Heightened Expectations: The Rise of the Human Growth Hormone Industry in America 0817319107, 9780817319106

Table of contents :
Contents
List of Figures
Acknowledgments
Introduction
1. Making Short Stature a Medical Matter
2. The Era of Early Growth Hormone Therapy in the United States
3. Short Stature as a Psychosocial Risk Factor in Need of an Effective Cure
4. Living the Promise of Human Growth Hormone Therapy
Epilogue: A Billion Dollar Industry
Coda
Notes
Selected Bibliography
Index

Citation preview

Heightened Expectations

ne NEW HISTORIES

of

Xu s

SCIENCE, TECHNOLOGY,

the

ENVIRONMENT, AGRICULTURE & MEDICINE

n e X us is a book series devoted to the publication of high-quality scholarship in the history of the sciences and allied fields. Its broad reach encompasses science, technology, the environment, agriculture, and medicine, but also includes intersections with other types of knowledge, such as music, urban planning, or educational policy. Its essential concern is with the interface of nature and culture, broadly conceived, and it embraces an emerging intellectual constellation of new syntheses, methods, and approaches in the study of people and nature through time. SERIES EDITORS Alan I Marcus Mark D. Hersey Alexandra E. Hui ADVISORY BOARD Amy Sue Bix Frederick R. Davis Jim Downs Richard A. Richards Suman Seth Vassiliki Betty Smocovitis Jessica Wang

Heightened Expectations

*

*

The Rise of the Human Growth Hormone Industry in America

AIMEE MEDEIROS

TH E UNIVERSIT Y O F AL ABA M A PRESS

TUSCALOOSA

The University of Alabama Press Tuscaloosa, Alabama 35487–0380 http://www.uapress.ua.edu Copyright © 2016 by the University of Alabama Press All rights reserved. Inquiries about reproducing material from this work should be addressed to the University of Alabama Press. Typeface: Scala Pro Manufactured in the United States of America Cover photograph: Young Boy’s Back View by Allie L. Harper; courtesy of the artist Cover design: Michele Myatt Quinn ∞ The paper on which this book is printed meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48–1984. Cataloging-in-Publication data is available from the Library of Congress. ISBN: 978-0-8173-1910-6 E-ISBN: 978-0-8173-8962-8

Contents

List of Figures­  vii Acknowledgments ix Introduction 1

1 Making Short Stature a Medical Matter  13

2 The Era of Early Growth Hormone Therapy in the United States  47

3 Short Stature as a Psychosocial Risk Factor in Need of an Effective Cure  79

4 Living the Promise of Human Growth Hormone Therapy  102 Epilogue: A Billion Dollar Industry  131 Coda 145 Notes 147 Selected Bibliography  179 Index 189

Figures

1. Two young working boys, Rock Hill, South Carolina, 1912  14 2. Undersized boys outside a garment factory in Gastonia, North Carolina, 1908  22 3. Young girl at work in a cotton mill in Lancaster, South Carolina, 1908  23 4. Eight-year-old boy at work in Fayetteville, Tennessee, 1910  23 5. Baby book record of height measurement for a child  35 6. Weight and height tables used in well-baby examinations  40 7. Excerpt from It’s a Small World: All About Midgets  49 8. Theatrical poster titled “The Rossow Midgets,” 1897  57 9. Chart of results of early clinical growth hormone research  68 10. “Midget Village” at the Century of Progress Chicago World’s Fair, 1933  73 11. Bottle of Growth Complex from Armour Laboratories, 1944  86 12. Anterior pituitary powder and tablets from Armour Laboratories  87 13. Parade Magazine cover article of a cHGH therapy recipient  105 14. Donation card of the National Pituitary Agency  106

Acknowledgments

When I pitched the idea for a paper on the history of the human growth hormone industry in a pharmaceutical history course taught by Elizabeth Siegel Watkins, I never imagined it would evolve into a book. I am so grateful it has and to everyone who supported me in this effort. I would like to thank my colleagues in the University of California at San Francisco’s Department of Anthropology, History and Social Medicine, in particular Dorothy Porter, Sharon Kaufman, Kelly Knight, Vincanne Adams, Barbara Koenig, and Brian Dolan. I am indebted to their collective genius and insight. I would also like to thank Catherine Kudlick for introducing me to disability as an analytical lens for historical scholarship. This book and I are the better for it. Research for this book was made possible by a National Science Foundation Improvement Grant (#1058143). The funding allowed me to conduct archival research at various institutions, including the American Philosophical Society, the Mandeville Special Collections Library at the University of California San Diego, the National Museum of American History’s Archives Center, and the Louise M. Darling Biomedical Library at the University of California, Los Angeles. Everywhere, I was helped by librarians, archivists, and staff who did not flinch at my sometimes odd requests. I would also like to acknowledge the efforts of Janice Goldblum at the National Academy of Sciences Archives, Polina Ilieva at the University of California San Francisco Archives and Special Collections, and Jim Kay at the Little People of America Archive for their support and counsel. This book also benefited from the insights of numerous readers, too many to list here. I am particularly grateful for the kind critiques of Elena Conis, the copy editing precision of my initial manuscript by Paul Murray, and the robust discussions held by a writing group comprised of Rebecca Kaplan, Deborah Brown, and Portia Pirnia. Their feedback and

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ACKNOWLEDGMENTS

encouragement were invaluable. I am thankful to the two reviewers of the manuscript (one who remains anonymous and Heather Munro Prescott). Your thoughtful comments, edits, and suggestions made this book stronger. Finally, I would like to acknowledge Anna Reget, the indexer. Hopefully readers will find her guide to key terms as useful as I have. Portions of this book were presented at various events, including annual conferences of the American Association for the History of Medicine and the History of Science Society. I am indebted to those colleagues who provided feedback and posed questions at each. It was at the 2013 Organization of American Historians annual meeting that I met an assistant editor from the University of Alabama Press (UAP) and the publishing process began. The team at UAP has been wonderful to work with and I am particularly grateful for acquisitions editor Elizabeth Motherwell’s and managing editor Vanessa Rusch’s guidance and assistance. Support from my siblings and mother was also invaluable. Their kind words and excitement about this project fueled my perseverance. My deepest gratitude and thanks go to my husband, Mark Medeiros. I will always be indebted to him for the countless hours he spent editing drafts, encouraging me, and taking care of our son during the evenings and weekends I spent glued to my laptop. I would not have been able to complete this book without him. Lastly, I dedicate this book to our son, Reed Marcin Medeiros, a vivacious boy full of amazing potential. His smile is my sole reward.

Heightened Expectations

Introduction “Ever wish you had the power to grow taller? You do It’s called growth hormone.”

Filled with expectation and potential, these lines1 introduce an adventure story titled “The Great Growth Hormone Caper,” found in a 2004 activity book marketing biotechnology company Genentech’s growth hormone product, Nutropin. Originally downloadable from the company’s Nutropin website, the book directly addresses short children and their parents with promises of height, eye-catching graphics, games, quizzes, and three activity stories featuring Bobby and his friends, otherwise known as the “kids of Nutropinville.” The first of the stories is called “The Great Growth Hormone Caper,” and describes the role of growth hormone (GH) in human development through the device of having Bobby’s doctor inform him that he might be missing this essential hormone. Bobby and the gang go on a quest to hunt down the missing growth hormone; the adventure ends when the mayor of Nutropinville informs them that their hometown was in fact built to help those who are GH deficient. At the end of the story, Bobby begins GH treatment; in the following two stories, the therapy helps him build more confidence on the baseball field (“Out of the Ballpark”) and gives him the ability to stop harassment by a bully (“Bobby and the Big Bully”). The activity book successfully frames growth hormone therapy as an appropriate remedy not only for growth hormone deficiency (GHD), but also for the social anxieties short boys face in sports and social settings.2 Genentech walked a fine line by featuring the Nutropinville activity book as an educational booklet on its website. In 2004 the company received approval from the Food and Drug Administration (FDA) for the use of Nutropin in treating children with idiopathic short stature (ISS), with an important caveat: the company had to adhere to a “risk management plan” put

