How and why do therapeutic interventions become obsolete?

A preliminary study of 20th century health technologies

 

Dr E M Rous Mb ChB MRCPsych
Consultant in Child and Adolescent Psychiatry
Pennine Care NHS Foundation Trust
The Tree House Children’s Centre
Stepping Hill Hospital
Stockport
SK2 7JE

ABSTRACT

Objectives
This study investigates how and why medical interventions become obsolete in the twentieth century.
Method
Therapies whose usage had declined were found via a sampling of the British Medical Journal and a review of the historical literature.
Results
There were similarities with the processes of decline described for non-healthcare technologies. The influences on the process are complex and involve factors other than whether a therapy is ineffective.
Conclusion
Negative trials were rarely sufficient reason for an intervention to become obsolete.

INTRODUCTION

Brief historical context
In the late twentieth century UK Government funded reviews reflected health policy advocating reduction of marginally effective interventions (1). Historically, evidence- based medicine was born in the twentieth century. The Medical Research Council Therapeutics Trial Committee started in 1931 (2). The first randomised clinical trial was designed by Austin Bradford Hill in 1946, but it only became the gold standard in European Drug Assessment during the 1970’s (3). The hierarchies of evidence used in UK Health Technology Assessments evolved from a Canadian publication in 1979 (4). The science of meta-analysis began in the 1980’s and systematic reviews became the standard tool for assessing research evidence in the 1990’s, with the Cochrane Collaboration initiated in 1992 (5). However, despite the collective NHS effort to scrutinise interventions for effectiveness, many therapies in use still lack an evidence base (6).

Aim of the study
This study investigates how and why therapeutic interventions have become obsolete in the twentieth century, asking the following questions:
• Why was the therapeutic intervention discontinued?
• What factors, including the status of the research evidence, influence whether a therapy is abandoned?

Current knowledge about declining technologies
In the history of technology literature, the decline of the British car industry was driven by bad marketing, poor design, flawed products and inadequate distribution networks (7). Product relinquishment is often driven by innovation and technology substitution. Successful innovation is inhibited by workforce opposition and weak economic climates (8). Product champions often resist innovative threats, adopting an entrenched commitment to their ‘old’ products (9)
An S-shaped curve has been described for technology diffusion and a reverse S-shaped curve for the process of decline: the whole process following a bell-shaped normal distribution curve. The time a technology stays at the peak of the curve depends on the emergence of a competing innovation (10). The spread of mature technologies is influenced by profitability, attitude of management and access to capital (10).
Consumers adopt innovations at different rates. The innovators are followed by early adopters, then the early majority, the late majority and finally the laggards (11). Similar categories have been described for the prescribers of new drugs (see ref 12 for Coleman’s Classic study).
There are few studies of declining technologies in healthcare. American researchers, studying heart transplants in the 1970’s identified three reasons why therapies were abandoned: ineffectiveness; adverse effects and being superseded by a better therapy (13). A time lag between publication of adverse effects and changes in practice has been shown (14) and persistence of ‘unproved’ technologies linked to a lack of scientific practice (15). In a UK study of barbiturate prescribing, doctors who were the slowest to change made less use of pharmaceutical references or postgraduate facilities and were more likely to have a pastoral approach (16).

METHOD

This study had three stages. Stage 1 was review of the historical literature, stage 2 was a hand search through two years of the British Medical Journal searching for example of therapies that had declined in use. In stage 3, the identified therapies were investigated further, focusing on the literature at the time of first use and in the phase of decline.

RESULTS

35 therapeutic interventions were identified. Most interventions had more than one influence on their decline. The following narrative illustrates the themes that emerged.

Adverse effects
Most therapeutic interventions have side effects and therapeutic decisions are made balancing risk versus benefits. This is illustrated by the story of lactation suppression by stilboestrol, which commenced in the 1930’s (41). Although research suggested that stilboestrol was only marginally effective (25, 32, 34, 35) prescribing continued through the forties and fifties, albeit controversially (36, 39). In 1967 a cohort study demonstrated a risk of thromboembolism (38) which was confirmed by a subsequent case control study (39). Interestingly the BMJ (40) advocated a strategy of managed risk and trials of lactation suppression continued into the 1980’s. Since the advent of HIV and the risks of vertical transmission, there has been a renewed interest in this topic recently (42).

