Historical perspective| Volume 3, ISSUE 2, P99-105, August 1981

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Climacteric symptom formation: Donovan's contribution

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      Engaged in evaluating the then newly introduced hormonal therapy of the climacteric syndrome, Donovan, late professor of obstetrics and gynaecology, of Rochester, NY, reached the conclusion that this complex of symptoms was only a clinical artifact. It was, he claimed, the result of the selective attention of doctors when securing medical histories. Though written 30 years ago, Donovan's paper is apparently still provocative enough to be regularly quoted. It has, however, never been closely examined.
      Looked at in a different light, Donovan's research appears even more interesting. The apparent paradoxes he reports disappear when it is remembered that symptoms are not data but means of communication. His perceptive picture of the influence of doctors on the formation of climacteric symptoms is especially convincing. Much of this is because the main conclusions of this research seem to have come almost as a surprise, forcing themselves on a worker engaged in a restricted field of his speciality. These circumstances probably also account for the reticence shown in drawing more general conclusions from its findings.


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        • Donovan J.C.
        The menopausal syndrome: a study of histories.
        Am. J. Obstet. Gynecol. 1951; 62: 1281-1291
      1. Late professor of Obstetrics and gynaecology, Rochester School of Medicine, Rochester, NY. Born in 1919, died in 1976.
      2. This article has been cited 12 times between 1970 and 1980, at a rate of once to three times a year. Science Citation Index, Institute for Scientific Information, Philadelphia, 1961 to the present.
      3. Oestrogens were already used experimentally in the early 1930s and, though expensive, were commercially available. The much cheaper synthetic compound, stilboestrol, was introduced in the late 1930s and the orally effective conjugated equine oestrogens in the early 1940s. The price of injectable oestrogens (alone or in combination) was also concurrently reduced.
      4. Donovan had hoped his paper would be judged by his peers and “that these clinicians would study the methods used in the collection of the data, and if these methods seem sound, would conduct similar studies whose results may provide a more sound basis for agreement or disagreement”[1].
      5. Almost all from outside the U.S.A. Seven of the 11 papers (vide [3]), the origin of which I was able to trace, were from Britain, 3 from Israel and 1 from Germany. Reaction in the U.S.A. at the time of publication is difficult to ascertain (Science Citation Index [3] only since 1961). The paper seems to have cast Donovan as an authority in the inter-disciplinary area between gynaecology and psychiatry [17]. This resulted in his being asked to contribute articles on the relationship between the two. Fifteen years ago the paper was mentioned by Neugarten and Kraines in their widely (but uncritically) quoted investigation of climacteric symptoms. (Neugarten, B.L., and Kraines, J.R. (1965) “Menopausal symptoms” in women of various ages. Psychosom. Med. 27, 266–273.) This may, in fact, have initiated the recent interest it has enjoyed.
      6. The numerous quotations from Donovan's paper [1] are marked by inverted commas. No other indication of their origin is shown.
      7. Donovan, J.C. (1955) (vide [16]).

      8. Cf. Crawford's horror when she learned that “in a recent examination 120 out of 121 medical students decided a 44-year-old woman going to her doctor with vague aches and pains was menopausal and concluded that no further diagnosis … was necessary” (Crawford, M.P.(1970) What happens at the change. New Society, 29 October 1970). Though exaggerated by lack of experience, the attitude of these students reflects clinical reality. Elstein and his co-workers (Elstein, A.S., Shulman, L.S. and Sprafka, S.A. (1978) Medical problem solving. An analysis of clinical reasoning. Harvard University Press, Cambridge, MA and London) for instance claim that “competent practicing physicians formulated their diagnosis only 30 seconds (p. 174) or one minute into the interviews” (p. 175, also see pp. 65, 83, 168, 241, 242, etc.). This is, however, not based “on a question answer type of interview technic” but is due to non-verbal processes and is influenced by the image of the patient (Wilbush, J. (1980) [31]).
      9. Who's Who in America (1976–1977) 39th edition, 11831, Rand McNally and Co., Skokic, IL. “John Charles Donovan Jr., Obstetrician and gynaecologist and educator; son of John Charles Donovan and father of John Charles Donovan III; University of Notre Dame and Rochester School of Medicine (MD 1945).” Donovan died in 1976 soon after the publication of this information (J. Am. Med. Assoc. 237 2117).
      10. Directory of Medical Specialities. 17th edition. 1976: 1152 (Marquis Who's Who, Chicago, IL.)
      11. There are very good historical and ideological reasons for the absence of enthusiasm for psychiatric concepts among gynaecologists and the poor co-operation between them and psychiatrists (Wilbush, J. (1980) [31] Sec. 11-0-0).
      12. It is interesting that, probably by coincidence, another effort at coordination of gynaecological and psychiatric treatment was concurrently taking place in Britain (Snaith, L. and Ridley, B.) (1948). Gynaecological psychiatry. A preliminary report on an experimental clinic. Br. Med. J. 2, 418–420).
      13. Donovan was the first of a number of residents in obstetrics and gynaecology who, in their middle year of residency, usually devoted entirely to pelvic pathology, were given the opportunity to become acquainted with psychiatric methods. As fellows in psychiatry they took part in a cooperative programme of combined studies established by the departments of obstetrics and gynaecology and psychiatry of the Rochester School of Medicine [15].
        • Wilson K.M.
        • Donovan J.C.
        • Romano J.
        An experiment in the teaching of obstetrics and gynecology at the graduate level.
        in: The application of clinical psychiatry in the teaching of obstetrics and gynecology. Am. J. Obstet. Gynecol.66. 1953: 654-662
      14. Donovan, J.C. (1951), vide [1], 1281–1291.