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INTRODUCTION

together by the FDA a year earlier when Eli Lilly received an identical stamp of approval for its recombinant Human Growth Hormone (rHGH) product, Humatrope. The plan included a commitment on the part of the company to eschew direct-to-consumer advertising, maintain a limited sales force, and practice controlled distribution.3 While the “Great Growth Hormone Caper” story helped Genentech stay true to its promise to the FDA by keeping the use of Nutropin rhetorically linked to GH deficiency, the stories of baseball and bullies conveyed to potential consumers and their parents the supposed real-life hazards of being a short boy and the genie-like promise of HGH therapy. Heightened Expectations traces how growth hormone therapy became synonymous with medically treating short boys in the hope of making them tall. The FDA’s approval of Eli Lilly’s Humatrope as a treatment for ISS in 2003 was more a reflection of a decade-long trend in pediatric care than a revolutionary move orchestrated by pharmaceutical companies. In fact, the connection between growth hormone deficiency and therapy had been progressively loosening. A mid-1990s National Institutes of Health (NIH)–funded survey of 434 US pediatric endocrinologists indicated that 58 percent of patients undergoing rHGH therapy had GHD. Girls with Turner syndrome made up the majority of the other 42 percent, and the rest were a hodgepodge of children with various conditions, including chronic renal insufficiency, familial short stature, and ISS. It is important to note that even though the majority of children subjected to rHGH therapy were short because of a diagnosed disease or biological dysfunction, the treatment targeted their stature and not their disease.4 Around the turn of the millennium, protocol caught up with clinical practice, as the FDA began granting approval for the use of HGH in a series of stunting but non-GHD conditions, including Turner syndrome (1996), Prader-Willi syndrome (2000), small for gestational age (2001), idiopathic short stature (2003), short stature homeobox-containing gene SHOX (2006), and Noonan syndrome (2007).5 Although the range of syndromes and conditions treated by growth hormone has expanded, promoting linear growth in children remains the main goal for the majority of the approximately thirteen growth hormone products on the market as of 2014. Heightened Expectations examines the relationship between the rise of the human growth hormone industry and the development of the modern notion of short stature, its stigmatization, and science’s mission to quantify and fix it.

INTRODUCTION

3

This book features three recurring themes. First, I demonstrate that pharmaceutical companies cannot be considered the sole culprits in framing short stature as a disease. Instead, the pathologization of this somatic reality has a long history, which stretches back to the nineteenth century and is linked to the cultural influence of emerging modern capitalism. Short stature developed into an indicator of substandard working and living conditions and joined a series of other somatic realities—including small frames and waif-like body types—that together constituted a reference system used by reformers to encourage governmental regulation of abusive labor practices during the late nineteenth and early twentieth centuries. Anthropometrists codified the anecdotal data from public health reformers and contributed to the normalization of average measurements and the pathologization of short stature by conducting large growth surveys of children. While historians of medicine have described at length both the rise of scientific medicine and the role of the laboratory in establishing the objectives and standards to be used in clinical practice, the manner in which the medical field has used data compiled by anthropometrists has received little attention. At the turn of the twentieth century, the results of the growth surveys began to slowly creep into private pediatric practice through the medium of growth charts, which presented average measurements as healthy norms. In this context, short stature began to signal a need for medical intervention at the individual level. As the medical specialty of pediatrics professionalized, the large growth surveys that provided data to the growth charts where forgotten as these diagnostic tools took on their own meaning by representing standards in child growth and development. The second theme of this book traces the origins of growth hormone therapy in the United States, and in doing so resets the beginning of the GH industry to the early twentieth century by examining the era before cadaver-based human growth hormone was used. This is in contrast to the traditional narrative that locates the industry’s origins in 1958, the year medical experts first reported on their successful therapeutic uses of human growth hormone. Even though we know today that early growth hormone therapy was ineffective, many early twentieth century medical experts interpreted the results of treatments with GH pharmaceuticals as promising, and it was their trial and error experimentation with growth-promoting medical regimens that brought GH therapy and the medical treatment of short boys closer together. Because clinical trials periodically served up seemingly

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INTRODUCTION

positive results, it took decades for animal-based growth hormone products to fall out of favor with physicians. Ultimately, however, pediatric endocrinologists were forced to admit the ineffectiveness of these pharmaceuticals. By the early 1950s growth hormone was no longer an option in treating GHD children. Instead, specialists turned to the male sex hormone testosterone for this purpose. According to pediatric endocrinologists of the era, this cure for short stature was a perfect fit for the ideal patient because there seemed to be a synergy between testosterone and the majority of children who sought out medical attention, that is, boys. Even after human growth hormone therapy was finally developed in the late 1950s, the link between the male patient and growth-promoting hormone treatment remained unbroken. The National Pituitary Agency (the federal agency in charge of the manufacture and distribution of cadaver-based human growth hormone in the United States), the Human Growth Foundation (a parent-run organization of families with children with short stature caused by growth hormone deficiency), and medical experts throughout the country campaigned for Americans to donate their pituitary glands before they died. They did so by advertising the success of mostly boy patients who had grown in height due to cadaver human growth hormone (cHGH) therapy and thereby overcame the pitfalls of being short. These human interest stories demonstrated that HGH therapy saved short boys from disappointing lives by spurring vertical growth. This message reverberated in advertisements for commercial cHGH in the early 1980s and continued to play a major role in recombinant human growth hormone marketing campaigns into the twenty-first century.6 The third theme in this history of the rise of the human growth hormone industry focuses on how, in the twentieth century, changing sociological notions about gender and masculinity influenced the development of medical treatment of children with short stature. During the 1960s and 1970s child psychology researchers attempted to substantiate scientifically the psychoanalytical notion that children felt inferior if they were short. These experts also sought to uncover the cause and the extent of the problems short children faced. By the early 1980s many experts believed that short stature impaired academic performance, hindered interpersonal relationships, and caused personality disorders, as short statured children responded in an unhealthy manner to the discrimination they faced. Sociologists contributed to this discussion by pinpointing who exactly faced the most social discrimination based on stature. In 1971 sociologist

INTRODUCTION

5

Saul Feldman coined the term heightism in a paper he presented at the annual meetings of the American Sociological Association. Feldman argued that “American society is a society with a heightist premise: to be tall is to be good and to be short is to be stigmatized.” He also explored the ways in which this discrimination manifested itself in language, male-female relationships, politics, economics, popular culture, and “degradation of self.”7 Journalists eager to carry Feldman’s social criticism into mainstream media quickly popularized his ideas. While child psychologists documented the hardships short children faced in childhood, sociologists warned about the adversity boys would continue to endure when they became men if parents did not seek out medical intervention for their short sons.

Manufacturing Desire This project treats the development of the stigmatization of short stature and the rise of growth hormone therapy as having equal roles in the making of the human growth hormone industry, a conceptual construction inspired by the notion of “desiring-production” put forth by Gilles Deleuze and Félix Guattari in their book Anti-Oedipus. Deleuze and Guattari propose that desire is mechanistic in nature; they use the term “desiring-machine” to explain the way in which the processes of production, distribution, and consumption are intertwined and produce a circular flow of desire. The history of the rise of the human growth hormone industry is a poignant example of the creation of a “desiring-machine,” demonstrating how anxieties, processes of production, and desires are grafted onto one another.8 It also shows how a multitude of actors—from pharmaceutical industry executives to parents—produce desire and contribute to the perpetuation of this billion dollor industry. Not only does this book treat the histories of HGH and the stigmatization of short stature on the same desire continuum, it also follows the development of scientific notions of the normal and abnormal. Inspired by Georges Canguilhem’s oeuvre The Normal and the Pathological, this book addresses medicine’s methods of assessing and defining normal and pathological phenomena and of framing pathology as a quantitative deviation from an established physiology. Canguilhem argues that once experiences are quantified they become distorted within a continuum of abstract normalcy and pathology; he pinpoints the laboratory’s role in scientific medicine as the culprit in obscuring natural variation.9 Heightened Expectations adopts Canguilhem’s

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INTRODUCTION

perspective and examines how public health supplied scientific medicine with continua, standards, and objectives that distorted natural variety and promoted conformity. In addition, Heightened Expectations hones in on the reciprocal relationship between disability and disease by exploring how disability provides a keen understanding of the perils of disease and deformity which are made most lucid by it.10 Although disability is deeply implicated in how we conceptualize health and illness, scholars often overlook the particular meaning-making relationship between it and disease. Historian Beth Linker offers a series of reasons as to why this is the case, including among other things the process of professionalization. According to Linker historians of medicine have adopted a scientific lexicon when describing health and disease in order to gain acceptance by the very field they write about. Privileging the molecular over the body, the cause over the symptom, and the laboratory over the environment, scientific medicine prefers a disease-focused approach to knowledge making. Diseases are defined, well-contained, discernable biological events, while disabilities are ambiguous, subjective, and interpretive phenomena. As Linker suggests, “within the history of medicine, we have an abundance of disease (including pharmaceutical) histories that cover smallpox, tuberculosis, and cardiovascular disease, but few—if any—accounts that look at these conditions from a disability perspective.”11 I aim to contribute to the subfield of disability in the history of medicine by demonstrating how an axiomatic understanding of ability operates in medicine and how disability provides both an interpretation for difference and a materiality to pathology. In the case of GH therapy, disability often served as a challenge while simultaneously highlighting the treatment’s curative limits.