Emergence of a rival innovation
Several therapies have been displaced by antibiotics; arsenic for syphilis, echinacea, altitude therapy for tuberculosis, and malarial therapy. The latter was used to treat syphilis between 1917-1940 with a 67% success rate (58, 84). As penicillin usage increased, malarial therapy was retained for end stage disease and was sometimes used in combination. Alongside competition from antibiotics, there was difficulty in obtaining parasites in non-endemic countries (83).
Modern psychiatry is a saga of marginally effective therapies superseding one another. Neurotic disorders were treated by electric therapy in the late nineteenth century (82), by psychoanalysis in the early twentieth century, by sexology (86) in the mid century, barbiturates in the 1960’s, which were substituted by minor tranquilizers in the 1970’s. Psychotic illness has been treated by sleep therapy, insulin coma, psychosurgery and electroconvulsive therapy. Since the 1950’s major tranquilizers and antidepressants have become mainstay treatments. The effectiveness of antipsychotic drugs led to a decline in the use of psychosurgery (58, 59), but popular literature such as ‘Suddenly Last Summer’ was also influential (87).

Attitudes of practitioners
Surgeons’ love of ‘neat operations’ (53, p 928) delayed the demise of sympathectomy and extracranial/ intracranial bypass (61). Interestingly, a recent Cochrane review has revisited the latter (62). Attitudes of practitioners were also important in the continued use of arsenic in combination treatment of syphilis until the late 1950’s (20). Venereologists feared that, as treatment by penicillin alone was less complex (20), it would be undertaken by general practitioners, thus threatening the role of the specialist (21). Reluctance of product champions to relinquish their favourite therapy was epitomised by Walter Freeman, who was still championing psychosurgery to his grave, despite the poor long term outcomes and the effectiveness of antipsychotic medication (58, 59, and 84).

Economic factors
Low profit margins led to the demise of echinacea: in 1921, it was a best selling antiseptic for its parent company (45), but by 1962 it was obsolete, only to be revived again later in the century. As naturally occurring remedies could not be patented at the time, the scope for profit was reduced. Other influences were the opposition of the American Medical Association to alternative medicines and competition from antibiotics.
Similarly altitude therapy, whereby sufferers from tuberculosis, travelled to the mountains for the air, was susceptible to market forces. Antituberculous drugs contributed to the decline of ‘rest cures’. However, reluctance of the residents of health resorts to accept sufferers of TB was also an important factor (80).
The capital and revenue costs of hyperbaric oxygen (HBO) therapy was one of the reasons why it was not developed in the UK as an adjunct to radiotherapy for head and neck cancer in the 1970’s (79).

Research evidence of ineffectiveness
Some therapies persisted despite evidence of ineffectiveness, particularly when there was no alternative: bland diets and milk drips for peptic ulcer for example (60). Supporters of HBO therapy in carbon monoxide poisoning (72) were still fighting their cause in the literature, after three negative trials (73, 77, and 78).
A lag time between the publication of negative trials and a change in practice was evident. The use of progesterones to prevent spontaneous abortion did not decline until 1967 in the US (31), three years after negative trials (32). The time lag for sympathectomy for peripheral vascular disease was even longer (51). Reconstructive arterial surgery was developed in the 1950’s but it was not until 1966 that the British Medical Journal (50) acknowledged it as first line treatment. Product champions of sympathectomy were still publishing until the early 1980’s (54, 56), when a negative trial comparing sympathectomy as an adjunct to reconstructive surgery with arterial reconstruction alone was published (55). It is still in use for patients who are not fit for surgery and recently a Cochrane review has been proposed (56).

Effect of prevention
The role of prevention in the decline of therapies is of particular interest to the public health fraternity, but examples were few. The iron lung was the mainstay of treatment for respiratory paralysis caused by polio until the 1950’s. Although the iron lung was replaced by ventilators, the polio vaccination programme also impacted on the incidence of respiratory paralysis (71). Similarly, exchange transfusion for rhesus disease became less common as anti-D was introduced in the late 1960’s and early 1970’s (81).