        • Donovan J.C.
        Psychologic aspects of the menopause.
        Obstet. Gynecol. 1955; 6: 379-384
        • Donovan J.C.
        Some psychosomatic aspects of obstetrics and gynecology.
        Am. J. Obstet. Gynecol. 1958; 75: 72-81
        • Donovan J.C.
        The doctor-patient relationship in gynecology.
        Clin. Obstet. Gynecol. 1965; 8: 174-183
        • Donovan J.C.
        Psychosomatic evaluation of the infertile couple.
        in: Textbook of gynecologic endocrinology. Harper and Row, New York1968: 551-564
      15. This is reflected in his being invited to speak on the psychological aspects of obstetrics and gynaecology (vide [16], items dated 1955 and 1958 both originally delivered as papers) and write about it in journals (ditto: item dated 1965) or textbooks (ditto: item data 1968).
        • Donovan J.C.
        • Salzman L.F.
        • Allen P.Z.
        Patterns of learning in medical school.
        J. Med. Educ. 1969; 44 (All of Donovan's writings dealing with education are in cooperation with others, whether as a junior [15] or senior author. E.g.: Donovan, J.C. and Lund, C.J. (1968) Internship in a university department of obstetrics and gynecology: a comparative study. J. Med. Educ. 43, 48–54.): 589-594
        • Donovan J.C.
        • Salzman L.F.
        • Allen P.Z.
        Studies in medical education: career choice and consistency of medical students.
        Am. J. Obstet. Gynecol. 1972; 112: 519-526
        • Donovan J.C.
        • Salzman L.F.
        • Allen P.Z.
        Studies in medical education: the role of cognitive and psychological characteristics as career choice correlates.
        Am. J. Obstet. Gynecol. 1972; 114: 461-468
      16. Donovan, J.C. (1968), vide [16].

      17. History-taking in gynaecology, and even more so in obstetrics, has always been highly structured. Emphasis is traditionally placed on factual information: date of menarche, length and periodicity of the menstrual cycle, amount of blood loss, presence of pain, etc. This has led to the printing of special “history sheet” the completion of which by a junior member of the hospital staff or, in private practice, a nurse-receptionist, often passes for “history taking”. Incidentally, this shifts the emphasis even more, in as far as the gynaecologist is concerned, from verbal to nonverbal clues in diagnosis, cf. [9].
        • Wilbush J.
        What's in a name? Some linguistic aspects of the climacteric.
        Maturitas. 1981; 3 (Cf.): 1-9
      18. Through repeated unstructured interviews. Each interview lasted 50 minutes, the patient being allowed to return as long as she felt the need to do so.
      19. This term (note North-American spelling) is used here in a technical sense. It denotes any illness or disease, the aetiology of which is preponderantly social and/or psychological rather than traumatic or metabolic. It therefore included psychosomatic and functional as well as psychoneurotic disorders (Wilbush, J. (1980) vide [31]).
      20. Donovan gives an example of “hot flashes” which one woman, recently widowed, interpreted as sexual feelings, referred to her vagina [1]. Such misinterpretations must be very common, especially in questionnaires. A good example is provided by the confusion this same symptom produced in the investigation conducted by Neugarten and Kraines [6].
      21. While sensations of “heat” are universal, few women outside the West pay them much attention (cf., Wilbush, J. (1981) [21], ibid [31]).
      22. Donovan had to administer some therapy in order to keep patients visiting his clinic. At first he gave injections of sterile water, but, though these were very effective, he had to change to a very dilute solution of oestrogen, for the nurses felt too embarrassed to inject water.
      23. I.e.: Their verbal symptoms, not their attitude.

        • Deutsch H.
        The psychology of women. Vol. 2. Grune and Stratton, New York1945: 403
        • Utian W.J.
        The true clinical features of post-menopause and oophorectomy and their response to estrogen therapy.
        S. Afr. Med. J. 1972; 46 (E.g:) (and other articles by the same writer): 732-737
      24. The inescapable corollary is that this treatment is valueless for climacteric disturbances produced by other stress factors. Hormonal medication cannot be expected to relieve the depression of the “empty nest”, if fed only or mainly by feelings of uselessness and neglect. The same applies when, as in many cultures, the main factor of stress is the woman's inability to bear children.
        • Wilbush J.
        The female climacteric.
        D. Phil. thesis. 1980; (Oxford. Especially sections 15-0-0 to 17-0-0)