Relevant Scholarship Heightened Expectations tells the history of the human growth hormone industry in America as one filled with unpredictability, setbacks, and doubt. It also explores the long-term effects of the discovery of growth hormone on notions of short stature. Historical scholarship on hormones— which employs the history of a hormone’s discovery and use in therapy as a lens to “illuminate complex and changing relationships” within medicine, science, and society—is therefore relevant to this project.12 The quest to discover GH harkens back to a time known as the “goldrush”

INTRODUCTION

7

era of hormones,” a term referred to by historian Alison Li to identify how the flurry of hormone research that took place during the 1920s and 1930s was interpreted.13 According to Nicolas Rasmussen, “hormones took pride of place as life’s master molecules, and the endocrinologist took precedence over the geneticist as the scientist offering the means to control life.”14 The role of hormones at this time cannot be overestimated and the history of growth hormone is part of this larger narrative, as this book will demonstrate. In addition, the histories of GH research and therapy are also part of another larger story about the relationship between government agencies, academic researchers, and pharmaceutical companies. GH can be found at the nexus of public and private interests for most of the twentieth century. Viviane Quirke’s work on cortisone explores the larger post-war trend in medical and pharmaceutical research, which is the close tie between private pharmaceutical companies and governmental agencies. In “Making British Cortisone: Glaxo and the Development of Corticosteroids in Britain in the 1950s–1960s,” Quirke pays particular attention to the influence the public pressure placed on Britain’s Ministry of Health had on the ability of Glaxo to dominate the corticosteroid market there.15 Harry Marks and Dominique A. Tobbell have also examined the complex relationships between businesses and government agencies but in a US context. Marks’s analysis is similar to Quirke’s as it demonstrates the role of the National Institutes of Health, Merck, and physicians in relation to the development of cortisone and adrenocorticotropic hormone (ACTH).16 Tobbell’s Pills, Power, and Policy furthers the analysis and focuses more on the politics of collaborations comprised of academic researchers, physicians, and drug companies during the Cold War era.17 Together, these works clearly demonstrate the porous boundaries between business motives and public interests. This project aims to further elaborate on this phenomenon by documenting its existence in the development of the human growth hormone industry. In 1976 Diana Long Hall and Thomas Glick urged historians writing about the history of endocrinology to use the stories of hormone discovery and therapy and the field of endocrinology in general as means “to throw light on the intellectual and social history of the twentieth century.”18 They suggested that the scientific controversy surrounding endocrinology and the problems the field faced in creating definitions—for example, struggling with the very definition of a hormone—were signs of deeper sociological issues at play. Historian Elizabeth Watkins’s account

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INTRODUCTION

of the history of estrogen is a prime example of this type of history. She has demonstrated the subjectivity of the endocrinology field and has explored a number of other themes, such as the “blind faith in the ability of science and technology to solve a broad range of health and social problems, the social and cultural stigmatization of aging, shifting meanings and interpretations of femininity and female identity, and the pitfalls of medical hubris in the twentieth century.”19 Her monograph The Estrogen Elixir is not only an example of the social history of a hormone but also speaks to women’s history of health sciences by probing issues related to gender. Women’s history of health sciences has contributed to the deconstruction of prevalent notions regarding the biological nature of gender and sex and also inspires the present historical analysis of the human growth hormone industry. Early works by Ann Douglas Wood, Carroll Smith-Rosenberg, and Charles Rosenberg examined both how science naturalized the weakness of middle-class women and how medicine was used to treat presumed failings stemming from femininity. By the early 1990s feminist historians had begun to delve deeper into the scientific construction of sex in order to expose the latter’s medical invention.20 Alice Dreger analyzed science’s role in the reification of sex, gender, nurture, and nature through the production of body-based knowledge during the late nineteenth and early twentieth centuries.21 Other historians have also explored medicine’s role in determining sex, the processes by which scientific and medical notions of sex and gender have migrated to the social fabric, and the impact of science’s privileged epistemological position on naturalizing social relations. All of this research is relevant to this project’s exploration of the influence of social and cultural notions of gender and sex on the discovery and therapeutic use of human growth hormone. The field of men’s studies contributes to the framework of Heightened Expectations with its use of the concept of hegemonic masculinity (a term first used by R. W. Connell). In men’s studies, gender is not simply an axis of power in which femininity/woman and masculinity/man act as polar but equal forces. Rather, gender is said to work as a hierarchical system wherein the type of masculinity associated with whiteness, heterosexuality, and a buff physique is preferred over other forms of masculinity and femininity.22 A series of publications has addressed how hegemonic masculinity has played a role in men’s and women’s health, medicine, and science. Ben Barker-Benfield’s “The Spermatic Economy” links the late nineteenth century rise in drastic gynecological surgeries and negative attitudes toward

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9

male masturbation to the growing pressure men faced to be self-sufficient, all while remaining morally subordinate to women.23 Jesse Berrett’s work focuses on the relationship between male anxieties about weight and manhood in post-World War II America.24 A growing collection of feminist works has also considered the impact of hegemonic masculinity on men, women, and the health sciences. The research of Laura Davidow Hirschbein and Elizabeth Watkins on the relationship between age, masculinity, and hormones has revealed the importance of youth in the construction of masculinity.25 Other relevant scholarship includes Gail Bederman’s Manliness and Civilization and Tom Pendergast’s Creating the Modern Man, which historicize the changing notion of manhood in the United States and provide additional insight into how this cultural development may have influenced growth hormone therapy, the medicalization of height, and the social stigmatization of short stature.26 Disability studies also theoretically grounds this narrative by challenging medical notions of difference—which often conflate disability with illness when describing a patient or person, and are void of voices and perspectives of those deemed afflicted—to raise awareness of unconscious discrimination and beliefs promulgated by modern medicine.27 Taking a cue from the work of disability historians, Heightened Expectations explores how notions of sameness, normalcy, and disability have influenced perceptions of short stature in America during the twentieth century.28 In doing so, the book contributes to existing disability scholarship by grappling with one of the core issues of the field, that is, the very definition of disability. At the root of the debate around the meaning of the term lies the language of ability. The latter, like gender and race, operates in society as an axis of power with its implied premise of and preference for normalcy and uniformity. Any attempt to define difference within this meaning-making modality perpetuates the cultural bias for sameness and similarity. The goal of this project is neither to construct a new term for disability nor to put short stature through a type of disability test in order to determine whether it is one or not. Instead, I demonstrate how the axis of ability operates within the modern context. I do so by mapping out important historical events and trends that have contributed to the stigmatization and pathologization of short stature. As should be evident by now, a wide range of scholarship—including the history of hormones, feminist scholarship on gender in medicine, men’s studies on hegemonic masculinity, and disability studies—informs this study. While previous work on the history of the human growth hormone

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INTRODUCTION

industry highlighted the dark side of HGH and used it to predict a dystopic future for medical technology, Heightened Expectations examines the broader social, cultural, medical, and scientific contexts of the history of this commercial enterprise. I peel back the superficial justifications for its existence to reveal the inner-workings of an industry based on desire and heightened expectations.