Changes in nosology
Changes in the understanding of aetiology also affected trends in treatment. For example, from the 1940’s to the mid 1960’s, female hormones were used to prevent miscarriage, in the belief that hormone deficiency was causal (25). As greater understanding developed about the role of chromosomal abnormalities in spontaneous abortion, this practice declined. Simultaneously, negative trials of progesterone augmentation were emerging (26, 28, 29, and 30) as were concerns about the safety of taking drugs in pregnancy, a prominent theme in the post thalidomide era (26, 88, and 89)

Table One:

 

	Type of influence/theme
	noxious	superceded	popular with doctors	uneconomic	ineffective
Prescribed drugs	1	2	3	4	5	references
Anticoagulant therapy for cerebrovascular disease	yes		yes		yes	17
Arsenic		yes	yes			18,19,20,21
Barbiturates	yes					16
Benzodiarone	yes					22,23
Borax		yes			yes	24
Clofibrate	yes				yes	14
Endocrine therapy for prevention of miscarriage	yes		yes		yes	25-31
Phenformin	yes					14
Stilboestrol for lactation supression	yes		yes		yes	32-42
Thalidomide	yes					43,44
Non-prescribed drugs
Echinacea		yes		yes		45
Lysergic acid diethylamide (LSD)	yes					46
Mercurial teething powders	yes					47-49
Surgical interventions
Sympathectomy	yes	yes	yes		yes	50-57
Psychosurgery	yes	yes			yes	58,59
Gastroenterostomy	yes	yes				60
Partial gastrectomy	yes	yes				60
Extracranial-intracanial bypass	yes				yes	61,62
Button operation for ascites	yes				yes	63,64
Adrenalectomy for essential hypertension	yes	yes				65-68
Colectomy for epilepsy					yes	64,69
Medical devices
Dalkon Shield and copper IUDs	yes	yes		yes		70
The Iron Lung		yes				71
Hyperbaric oxygen chamber				yes	yes	72-79
Other
Altitude therapy		yes		yes		80
Exchange transfusion for rhesus incompatibility						81
Electric therapy	yes	yes	yes		yes	82
Insulin coma	yes	yes			yes	18
Fetal cell transplants for parkinsons disease	yes					61
Bland diet for peptic ulcer		yes	yes		yes	60
Milk drips for peptic ulcer		yes			yes	60
Gastric freezing	yes				yes	60,64
Malarial therapy	yes	yes		yes		18,58,83,84
Pancreatic extract		yes	yes	yes		85
Sleep therapy		yes			yes	18
Total	23	18	8	6	17

 

Summary of Main findings
This study found many influences on how and why a therapy is abandoned. The process was complex, even when there was evidence of harm or lack of effectiveness. There were similarities with non-health technologies. The decline in use of a therapy was often related to the development of a rival innovation. Even when there was good evidence that the newer technology was superior, there was reluctance to change.
Although there was some evidence of economic factors in the pre NHS era, these feature less in accounts than risks and benefits of treatment. In addition, prevention of disease and a change in the understanding of aetiology were contributing factors.

Limitations of this study
This study represents a small sample from the literature, mainly in the last part of the twentieth century. It is limited to studies published in English language and therefore has a UK/US bias.

CONCLUSIONS

There are multiple influences on how and why therapeutic interventions become obsolete. Negative trials alone are rarely sufficient for an intervention to be discontinued. Controlling the use of marginally effective therapies should focus on promotion of effective rival innovations, marginalisation of recalcitrant product champions, limitation of funding and dissemination of research evidence.

ACKNOWLEDGEMENTS

This study was conducted as part of an MSC at the University of Manchester supervised by Professor John Pickstone. Dr Stephen Watkins, Director of Public Health in Stockport is thanked for his support and encouragement for this research.
Competing interests
None
Ethical Approval
Not required
Funding
This research was self- funded.

