor hospitals by hospital ownership, with municipally owned hospitals more likely and federally owned hospitals less likely to produce donation, compared with for-profit and not-for-profit hospitals. Other organizational characteristics associated with donor hospitals were level of trauma services, whether the hospital had a transplant surgery program or a hospital ethics committee, and whether it was located in the South Atlantic, Southwest Central, or Pacific regions of the United States. CONCLUSIONS: Among hospitals not currently producing organ donations, there is a sizable subgroup with donor potential. This area merits further attention.

Effect of therapeutic innovation on perception of disease and the doctor-patient relationship: a history of general paralysis of the insane and malaria fever therapy, 1910-1950.

OBJECTIVE: The purpose of this study was to examine the effect of therapeutic innovation on the interpersonal style of physicians by using the historical example of the treatment of general paralysis of the insane by malaria fever therapy. METHOD: The study employed historical qualitative and descriptive methods to analyze medical and popular literature and medical records. These medical records were from a single institution and contained verbatim transcripts of patient interviews and doctors' conferences. The author examined records of patients diagnosed with neurosyphilis from the periods before (1910-1928) and after (1928-1950) the introduction of malaria fever therapy. RESULTS: Before the introduction of malaria fever therapy, physicians saw their neurosyphilitic patients as "hopeless," "immoral," and "stupid" paretics--objects to be acted upon, a view consistent with the cultural belief that syphilitic patients were sinful and depraved. After the introduction of malaria fever therapy, doctors wrote more positively and empathically about their neurosyphilitic patients, allowing patients to become active participants in their therapeutic regimens. Patients with neurosyphilis voluntarily sought admission specifically for fever therapy, seeing the asylum as a place of cure rather than as an institution of confinement. CONCLUSIONS: This history illustrates that biological therapies can powerfully affect physicians' perceptions of patients and need not remove them from patients' subjective experiences. Instead, biological treatments may enhance physicians' ability to empathize with their patients' suffering.

Punishment or therapy. Patients, doctors, and somatic remedies in the early twentieth century.

Although it has been argued that psychiatrists entered the modern era with the introduction of shock therapies and lobotomy in the 1930s and antipsychotic drugs in the 1950s, practicing psychiatrists of the 1910s and 1920s did not feel they were in the dark ages of therapeutics. These early twentieth-century psychiatrists had a variety of somatic remedies at their disposal. For example, they had a plethora of sedatives and hypnotic agents from which to choose, although these drugs too often produced troublesome side effects, and, from the point of view of these physicians, too closely resembled physical restraint in their effects on the patient. As we saw, physical restraint had a sullied reputation, psychiatrists believing it, at best, to be a necessary evil and not part of a therapeutic regimen. This did not mean psychiatrists felt helpless in treating insanity for they firmly believed that, unlike drugs and physical restraint, hydrotherapy acted therapeutically. Our examination of every-day treatment practices at Stockton and Patton state hospitals revealed that physicians found hydrotherapy to be a useful remedy on nearly all patients irrespective of diagnosis. The Agnews' investigation allowed us to examine the basic assumptions underpinning early twentieth-century therapeutics, and two major conclusions can be gleaned from this examination. First, how doctors perceive disease is inseparably linked to how they treat disease. In the case of hydrotherapy, physicians believed it effectively controlled their patients' behavior. To assert that it had therapeutic value and to differentiate it from mechanical restraint, however physicians transformed how they saw disease and therapy such that wrapping and bathing the "excited" and "frenzied" patients were therapeutic. Rather than seeing disruptive behavior as simply something in need of physical restraint, hydrotherapy allowed physicians to see these behaviors as the essence of disease and the primary object of their therapeutic ministrations. Second, patients' conceptions of disease and therapy may differ markedly from their physicians, which may be particularly true when disease is defined by visible behavior. At Agnews, patients spoke a different language than their physicians such that restraint differed little from therapy. In contrast to their doctors, patients were unable to see their behavior as necessarily pathologic, and, thus, were unable to recognize and to speak of the difference between mechanical restraint and hydrotherapy; both kinds of technologies simply restricted their bodily movements. With a different therapeutic practice such as malaria fever therapy, doctors and patients saw disease and its treatment in a new light.(ABSTRACT TRUNCATED AT 400 WORDS)

A case study in planning for public health education: the organ and tissue donation experience.

The chasm between the supply and demand of donated organs and tissues continues to grow despite widespread public awareness of transplantation and numerous efforts to educate the public about organ donation. It is fast becoming a significant public health problem in this country. The need for more effective public education is well documented in the literature on transplantation and is a primary objective of organizations in the transplant field. In response to this need, the Division of Organ Transplantation in the Health Resources and Services Administration of the Public Health Service initiated a project to examine the nature and scope of donation education initiatives throughout the country, to identify shortcomings, and to suggest ways the Federal Government could contribute to the effectiveness of public education in organ and tissue donation. The project resulted in the development of a protocol that also is applicable to other health education programs. Its major steps consisted of assessing the status of donation-related public education in the United States, identifying existing needs in donation education by applying principles learned from other public health education programs, and identifying roles that could be assumed to help strengthen the American public's commitment to organ and tissue donation. These roles, which could be adopted by an transplant-related organization, were as broker of knowledge, producer of educational strategies, energizer through communications research, and catalyst by bringing together other groups. This approach to needs assessment and planning may provide useful insights both for those concerned with transplants and for professionals conducting education campaigns related to other public health issues.

Trauma system development and future directions.

Traumatic injury, both unintentional and intentional, is a serious public health problem. Trauma care systems play a significant role in reducing mortality, morbidity, and disability due to injuries. However, barriers to the provision of prompt and appropriate emergency medical services still exist in many areas of the United States. Title XII of the Public Health Service Act provides for programs in support of trauma care planning and system development by states and localities. This legislation includes provisions for: 1) grants to state agencies to modify the trauma care component of the state Emergency Medical Services (EMS) plan; 2) grants to improve the quality and availability of trauma care in rural areas; 3) development of a Model Trauma Care System Plan for states to use as a guide in trauma system development; and 4) the establishment of a National Advisory Council on Trauma Care Systems.

Women in medical education: a decade of change.

The 1970s was a decade of remarkable growth for women in academic medicine. The percentage of women entering medical school, the number of women on medical-school faculties, and the number of women in senior administrative positions have all increased during the past 10 years. Although substantial modifications have occurred in admission practices and in the general responsiveness of academic medicine to women, it is difficult for women in medical academia to be optimistic, because the number of women at senior professorial ranks and in administrative positions has been slow to change. The challenge to academic medicine in the 1980s is to ensure that women have equal access to leadership positions.

Women doctors: productivity in Great Britain and the United States.

There is a difference in the productivity of women doctors in Great Britain and the United States. Postulated reasons for this difference are discussed as well as the implications for medical education and meeting health manpower needs.

Cost containment education efforts in United States medical schools.

Noting the increasing nationwide concern with factors relating to rising health care costs, the Association of American Medical Colleges surveyed 119 U.S. medical schools in the summer of 1978 to ascertain the degree of program activity in the area of cost containment education. A 100 percent response was achieved. An analysis of this data indicates that considerable activity is underway. Forty-one institutions (34 percent) have programs underway or planned specifically to teach health care cost containment to undergraduate medical students or residents or both. The majority of such programs were introduced during the past two years. The costs of such programs are fairly modest, averaging $22,680 per year. Respondents indicated that further activities might be enhanced by development of a primer for faculty and students on elements of cost containment education and the organization of a series of regional workshops related to this subject.