Organization of the Book Taking into consideration the dynamic relationship between public health, scientific medicine, cultural norms, and pediatric care, this work begins by analyzing how nineteenth and early twentieth century efforts by public health reformers led to the creation of scientific standards for the stature of the normal healthy child. This in turn unintentionally created systems of standardization that stigmatized physical deviancy, including short stature. Chapter 1 describes the transference of the stigmatization of short stature from the world of reformers to the clinic, a process which pathologized this somatic reality and made it worthy of medical intervention. Chapter 2 explores developments in scientific medicine that brought forth growth hormone therapy and the ways in which they contributed to the pathologization of small stature. It considers the gendered framework of clinical endocrinology, the history of male “midget” entertainment in the United States and its relationship to changing notions of manliness, early attempts to therapeutically use growth hormone, mainstream media’s interpretation of the development of GH therapy, and the ways in which male “midget” performers tried to remain seen as viable and appropriate entertainment at a time when their short stature was interpreted in the popular media as a treatable medical condition. The chapter examines the modern impulse to diagnose and advocate for the treatment of abnormal-looking people, even those who had previously been acclaimed because of their physical exoticness. I argue that by the 1940s being a short man was less acceptable than it had been previously, as short stature was understood as a visible but treatable symptom of a hidden disease. Chapter 3 focuses on the importance for the HGH industry of the period between animal-based growth hormone therapy and human growth hormone therapy. In the 1950s, as cynicism grew over the therapeutic efficacy of growth-promoting pharmaceuticals, psychology texts and advice books for parents popularized the psychoanalytical notion that biological deficiencies

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in children—including short stature—cause an inferiority complex. The decline of infant mortality rates during the first three decades of the twentieth century contributed to child experts’ emphasis on children’s psychosocial development and normal physical growth. Psychoanalysis highlighted the relationship between the two, reframing the meaning of biological variation. Although pediatric endocrinology and psychoanalysis are separate medical fields, they converged in their attention to short-statured, male, youthful bodies in the post-World War II era and together transformed short stature into a psychosocial risk factor in need of treatment. Chapter 4 sheds light on the relationship between the availability of effective HGH therapy, the creation of national growth standards, sociologists’ increased interest in heightism in America, and the upsurge in child psychologists’ concern over childhood short stature from the early 1960s to the early 1980s. It also examines how this context provided the perfect tableau for the selling of human growth hormone on the free market beginning in the early 1980s, and how the market itself was affected by the outbreak of Creutzfeldt-Jakob disease (CJD) and by the introduction of synthetic human growth hormone in 1985. I also consider the degree to which these events transformed the HGH industry. While an epilogue explores the human growth hormone industry up to the present day, the heart of this book’s analysis purposely ends in the mid-1980s. I chose this approach in order to recover a portion of the history of the human growth hormone industry commonly overshadowed by the role of growth hormone in the rise of biotechnology and the impact of recombinant HGH on the available quantity of human growth hormone. The era before rHGH therapy is often portrayed as one characterized by limited resources, substandard technology, and a low degree of success. But this portrait of pre-1985 growth hormone therapy in the United States is misleading. Throughout the twentieth century, growth hormone therapy was seen as an effective treatment for short stature due to GHD, as it supposedly saved thousands of children from lives of “hellish dwarfism.”29 Even its well-documented supply issue was much more complicated than it seems on the surface. Claims of limited amounts of growth hormone were over-reported by medical experts and clinicians in the hopes of encouraging Americans to donate their pituitary glands to science. Such misleading claims were also perpetuated by advertisements for rHGH in the mid-1980s that claimed biotechnology had solved the problem of limited supply by providing “virtual endless quantities . . . for every child who needs it—or will ever

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INTRODUCTION

need it.”30 In the case of the history of the growth hormone industry, hindsight is not 20/20. This book explores how the histories of growth hormone therapy and the social stigmatization of short stature found each other during the era of scientific medicine. While the pathologization of short stature speaks to the medicalization of somatic realities newly perceived as deficits, the quest to discover, isolate, and use growth hormone reflects the shift in the medical field toward searching inside the body for causation instead of outside in the environment. During the mid-twentieth century, the short, middle-class, full-of-potential, white boy became the poster-child for growth hormone therapy. Taken together, the histories of the rise of the human growth hormone industry and the social stigmatization of short stature alert us to the implications of the medicalization of social stigmas, the reflexivity between pathology and treatment, and show us how height matters.

1

Making Short Stature a Medical Matter

Lewis Hine was in Rock Hill, South Carolina when he photographed Charley Brazell and Floyd Brown. Charley and Floyd stood for the camera without emotion. Their bare feet conveyed their poverty while their oversized clothes emphasized their small stature. The boys, aged thirteen and fourteen respectively, worked in the textile industry and together served as evidence documenting the harmful health effects of child labor. During the ten years Lewis Hine worked as the photographer for the National Child Labor Committee’s (NCLC) campaign to end child labor, he snapped thousands of photographs of working children and collected field notes from the conversations he had with those he photographed. When Lewis interviewed Charley and Floyd, the latter admitted that he had “been sweepin and doffin’ unto four years,” and Charley suggested that the work had compromised their stature: “the mill has kep’ us from growin.”1 As this testimony provided additional evidence of the dangers of child labor, Hine hoped that Charley and Floyd’s evocative answers and small bodies would convince the public that factory work was harmful to children’s health and needed to be abolished. US history books and relevant websites still use Hine’s photographs as a record of the experiences of poor working-class children in the early decades of the twentieth century.2 Often featuring little white bodies next to large factory machines, the photos depict the desperation of impoverished children stuck at dangerous work sites. Even so, one must not overlook the calculated composition of the images and the power they have had in popularizing the idea that imperfect bodies tell us that something is wrong. It is not by chance that Charley and Floyd bore no emotions on their faces, wore no shoes, and appeared small in stature for their ages. This formulaic pathetic portrayal of working children was a staple of Hine’s work and has stood the test of time.

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CHAPTER 1

Figure 1. A Lewis Hine photograph of two young working boys, Charley Brazell and Floyd Brown from Rock Hill, South Carolina, May 1912. The original caption read: “‘The mill has kep’ us from growin.’ Charley Brazell says 13 years old but couldn’t write his name. Doffing 2½ years, spinning room. Highland Park, No. 2, Rock Hill, Floyd Brown said 14 years old (?) ‘been sweepin and doffin’ unto four years sure as I kin remember.’” From the National Child Labor Committee Collection, Library of Congress Prints and Photographs Division, Washington, DC.

This chapter explains how the photo of Charley Brazell and Floyd Brown has maintained its cultural value. It begins by shedding light on how efforts by concerned reformers in Europe and then the United States contributed to the modern social stigmatization of short stature and the medicalization of children’s height by turning small stature into an indicator of ill health. Next, it looks at how the practice of measuring children moved beyond the world of nineteenth century reformers, exploring how it was used and understood by scientists who hoped to assess population-level health by rounding up children en masse for growth surveys. The data from these surveys were then used to establish standards that doctors used to evaluate individual children. As pediatricians assumed an authoritative role in the supervision of children’s health by the 1930s, public health officers and educators championed the popularization of measurement and celebrated averages as healthy norms, thereby stigmatizing short stature. In the end, although discrimination against short stature can be traced back to antiquity, the modern trends detailed in this chapter ushered in a unique sensibility of this cultural bias, one influenced by the rise of capitalism, championed by reformers, endorsed

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by scientific medicine, popularized by public health campaigns, and taken up as an effective tactic in the medical observation of children.

Industrialized Childhoods Industrialization transformed the lives of millions of children in the United States during the nineteenth century. Already in the antebellum period, the market economy ushered in many changes—including new employment opportunities in mass manufacturing. Thousands of Americans abandoned the farm and made their way to the factory. Although native-born males formed the largest group of early manufacturing laborers, women and children also found work in the first large-scale mills erected in New England in the 1820s.3 According to historian Thomas E. Cone, “in 1820 about half of all textile workers in Massachusetts, Connecticut, and Rhode Island were children, and in 1832, boys under twelve comprised 43 percent of cotton mill workers.”4 This trend continued throughout the century and had a particular impact on poor young people’s lives. Impoverished children worked long hours and struggled to reap the rewards of public education. Starting with Massachusetts, states tried to regulate child labor during the antebellum period, but the number of children working in factories only grew.5 Reformers were outraged by the high rate of working children. American educator and politician Horace Mann stated that “it is obvious that children of ten, twelve, or fourteen years of age may be steadily worked in our manufactories, without any schooling, and this cruel deprivation may be preserved for six, eight, or ten years, and yet during all this period, no very alarming outbreak will occur to rouse the public mind from its guilty slumber.”6 Still, child labor persisted and intensified after the Civil War, when America’s industrial revolution went into high gear. As industrialization exacerbated inequalities between the rich and the poor, the government failed to create any type of social safety net, forcing many poor families to send their children off in search of industrial employment.7 Young people found jobs delivering newspapers, making brooms, working in mills and mines, and helping their parents with piecework at home.8 Although agricultural employment dominated child labor from the 1880s to the 1930s, it was the flow of young people toward this new type of urban, industrial work that angered American union organizers, social reformers, and public health officials. Nineteenth-century organizers against child labor used the standard