BIBLIOGRAPHY

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References relating to table1
Anticoagulant therapy
17. Fields WS, Lemak NA. A History of Stroke- Its Recognition and Treatment. Oxford: OUP, 1989: 113-4.
Arsenic
18. Micale MS. ‘The psychiatric body’ in (eds Roger Cooter and John Pickstone) Companion to Medicine in the Twentieth Century. London: Routledge, 2003: 323-347.
19. Louise EM. The treatment of syphilis with penicillin. British Journal of Venereal Disease, 1948, 24:11-15.
20. Willcox RR, Jefferies FJG, Elliott MC, Treatment of early syphilis with penicillin, British Journal of Venereal Disease, 1958; 34:14.
21. The Venereologists Group Committee of the British Medical Association in association with The British Cooperative Clinical Group. Treatment of venereal disease outside the hospital service. Results of a survey undertaken by the Venereologists Group Committee and the British Clinical Cooperative Group. British Journal of Venereal Disease, 1959, 35:111
Barbiturates
See Mapes(16)
Benzodiarone
22. Lee H and Davey GF. British Medical Journal (Letter), June 6 1964, 1:1531.
23. Harrison MT and Cameron AJV. Iodine- induced hypothyroidism due to benzodiarone (Cardix). British Medical Journal, March 27 1965, 1: 84.
Borax
24. Jensen J. The Rise and Fall of Borax as an antiepileptic drug. Archives of Neurology, 63(4): 621-622.
Clofibrate
See Finkelstein (14)
Endocrine therapy for the prevention of miscarriage
25. Browne JSC, Henry JS, Venning EH. The significance of endocrine assays in threatened and habitual abortion. American Journal of Obstetrics and Gynaecology, 1939; 38: 927.
26. Jacobson B. Hazards of norethindrone therapy during pregnancy. American Journal of Obstetrics and Gynaecology, 1962; 84; 7: 962-968.
27. Nilsson L. Treatment of threatened abortion with progesterone. Acta Obstetrics and Gynecology Scandinavia, 1963, 42: Suppl 6: 129-135.
28. Fuchs F. Progesterones and 6 methyl-17-aceoxy-progesterone in threatened abortion and premature labour. Minerva Ginecologica, 1965, Jan 15, 17; Suppl: 67-70.
29. Shearman RP& Garnett WJ. Double blind study of effect of 17-hydroyprogesterone caproate on abortion rate. British Medical Journal, 1963, Feb 2, 1: 292-295.
30. Klopper A & MacNaughton M. Hormones in recurrent abortion. The Journal of Obstetrics and Gynaecology of the British Commonwealth, 1965; 72:1022-1028.
31. Heinonen OP. Diethylstilbestrol in pregnancy- Frequency of exposure and usage patterns. Cancer, 1973, 31: 573-577.
Phenformin
See Finkelstein (14)
Stilboestrol for lactation suppression
32. Kirland JA, Greenberg BG, Flowers CE. Suppression of lactation. A double-blind hormone study. Obstetrics and Gynaecology, 1960; March, 15, 3: 292-298.
33. Brown WE, Hagler-James, Morgan FE, Smith M. The inhibition of breast engorgement and endocrine substances and its possible prevention of puerperal abscess. Southern Medical Journal, 1960; May: 548-553.
34. Markin K & Wolst MD. A comparative study of hormones used in the prevention of postpartum breast engorgement and lactation. American Journal of Obstetrics and Gynaecology, 1960, July; 80; 1; 128-137.
35. Bare W, Cornfield E, and Lippo F. Suppression of lactation-use of fluxymesterone-ethinyl combination. Journal of the American Medical Association, 1960, Aug 20: 1814-1817.
36. Martin D. Puerperal lactation. Physiology and suppression. General Practitioner, 1964, Oct, 4: 79-86.
37. MacDonald R. Norethynodrel and mestranol (Enavid) in the prevention of recurrent abortion. The Lancet, 1965, Aug 21, 362-365.
38. Daniel DG, Campbell H, Turn bull AC. Puerperal thromboembolism and suppression of lactation. Lancet, 1967; 2: 287.
39. Jeffcoate TNA, Miller J, Roos RF, Tindall VR. Puerperal thromboembolism in relation to the inhibition of lactation by oestrogen therapy. British Medical Journal, 1968;4:19-25.
40. British Medical Journal Editorial. Thrombosis and inhibition of lactation. British Medical Journal, 1968, Oct 5, 4:1-2.
41. Vorherr H. Suppression of lactation postpartum. Obstetrics and Gynecology, 1972; July: 145-152.
42. Oladapo OT & Fawole B. Treatments for the suppression of lactation. (Protocol) The Cochrane Database of Systematic Reviews, 2006, Issue 2. Art No: CD005937.DOI:10.1002/14651858.CD005937.
Thalidomide
43. Kelsey FO. Problems raised for the FDA by the occurrence of thalidomide embryopathy in Germany 1960-1961. American Journal of Public Health, 1965, 55, 5: 703-707.
44. Smithells RW. The thalidomide legacy. The Proceedings of the Royal Society of Medicine, 1965,58: 491-492.
Echinacea
45. Taylor VE. Pharmaceutical botany in the US 1900-1962. Its heyday, decline and renaissance. Pharmacy in History, 1996, 1: 20-23
LSD
46. Ulrich RF & Patten BM. The rise and, decline and fall of LSD. Perspectives in Biology and Medicine, 1991;34;4:561-578.
Mercurial teething powders
47. Dally A. The rise and fall of pink disease. Social History of Medicine, 1997: 291-304.
48. Dathon JG. Pink Disease-ten years after (the epilogue). The British Medical Journal 1965,1: 1181-1182.
49. MacGregor ME & Rayner PHW. Pink disease and primary renal acidosis. The Lancet, Sept 21 1964, 1083-1085.
Sympathectomy
50. BMJ editorial. Treatment of intermittent claudication: British Medical Journal, 1966, April 16, 5493:931-932.
51. Richard RL. Lumbar sympathectomy for chronic occlusive arterial disease, American Heart Journal, 1971; 81: 735-7.
52. Taylor I. Lumbar sympathectomy for intermittent claudication. The British Journal of Clinical Practice, 1973; Feb; 27; 2: 39-44.
53. Warren R. Sympathectonism. Archives of Surgery, 1976; Aug; III,928.
