Book Review

Formative Years: Children's Health in the United States, 1880–2000

N Engl J Med 2003; 348:1190-1191March 20, 2003

Article

Formative Years: Children's Health in the United States, 1880–2000
Edited by Alexandra Minna Stern and Howard Markel. 304 pp., illustrated. Ann Arbor, University of Michigan Press, 2002. $60. ISBN: 0-472-11268-6

This interesting collection of historical essays was presented at the University of Michigan in September 2000 at a symposium named for the first professor of pediatrics, David Murray Cowie. It is not intended to be a comprehensive history of pediatrics or child health, but rather a book that highlights the interaction among medicine, sociology, and politics during the late 19th century and the 20th century. The introduction, by editors Alexandra Minna Stern and Howard Markel, provides continuity, perspective, and cohesion. The editors explain that this diverse set of essays presents the subject in broad strokes. However, each essay illustrates the importance of the sociologic and political factors that influenced events, and each is well referenced.

Part 1 covers the development of pediatrics as a separate specialty. In 1860, at New York Medical College, Abraham Jacobi became the first professor of diseases of children (and was the first to use the term “pediatrics” in English). Significantly, he called his chair “infantile pathology and therapeutics” to emphasize the importance of therapy as well as observation. In 1880, the American Medical Association established the Section of the Diseases of Children (as one distinct from the Section of Women and Children), and in 1888 the American Pediatric Society was founded, with Jacobi as its first president. By 1890, pediatrics was entrenched in major cities throughout the country. In 1930, the American Academy of Pediatrics was founded (with 8 women among its 60 founders), and in 1933 the American Board of Pediatrics was formed. The origins of the relationship between public health workers and pediatricians are also explored in this part of the book; among the topics covered are the establishment of “milk stations” for impoverished children, which became excellent training sites for young pediatricians, and campaigns to educate parents about illness prevention and child rearing. The essay entitled “Technology in the Nursery” covers the conflicts between clinical trials and empiricism in the evolution of the incubator and the ventilator.

Part 2 of the book is entitled “Standardizing the Child.” The contributors, again illustrating the sociology of the time, discuss the development of tools for measuring growth and development and the struggle to evolve from the concept that average is normal to a recognition of the importance of variation from the mean. The difficult times associated with the eugenics movement, the social construction of what is a “normal” adolescent, and misconceptions about size, body type, and age at menarche are thoughtfully presented, as are the role of “constitutional psychologists” and the concept of physiological age, rather than only chronologic age, as a benchmark. The use of growth hormone is discussed as a marker of how society uses adolescence to express its anxieties that those who are not at least average might be left behind.

Part 3, called “`Discovering' New Diseases in Children,” presents a number of case studies to demonstrate how sociologic influences have delayed or facilitated medical progress. The essay entitled “Going to School, Getting Sick” describes the concern in the 1870s and 1880s that poorly lit classrooms and overworked eyes resulted in myopia, that poor ventilation in schools was responsible for much disease, and that overworked children risked “cachexia scholastica.”An excellent essay on juvenile diabetes describes a model for the development of managerial medicine as a practice that uses tabulation of data to achieve improved quality of care. The essay entitled “The Discovery of Child Sexual Abuse in America” illustrates the presence of hidden issues. Societal and medical avoidance of the presence of sexual abuse (until C. Henry Kempe challenged the profession to recognize this prevalent and serious problem) is effectively presented in a description of the delayed awareness that gonorrhea in children may indicate sexual abuse, challenging the previously held but undemonstrated theories of nonsexual transmission. The author of the final essay discusses the fetal alcohol syndrome and other conditions to cover the gradual recognition of fetal teratogens, whether pharmaceuticals (e.g., thalidomide), substances (e.g., alcohol and tobacco), environmental factors (e.g., mercury), or viral agents (e.g., rubella).

Most of the essays cover a specific subject with an appropriately variable time course, and thus the book lacks some feeling of historical progression. Nonetheless, it is quite readable. Each essay stands on its own, and yet all the essays carry the central theme that medical developments are heavily dependent on sociologic and political events, which greatly influence their recognition and acceptance. I recommend this book as good reading for everyone interested in the development of pediatrics and child health in the United States.

John E. Lewy, M.D.
Tulane Medical School, New Orleans, LA 70112
jlewy@tulane.edu