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strategies of reformers—including anecdotal evidence and moral suasion— to convince their contemporaries to support legislation regulating the practice. Perhaps one of the most compelling pieces published at the time documenting the horrible working and living conditions of the poor was Jacob Riis’s How the Other Half Lives. Published in 1890, Riis’s book portrayed the poverty children endured in New York City, although it did not prove scientifically the ill effects of industrialization on the poor. Still, his wildly popular publication convinced enough New York City legislators to pass local regulatory laws.9 In 1900 the regulatory accomplishments of Riis and his supporters were overshadowed by the US census, which indicated (incorrectly) a rise in child labor.10 This apparently bad news inspired a new crop of reformers to take a more scientific approach to ending child labor. Known as Progressives, these reformers believed they could influence public opinion and move average citizens to demand action from authorities through public campaigns and investigative reporting that documented the horrors of child labor. Throughout the nineteenth century, a similar approach had already been used in Britain and France with much success. Thus, at the turn of the century, the anti-child labor movement in the United States took a decidedly scientific turn and began collecting what activists perceived as indisputable evidence in order to prove the need for federal legislation abolishing child labor.

European Efforts to Protect Working Children Progressives were encouraged by British reformers’ success in getting laws regulating child labor passed. During the late eighteenth and early nineteenth centuries, British public health officials identified children as the most innocent victims of the harsh realities of industrial work and focused on persuading government to pass ameliorative legislation. Public health officers and social reformers collected scientific data to document the impact of brutal working conditions on children. They conducted surveys, in which they measured and compared the stature of working children to that of their non-working peers. The results demonstrated how industrial work was harmful to the former, as children working in the factories were found to be smaller—and therefore less healthy—than children who did not work. Reports based on these surveys influenced public policy throughout Europe, with Britain being the first to pass regulatory laws aimed to protect

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working children and women.11 These “Factory Acts” limited the number of hours women and children could work, restricted where they could be housed, and provided maximum hours for specific ages, all in the hopes of improving the health of the workers.12 While reformers were successful in getting legislation passed, it was difficult to enforce the compliance of the components meant to protect children. Non-compliance by business owners ran so high that the British government assigned public health reformer Edwin Chadwick to orchestrate a project investigating the level of misconduct. Chadwick asked medical commissioners to measure working children’s height, weight, and overall stature; the results were then compared to data collected from non-working children. As expected, the measurements showed that factory children were, on average, shorter than other children. This data substantiated accusations made about the causal relationship between unsafe working conditions and poor health in children. It also became the basis of Chadwick’s 1833 Report on the Employment of Children in Factories and inspired the passing of the Factories Regulation Act that same year.13 The 1833 Act strengthened already existing restrictions on child labor and linked the health of children to working conditions. It prohibited children under nine years of age from working in various types of factories, required special accommodations for workers between the ages of nine and thirteen, and demanded that children be examined by “a surgeon or medical man who shall certify on inspection of the child that he believes it be of the full growth and usual condition of a child of the age prescribed.”14 It also made factory inspectors responsible for conducting checks to make sure factories in their district adhered to the new, stricter regulations. Still, even though the law specified punishment for non-compliance, many factories failed these inspections. The success of Chadwick’s work and the publication of his findings complemented similar child labor reform projects throughout Europe and helped transform short stature into an indicator signaling substandard working and living conditions. By the mid-nineteenth century, short stature joined a series of other somatic realities—including small frames and waif-like body types—to constitute a system of reference used by reformers and legislators to document the harm done to children by industrialization. As British government officials continued to conduct surveys to assess the impact of industrialization on children, French reformers began collecting similar data. Well-known public health advocate Dr. Louis-René

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Villermé led the charge. In 1832, he was appointed by the Académie des Sciences Morales et Politiques to examine the health of working children in textile factories throughout France. His fieldwork included measuring and comparing the height of working children to non-working children; his reports documented the deficiency in height of the former and advocated for the end of their exploitation. Even before his work was completed, Villermé expressed his conviction of the need for a law specifying the “maximum duration of work for children in factories” and suggested that it should be “a copy of one passed in England.”15 In 1840 his findings were issued in a report titled Tableau de l’état Physique et Moral des Ouvriers: Employés dans Le Manufactures de Cotton, de Laine et de Soie; a year later France passed its first child labor law. While the legislation was weakly enforced, Villermé continued to conduct field studies, publish reports, and work with other reformers to convince the government of the need for more restrictions, based on the belief that “the circumstances which accompany poverty delay the age at which complete stature is reached and stunt adult height.”16 In 1871, several years after Villermé’s death, France finally passed a law restricting child labor.17 The measurements of thousands of working children contributed to the law’s passage as Villermé and other reformers used small frames, waif-like body types, and short stature as a system of reference signaling mistreatment. Chadwick’s and Villermé’s success inspired Progressive reformers in the States. By the 1880s the meaning of short, frail, tiny bodies in France and Britain transcended mere numbers on a ruler or a scale, serving instead as indicators of the impact of the poverty and exploitation inflicted upon helpless children by industrialization. Twentieth century Progressives hoped to follow the example of their European counterparts in their quest to convince all levels of government to regulate child labor.

The Progressive Movement’s Anti-Child Labor Campaign By 1900 New York City was at the heart of the Progressive anti-child labor movement in the United States. Home to over thirty settlement houses, countless humanitarian organizations, impoverished immigrant enclaves, and unprecedented wealth, the city led the way in implementing local-level regulatory legislation in child labor.18 In 1902, proud of the New York statelevel child labor laws already in place, Progressive reformers created a temporary committee to investigate their effectiveness. Led by Florence Kelley and

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Lillian D. Wald, the committee found that the laws had in fact failed and child labor was rampant in their state; they therefore lobbied for stricter legislation. Legislators complied and this political success led Kelley, Wald, and others to extend their efforts further. In 1904 the committee was renamed the National Child Labor Committee and its anti-child labor crusade went national.19 The NCLC aimed to “properly inform” the public about the prevalence and perversity of child labor and to inspire a “national sentiment upon the subject” that would persuade the passage of legislation detailing increased government regulation.20 The organization created a model law based on sections of existing legislation and advocated for its passage state by state. In addition, its members also campaigned for passage of the model law at the federal level.21 With these goals in mind, NCLC activists organized a passionate anti-child labor campaign incorporating their own notion of childhood. NCLC members lectured audiences across the country about how child labor was un-American in the way it exploited the most vulnerable members of society and contributed to degeneracy by not allowing children to experience “normal birth,” “physical protection,” “happiness,” “useful education,” and “the right to progress”—all components of what the NCLC termed the “new view of the child.” This new vision promoted the concept of a normal childhood—meaning an upbringing that would mold children into healthy, happy, educated citizens ready to lead the next generation—and served as the backdrop for the anti-child labor movement.22 Like other Progressive organizations, the NCLC used investigative reporting to persuade Americans to demand the abolition of child labor in the United States.23 The NCLC’s leaders traveled to areas where many industries notorious for their exploitation of children were located and lobbied locally for an increase in government regulation, organized anti-child-labor committees, and presented eyewitness accounts of the horrors of child labor. In order to increase the credibility of their claims about child labor and the potency of their message, the NCLC hired Lewis Hine as its official full-time photographer in 1908.24 Hine was no stranger to investigative photography. While a teacher at the Progressive-minded Ethical Culture School in New York City, he had photographed immigrants being processed at Ellis Island. He had also previously free-lanced for the NCLC, worked for the National Consumers League, and taken photos for the Progressive project, the Pittsburgh Survey. Heavily