54. Blumenberg RM & Gelfand ML. Lumbar sympathectomy for limb salvage: a goal line standard. The American Journal of Surgery, 1979, Aug, 138: 241-245.
55. Sartioni B, Llapis C, Hayes J, Kimmin S, Evans WE. Prospective randomised study of concomitant lumbar sympathectomy with aortic reconstruction. The American Medical Journal of Surgery, 1982, June, 143: 755-760.
56. Walker P. Is there still a place for lumbar sympathectomy?, Journal of the Canadian Medical Association, 1982, Sept; 127: 353-354.
57. Overbeck KM, Hansrani MD, Lees T. Sympathectomy for peripheral arty disease. (Protocol) The Cochrane Database of Systematic Reviews 2006, Issue 2. Art No: CD005980. DOI: 10.1002/14651858.CD005980
Psychosurgery
58. Valenstein ES. Great and Desperate cures. The Rise of Psychosurgery and other Radical Treatments for Mental Illness. USA: Basic Books Inc: 1986.
59. Pressman JD. The Last Resort-Psychosurgery and the Limits of Medicine. Cambridge: Cambridge University Press, 1998: 401-442.
See Micale (19) also.
Gastroenterostomy and partial gastrectomy
60. Christie DA and Tansey EM (eds). Peptic Ulcer: Rise and Fall. The Transcript of a Witness Seminar held at the Wellcome Institute for the History of Medicine, London, 12 May 2000, Volume 14, November 2002.
Extracanial-intranial bypass
61. Deyo RA & Patrick PL. Ineffective or needlessly extensive surgery. In Hope or Hype. New York: Amacom., 2005: 209-211
62. Fluri F, Engelter S, Lyrer P. Extracranial-intracranial bypass surgery for occlusive cerebrovascular disease. (protocol). The Cochrane Database of Systematic Reviews 2006, Issue 2.Art. No.CD005953.DOI:10.1002/14651858.CD005953.
Button operation for ascites
63. Chalmers TC, Eckhardt RD, Davidson CS. Evaluation of the peritoneal-button operation for ascites- a report of 17 cases. The New England Journal of Medicine (1950), 30 Nov, 243, 22: 857-9.
64. Hiatt HH. Protecting the Medical Commons: Who is responsible? The New England Journal of Medicine, July 31, 1975: 235-241.
Adrenalectomy for essential hypertension
65. Zintel HA, Wolferth CC, Jeffers WA , Hafkenschiel JH, Lukens FDW. Ninety-five percent subtotal adrenalectomy for essential hypertension. Surgical Forum,1950: 556-8.
66. Zintel HA, Wolferth CC, Jeffers WA , Hafkenschiel JH, Lukens FDW. Subtotal adrenalectomy in the treatment of patients with severe essential hypertension. Annals of Surgery, Sept 1951,134, 3: 351-60.
67. Zintel HA, Mackie JA, Jeffers WA, Wolferth CC, Hills AG, Sellers AM, Hafkenschiel JH. Combined adrenalectomy-sympathectomy in the treatment of patients with essential hypertension. Surgery, Sept 1953, 34, 3,:438-44.
68. Mackie JA, Zintel HA, Wolferth CC, Jeffers WA , Hafkenschiel JH, Langfield SB , Sellers AM, Hills AG. A Comparison of thoracolumbar sympathectomy and bilateral adrenalectomy-sympathectomy in the treatment of essential hypertension, Surgical forum,1955, 5: 169-73.
See also Hiatt (64)
Colectomy for epilepsy
69. Korczyn AD, Neufield MY, Elian M. Bacillus epilepticus: Treatment of epilepsy by colectomy and vaccines. Neurology, Oct 1994, 44 (10), 1965-1969.
See Hiatt (64) also.
Dalkon Shield and copper IUDs
70. Gelijins AC & Pannenborg CO. The development of contraceptive technology-case studies of incentives and disincentives to innovation. International Journal of Technology Assessment in Healthcare, 1993, 9:211-232.
The iron lung
71. Meyer JA. A practical mechanical respirator, 1929: The ‘Iron Lung’. Annals of Thoracic Surgery, 1990, 50: 490-3.
Hyperbaric oxygen chamber
72. Robin ED Et al. Some defenders of hyperbaric oxygen. Chest, 1988; 94; 2: 414-421.
73. Raphael JC et al, Trial of normobaric and hyperbaric oxygen for acute carbon monoxide intoxication. The Lancet, 1989; Aug 19: 414-418.
74. Ingle R. Hyperbaric oxygen therapy. Journal of the American Medical Association (letter), 1990, Oct 10; 264; 14: 1411.
75. James BJ. Hyperbaric oxygen for carbon monoxide poisoning. The Lancet (letter),1990: 335 549.
76. Stevens A (ed). Hyperbaric oxygen therapy. Health Technology Evaluation Research Reviews II. Southampton: Wessex Institute For Health Service Research and Development, University of Southampton, 1994; section 12.
77. Weaver LK, Hopkins RO, Elliott G. Carbon monoxide poisoning. New England Journal of Medicine, 1999; Apr 2: 1290.
78. Scheinkestrel CD, Bailey M, Myles PS et al. Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled trial. Medical Journal of Australia, 1999, 170: 203-210.
79. Coles C. Hyperbaric oxygen therapy. Combination with radiotherapy in cancer is of proved benefit but rarely used. The British Medical Journal, 1999, 2: 231-232.
Altitude therapy
80. Rogers FB. The rise and decline of altitude therapy of tuberculosis. Bulletin of the History of Medicine, 1969; 43: 1-16.
Exchange tranfusion
81. Finn R. RH haemolytic disease. Recent advances in Rh isoimmunisation prevention, British Medical Journal, 1970: April 25, 2:219-220.
Electric therapy
82. Stainbrook E. The use of electricity in psychiatric treatment during the nineteenth century. The Bulletin of the History of Medicine, 1948; 22 (2): 156-177.
Insulin Coma
See Micale (18)
Fetal cell transplants
See Deyo (61)
Bland diet for peptic ulcer and gastric freezing
See Christie (60)
Malarial therapy
See Micale (18) and Valenstein (58)
83. Nichol WD. General paralysis of the insane. British Journal of Venereal Disease, 1956; 32: 9-16.
84. Braslow J. Mental Ills and Bodily Cures- Psychiatric Treatment in the First Half of the Twentieth Century. University of California Press, Berkeley USA, 1997: 71-94.
Pancreatic extract
85. Tattersall R. Pancreatic organotherapy for diabetes 1889-1921. Medical History, 1995, 39, 288-316.
Sleep therapy
See Micale (18)