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funded by the Russell Sage Foundation, the Pittsburgh Survey aimed to use social science methods to document working conditions in an industrial city, and to employ the data collected in convincing its audience about the need for reform. The survey’s organizers also hoped their study would serve as a model for future projects, which it did. The NCLC anti-child labor campaign employed similar strategies and personnel, including photographer Lewis Hine. Hine believed in the NCLC cause. He opposed blaming the poor for their poverty and hoped that his images of working children would stir the compassion of middle-class Americans, who would then urge government officials to bring an end to child labor in the country. Motivated by his beliefs and the organization he worked for, Hine used small stature as a visual code to communicate the inappropriateness of factory work for children, the maltreatment of employees, and the unhealthy state of working conditions.25 Lewis Hine worked for the NCLC from 1908 to 1918 in the capacity of photographer, field data collector, and exhibit director. He traveled throughout the country, documenting industries most known for exploiting children, including the mining industry in West Virginia, textile mills in the South and New England, and the tobacco industry and canneries in the Gulf states. During site visits, he did his best to document children’s working conditions by using the tools of the social scientist: field notes, interviews, and photographs.26 Sometimes Hine lied to employers about the true subject of his photos, telling them he was interested in capturing images of the machines at work. If he was refused entry to the workplace altogether, Hine would wait outside the factory to catch a photo of children on their way home or to work.27 It is important to note that Hine and other reformers made a distinction between healthy and harmful child labor.28 While they had no qualms about children working on a family farm or learning a trade through an apprenticeship, they did take issue with jobs that took children away from school, exploited them as cheap labor, and were physically dangerous. In his work, therefore, Hine focused on the relationship between certain types of work— such as factory work or mining—and diminished child welfare. Hine also focused on a certain type of children—white ones. The director of Hine’s photographic assignments, Alexander J. McKelway, was also the head of the NCLC Southern Committee. According to social scientist Peter Seixas, it was probably McKelway who decided what type of children to document, since “he typified Southern Progressive reformers who fought for

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limited and specific humanitarian changes while being careful not to upset the basic social, racial and economic arrangement which ruled southern society.”29 In addition, the leaders of the anti-child labor movement also identified white children as the most victimized by industrialization. Florence Kelly once remarked, “the most unfortunate of our little fellow citizens were the white, English-speaking, native children of the Southern cotton states.”30 Consequently, in order to rally support from other Progressives and white middle-class Americans alike, Hine’s lens was directed toward capturing frail, small, and pathetic white bodies forced to work. Small stature mattered to Lewis Hine, the NCLC, and Progressive reformers because it functioned as an indicator of age, maltreatment, and/ or compromised health. Understanding the power of the perceived relationship between health and height, Hine communicated the short stature of his subjects by strategically placing children in his photos and providing captions often alluding to their smallness and/or providing their “exact” height. This visual technique is evident in a photograph taken outside the front steps of Loray Mill in Gastonia, North Carolina. The image includes seven male workers. One worker stands in the background at the entrance of the mill, while four small boys occupy the center of the photographer’s vision. Two taller men stand on either side of the boys, providing a contrast in height, in order to communicate to the viewer in no uncertain terms that the four small workers in the center are young boys.31 When photographing children inside factories, Hine often placed his subjects near large machinery so as to provide a sense of scale and of their small stature. This was the case, for example, of a series of photographs taken in South Carolina and Tennessee.32 In one image, a huge machine towers over a girl working as a spinner at the Lancaster Cotton Mills in South Carolina; her factory surroundings help demonstrate her short stature. In another photograph, Hine documents Leo, an eight-year-old boy at Elk Cotton Mills in Fayetteville, Tennessee at work. The barefoot young worker gazes at the camera as he stands in front of a textile machine. His small stature is conveyed by the machine’s frame behind him and the other taller workers featured in the background of the spinning room. Small-statured workers were preferred for Leo’s job, which was picking up bobbins stuck in the open space in the middle of the frame. Young boys like Leo were paid a daily flat rate to climb the machines to retrieve the bobbins. Accentuating Leo’s small body, Hine’s photo depicts the vulnerability of this young boy hired for such a dangerous job.33

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Figure 2. A Lewis Hine photograph taken outside of a factory in Gastonia, North Carolina, November 1908. The original notation read: “Boy with Coat in Hand Is 11 Years Old.” From the National Child Labor Committee Collection, Library of Congress Prints and Photograph Division, Washington, DC.

Although Hine believed his photographs alone could convince Americans that child labor hurt children and should be abolished, his field notes aimed to drive home the point of his visual testimony even further. Hine wrote captions for his photographs based on these field notes, intending for photo and caption together to create a “photo story” of child labor in America. The captions often describe the subject’s location, include quotes from the children, and record the duration of children’s work, pay, and health. Hine was methodical in his approach to measuring the height of his subjects. Unable to use a ruler to measure the children, he memorized the lengths between each of his vest’s buttons and the floor. While on site, Hine measured the children with his vest and recorded the measurements on a concealed notepad.34 Consequently, he was not only able to visually demonstrate the small stature of his subjects but also to feature specific measurements of them in his photo captions. Hine’s captions allowed him to emphasize certain traits of his subjects, to provide additional context highlighting the dangers of child labor, and to better control the message of his photographs. By capturing the perfect

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Figure 3. A Lewis Hine photograph of Sadie Pfeifer at work at a Cotton Mill in Lancaster, South Carolina. The original caption read: “Sadie Pfeifer, 48 inches high, has worked half a year. One of the many small children at work in Lancaster Cotton Mills. Nov. 30, 1908.” From the National Child Labor Committee Collection, Library of Congress Prints and Photograph Division, Washington, DC.

Figure 4. A Lewis Hine photograph of a boy at work in Fayetteville, Tennessee, November 1910. The original notation read: “Leo, 48 Inches High, 8 Years Old.” From the National Child Labor Committee Collection, Library of Congress Prints and Photographs Division, Washington, DC.

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image and composing compelling prose, Hine wanted to convince viewers that factory work was harmful and to move them to demand that legislatures start passing laws protecting children. Various newspapers, Progressive journals, and NCLC publications featured Hine’s photos and captions. NCLC leaders included slides of Hine’s work in their lectures to further document their conclusions about the exploitation of children. Moreover, the organization made a small income from renting these slides to other reformers hoping to do the same. Hine himself presented his work at NCLC meetings, advertised his services, and lectured to the public about what he saw as the horrors of child labor. He also served as the official photographer for non-NCLC projects, including the 1911 Child Welfare Exhibit held at the seventy-first Regimental Armory in Manhattan. His exhibit at the Armory featured photos documenting smiling, proportionate, similar-statured children experiencing and benefiting from the “new view of the child” as they played on jungle gyms and sat at their school desks ready to learn juxtaposed with images of short-statured children at work operating massive machinery and risking their lives doing dangerous tasks.35 After several years with the NCLC, Hine became the director of its exhibit’s department and further influenced the dissemination of his own work and the message of the organization by creating additional exhibitions and posters. In 1915 he curated the NCLC exhibits hosted by the Panama Pacific International Exposition (PPIE) in San Francisco and the Panama-California Exposition in San Diego. Panel displays went beyond the typical “photo story” and featured thought-provoking text. For example, a panel exhibit at PPIE asked visitors What are we going to do about it? and urged them to “try and protect childhood.”36 Hine’s exhibits also suggested that child labor was un-American. One of his traveling exhibit panels stated: “Child labor IS FUNDAMENTALLY WRONG: It is a contradiction of the basic principles of this free republic that upon the SHOULDERS of a CHILD who has not attained full physical development, had a reasonable time for play or education, there should be put the smallest fraction of the burdens of modern competitive life.”37 In short, Hine’s exhibits and photo displays provided even more comprehensive context than captions alone and framed short-statured children not only as victims of industrialization but also as symbols of a society that had veered away from its fundamental democratic principles. By the time Hine left the NCLC, he was considered the most successful

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photographer of social welfare in the country, due to the wide distribution and abundance of his work.38 Hine’s photographs influenced the way Americans envisioned and interpreted short stature, although the NCLC’s anti-child labor movement had to wait until 1938 to declare victory. That year the federal government finally regulated child labor with the passage of the Fair Labor Standards Act. Although it had taken decades for the legislation to be passed and scholars disagree as to the impact of the NCLC’s campaign on the final outcome, Hine’s imagery of short, frail children certainly endorsed the notion that small bodies conveyed trouble.

Anthropometry in America During the first several decades of the twentieth century, Progressives fine-tuned their skills in investigative photojournalism. Images documenting perceived truths proved powerful in a series of campaigns, including anti-child labor. While the public could have been moved to tears by the heart-wrenching personal stories and photographs of young children at work they had collected, it could have also interpreted them as merely anecdotal since they lacked statistical evidence substantiating the abnormal nature of working children’s stature, even though these data existed. Thousands of measurements collected by anthropometrists who had conducted large growth surveys were available by the 1900s. Although unused by Progressives, these data further evidenced the harmful effects of industrial work on children and helped shape medical notions of normal height and contributed to the stigmatization of short stature. Population statistics had grown in importance during the mid-nineteenth century with the publication of Charles Darwin’s The Origin of Species (1859), which fueled scientists’ curiosity to better understand human variation. As information about populations was gathered, speculation grew over the influence of genetic inheritance, the potential meanings of body stature as an indicator of mental ability, the power of so-called biological markers (such as race and gender) on personhood, and humanity’s ability to direct human evolution, a strategy later known as eugenics. Inspired by Darwin’s idea of natural selection, anthropometry took on the study of human measurements in order to better understand variation, an endeavor often infused with the eugenic perception of Anglo-Saxon superiority. Scientists rushed to document what physically made people different as the first step in exploring the ways in which human variation had been and could be influenced.39

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Henry Bowditch was one of the American scientists to seriously engage in anthropometry. When he returned to Boston after traveling to France and Germany—where he had studied physiology and worked in the laboratories of Claude Bernard in Paris and Carl Ludwig in Leipzig—he became an assistant professor of physiology at Harvard Medical School and served on Boston’s school committee. Bowditch used his role on the committee to orchestrate a major growth survey to study human variation among the city’s schoolchildren. Bowditch’s Boston Growth Survey was the first of its kind in the United States, and data derived from it became the foundation for subsequent studies and pediatric growth tables. The object of this 1875 study was to “determine the rate of growth of the human race under the conditions which Boston presents.”40 Bowditch collected close to 24,500 measurements and conducted thousands of interviews with children, for the purpose of assessing the growth rate of various races, immigrants, natives, and girls and boys living in Boston and comparing his findings to the results of earlier European studies. Based on collected measurements, he was able to contribute to the ongoing eugenic discussions in anthropometry, which spoke to scientists’ anxiety over data from white native boys and what they might say about white male superiority if they weren’t able to measure up to expectations. The results of Bowditch’s study might have given concerned researchers a sigh of relief, as the measurements led him to conclude that girls weighed more and were taller than boys only between eleven and fourteen years of age; that children of American-born parents living in Boston were taller and heavier than children of foreign-born parents; that private school boys were taller and weighed more than their public school counterparts; and that geography, climate, and living conditions played a role in growth, which spoke to concerns over immigrants and their capacity to realize their own physical potential in their non-native land. Bowditch’s findings were published in a series of reports of the Board of Health of the State of Massachusetts, which he chaired during the late 1870s. In 1880, the Massachusetts Board created a circular about Bowditch’s growth survey and distributed it to various institutions encouraging them to collect similar data. The board wanted to explore the influence of environment on the growth of children and “the physique of adults,” to investigate the relationship between immigration and “the physique of a given race,” to compare and contrast the effects “of city and country life on growth and development,” and to investigate the relationship “between disease and growth rate”

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on a larger scale.41 Those interested in anthropometry and lucky enough to have the resources to execute a large study responded to Massachusetts’s request with enthusiasm. Two of the most well known of these post-Bowditch studies were the 1881 Milwaukee study orchestrated by George W. Peckham and a study in St. Louis organized by Dr. William Townsend Porter. Each study was massive. In 1881 G. W. Peckham, a biology teacher in Milwaukee interested in charting the growth of German immigrant children, took the measurements of 10,000 children between the ages of four and eighteen. Ten years later Porter, curious about the relationship between school performance and physique, measured 33,500 public school children in St. Louis.42 While these two men had different agendas, they, like Bowditch, found schools to be the perfect clearinghouses for their work and were excited about their contributions to the growing data on the health of American children. Together they provided height averages that were later used by physicians as healthy norms. In schools across the country students were rounded up, measured, interviewed, and assessed, all in the name of anthropometry and sometimes to the dismay of parents and onlookers. People questioned the validity of the studies and the practice of those conducting the measurements. For example, in 1890 the Worcester Daily Telegraph criticized Clark University professor Franz Boas when he began conducting a growth study of schoolchildren in Worcester, Massachusetts after obtaining approval from the local school board. Boas planned to record a series of measurements, including height, weight, head size, and the personal history of each child measured by using the most up-to-date equipment, such as calipers. He saw this study as a wonderful opportunity to research human variation, as Worcester had recently experienced an influx of immigrants from diverse locations eager to work in its factories, and the public school system counted half of its population as “foreign-born” or “children of immigrants.”43 Boas was not the only scientist curious about the relationship between health and immigration; indeed, the growth and development of immigrant children had long since been of interest to anthropometrists. Boas’s project hit a snag when it became embroiled in a feud between those affiliated with Clark University and Worcester journalists and residents who distrusted them. As Boas geared up for his study, journalists challenged both its validity and his reputation. Reports claimed that “children at school have their anatomies felt of and the various portions of their

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bodies measured for no reason established in science,” and that Boas was a man sporting dueling scars on his face. Worse, he was an immigrant from Germany “unknown to Worcester, either personally or by established reputation, except as the representative of an institution under a blood red cloud.” One report painted a picture of the collection of measurements as an opportunity for Boas “to measure the thighs of Worcester schoolgirls.”44 The Worcester Daily Telegraph brought “the caliper question” to its readers and created a ballot for them to fill out as they voted on whether the study should continue.45 While this attack on the Worcester study was more personal than criticism drawn by other growth studies, it does reflect the resistance from parents and the community these kinds of measurements engendered. Even after receiving such harsh criticism, the Worcester school board continued to support Boas and his four assistants. While Boas’s team measured and interviewed pupils, a journalist from the Worcester Daily Telegraph observed their execution of the study. The local media was so opinionated and boisterous that Boas made sure to secure “permission from 80 percent of the parents” and claimed he did not measure any child without parental consent.46 While Boas left Worcester and Clark University shortly after the conclusion of his growth study, he continued his work on children’s growth and coordinated a major continental anthropometric study for the Chicago Columbian Exposition in 1893. With the help of specialists in the field, Boas collected children’s measurements from various North American cities, including Toronto, Canada and Oakland, California. He then merged his findings with previously published studies, a common practice in anthropometry, to represent the growth and health of North American children and to establish a set of population standards. A total of nearly 90,000 children between the ages of five and eighteen were surveyed.47 A display featuring the project was shown in the anthropology building of the Chicago fair among other exhibits featuring anthropometric equipment and data from various native peoples of North America.48 Whereas Boas’s motivation for his growth study and the inclusion of his measurements among exhibits featuring Native Americans reflected early anthropometric attempts to document human variation by comparing and contrasting population standards, his work also helped establish normal growth rates in children. In addition, his work on height transcended the fair when his data were featured in a report of the US Commissioner of Education.49 Schools served as important sites for the collection of measurements

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of large numbers of students even before they became ideal places for the medical inspection of children. In 1889 the new US Commissioner of Education, William Torrey Harris, took notice of the growing number of anthropometric studies conducted in America’s public schools and wondered if physical traits could provide clues as to which pupils were most susceptible to personal decline. As this idea gained merit in scientific circles at the end of the nineteenth century, Harris decided to hire Arthur MacDonald to further explore the connection between physical features, the potential of instruction, and the capacity of the mind. In 1892 MacDonald left his position as a docent at Clark University, joined the Bureau of Education, and quickly established his role as the “specialist in education as a preventive of Pauperism and Crime.”50 MacDonald was eager to dive into his work. During his tenure at the bureau, he attended two European conferences on criminality and anthropology, wrote several books about the relationship between physical stature and the mind, and conducted multiple studies on schoolchildren attending Washington, DC public schools.51 In the report “Experimental Study of Children Including Anthropometrical and Psycho-physical Measurements of Washington School Children,” MacDonald justified his endeavors, reported on his methods and findings, and provided conclusions. His work with schoolchildren in DC spanned four studies: “one was a special study of 1,074 children, which considered the cephalic index and sensibility to heat and locality upon the skin, with relation to sex, mental ability, and sociological conditions” and was conducted by MacDonald himself; another was an “anthropometrical and sociological study of all of the school children, based upon measurements by the teachers;” the third “was a purely psychological inquiry as to comparative mental ability in the different school studies as reported by the teachers;” and “the fourth was a study of the abnormal children in the schools as reported by the teachers.”52 This report, published by the Bureau of Education and reprinted in a variety of other mediums, included MacDonald’s intent, an elucidation of the experiments conducted on schoolchildren, and a description of the collection of their body measurements. His studies were meant to provide insight into normal child growth and development: “As pupils are examined periodically to test their mental growth and improvement, it is just as necessary to fare that their physical condition and development be ascertained, so that progress may be gained in body as well as in mind.”53 MacDonald, like many other anthropometrists, believed in taking an extensive set of measurements in order to assess