86. Bejin A. ‘The decline of the psychoanalyst and the rise of the sexologist’ in (P Aries and A Bejin eds), Western Sexuality: Practice and Precept in Past and Present Times. Oxford and New York: Blackwell, 1985: 181-200.
87. Williams Tennessee. Suddenly Last Summer (1958), various publishers including New York: Signet books, 1960 and London: Josef Weinberger Plays,1969.
88. Dillon S. Progesterone therapy in early pregnancy and associated congenital defects. General Practitioners Forum, 1970: July; 205: 80-86.
89. Camelleri AP & Gauci NM. Progesterone depot in threatened abortion. Obstetrics and Gynecology, 1971, Dec, 38, 6:893-895.
APPENDIX

Search strategies
Research Questions:
Which therapies were discontinued during the twentieth century?
What were the influences on their decline?

Search 1
Database
Wellcome Library online catalogue
Key words
Therapy, technology, decline, therapeutic, drug, history.

Search 2
Database
British Medical journal
Hand search of years 1955 and 1965 for therapies no longer in use

Search 3
Database
Index Medicus 1940-1999
Hand search for therapies identified by searches 1-3, looking for research at the time of introduction and time of decline.
Search 4
Database
Medline
i) 1968-1980
key words: lactation suppression; oestrogen
ii) 1974-1999
key words: innovation in medicine; therapeutic; history of medicine-20th century.

In addition a number of texts on the history of specific therapies/ conditions were searched for therapies that had become obsolete. Colleagues also suggested relevant references on the topic.

 

First Published June 2010

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