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physical condition. “Experimental Study of Children” also described how he measured children’s heads, sitting height, standing height, their hand grasp strength, and responses to shocks administered to their temples. He recruited teachers to help him with his study; they measured their pupils and filled out questionnaires assessing the children’s abilities.54 Even though MacDonald was concerned with many of the educational issues of the day (including the maximum level of work suitable for a child in different periods of growth and the possibility that the vital force in children was overtaxed during growth spurts, making them unable to learn), his conclusions ran the gamut and often negatively implicated certain body structures, including short stature.55 MacDonald linked low intelligence with short stature—proposing that “bright boys are in general taller and heavier than dull boys”—and class to stature: “Children of the nonlaboring classes have, in general, greater height, sitting height, and weight than children of the laboring classes.”56 Shortly after the publication of his findings, MacDonald’s investigation of what he had called the “normal modern civilized man” gave way to an obsession with establishing a laboratory at the Department of Justice for the study of the criminal, pauper, and defective classes. He argued, “the government pays out hundreds of thousands of dollars for erection of monuments for the study of rocks, plants, and animals, it would seem proper that it pay out a few thousand dollars to study in a rigid, scientific way its greatest enemies—the criminal and abnormal classes.”57 By the time MacDonald’s laboratory campaign had reached full force and a few years before the publication of the Washington, DC studies, his relationship with his supervisor had turned sour due to an unrelated scandal around a book he had written about women with sexual abnormalities. In 1903, Commissioner of Education Harris fired MacDonald. Ultimately, Harris’s dealings with MacDonald eventually turned the former off of anthropometry completely. When asked to comment on the elimination of MacDonald’s job, Harris stated, “to ask any teacher to measure children was a piece of impertinence.”58 Even so, schools remained significant places for collecting measurements from children, a practice that became medicalized and grew ever more popular during the early decades of the twentieth century.

The Medicalization of Height The weighing and measuring of infants and children for medical reasons predates the large growth surveys conducted in the United States and its

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increased standardization during the nineteenth century played an equally important role in the modern medicalization of height and the stigmatization of short stature. As early as the 1820s pioneers in the field of pediatrics—for example, Charles Michel Billard—had pointed to the importance of average growth measurements in caring for children, in particular infants. Billard’s influential 1828 text Traité des Maladies des Enfants Nouveau-nés et à la Mamelle (which was translated into English in the 1830s) included a list of measurements of newborns based on a handful of the author’s own observations and meant to help physicians gauge the normalcy of infants under their care.59 The work of Belgian mathematician, astronomer, and statistician Adolphe Quetelet buttressed the practical work being done by physicians like Billard. Quetelet’s 1835 A Treatise on Man and the Development of His Faculties (first translated into English in 1842) presented his idea of the “average man,” a concept that would have a profound impact on social science and medicine. Quetelet attempted to devise a series of standards—based on statistical averages— which were to be seen as ideals. In establishing the composition of the average man, Quetelet championed the idea of developing average measurements of height and weight and “exact tables which might enable one to ascertain, at different ages, the values of these physical qualities, and the limits within which they are found connected in individuals regularly formed.”60 While he posited the usefulness of such quantification for the post-mortem verification of age and the recruitment of men into the military, Quetelet was most interested in arriving at a series of average height measurements for girls and boys.61 Pulling data from various sources representing a wide range of economic classes—among them the “junior schools of Brussels, the Orphan Hospital,” and “boarding-houses”—Quetelet’s treatise included a table depicting the rate of growth from birth to twenty years of age.62 As Quetelet suggested in his text, little research had been done “to measure the height and weight of man,” either after birth or before “complete development;” his tables provided an innovative nineteenth century opportunity to compare an individual’s measurements with averages.63 In doing so, Quetelet’s work further established the value of height and its relationship to growth to the social scientist and the physician. In the 1880s the medical practice of measuring and weighing minors became increasingly standardized due to the growing use of averages. Bowditch championed this effort in the United States, recommending that physicians compare their patients’ data to averages collected by growth

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surveys. In 1881 Bowditch gave a lecture at the second annual meeting of the American Medical Association (AMA)’s section on pediatrics, at which he stressed the “importance of securing statistics in regard to the physique of growing children” and called attention to the “relation between growth and disease.”64 He had written previously about the possible relationship between growth and certain diseases—especially fevers—and by the time he gave the talk at the AMA gathering he seemed convinced of the usefulness of average measurements of height and weight as guidelines in clinical care.65 Bowditch argued, “it seems probable that the accurate determination of the normal rate of growth in children will not only throw light upon the nature of diseases to which childhood is subject, but will also guide us in the application of therapeutic measures.”66 Bowditch’s recommendation to use anthropometric data as diagnostic tools in clinical care came at a unique moment in the development of pediatrics, as physicians engaged in caring for children were developing their own specialized field.67 Pediatricians attempted to establish themselves as specialists by meeting in a separate section at the AMA’s annual meetings, publishing the first journal dedicated to the medical care of children, and establishing their first professional society the American Pediatric Society (APS). The first pediatric textbook in the United States soon followed and further solidified the medical care of minors as unique and worthy of being classified as a specialized field.68 Intended for the “physician who practises among children and of the student who expects to do so,”69 L. Emmett Holt’s The Diseases of Infancy and Childhood exclusively and purposefully dealt with “matters which are peculiar to early life.”70 Growth was undeniably one of those matters, and the book devoted an entire chapter to the subject.71 In “Growth and Development of the Body,” Holt recommended both the observation and assessment of weight and length.72 He explained that “observation upon growth and development are of the utmost importance during infancy and childhood. Only by this means are very many diseases detected in their incipiency.”73 Holt’s method of assessment included a comparison to averages. He argued that “by familiarity with what is normal detection of the abnormal soon becomes easy.”74 While weight was the most important indicator, length, head, and chest circumferences were also included as core measurements in the observation of children’s health. In order to allow readers to compare patients’ measurements with data deemed normal, Holt included tables in the textbook. The main diagnostic

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tool for quantifying and assessing height featured average measurements of children’s stature from birth to sixteen years of age; it also included weight, head and chest circumferences. The table was divided by gender, with boys’ data in bold and listed first. The averages for five- to sixteen-year-olds came from data from Bowditch’s Boston study, while the averages for infants were derived from measurements taken from the New York Infant Asylum and Sloane Maternity Hospital. Measurements reflecting healthy averages for children six months to four years were based on five hundred of Holt’s own clinical cases.75 While the averages featured on the chart served collectively as a diagnostic tool for determining the health of a child, Holt’s textbook also featured a critical context to these numbers. Footnotes featured a reference to findings from an 1895 study conducted by Franz Boas, which observed that firstborn children six years older than their siblings exceeded the latter in height and weight. There was also mention of the study of children from St. Louis, which indicated that the boys and girls measured by Porter grew slower than their peers from Bowditch’s Boston study.76 In the end, even with these caveats, it was the table, and not the footnotes, that was intended to be the pediatrician’s diagnostic tool.77 Holt’s presentation of average height measurements and how they should be medically interpreted was not majorly revised until the textbook’s seventh edition.78 In this version, both race and nutrition were directly discussed in the section dealing with height. The textbook suggested that “regular gain in weight and growth in height are phenomena of normal nutrition” and that the relationship of weight to height was “little influenced by race conditions.” There was also mention of the how average measurements should not be regarded as normal.79 The previous editions had not included such considerations. Edits to the eighth edition further developed the chapter pertaining to growth. Whereas previously the text emphasized exclusively the importance of observing growth, the new version mentioned the role of glands. It suggested that “the thyroid certainly stimulates growth; the influence of the others like the pineal body, the pituitary, and the adrenals has not yet been definitely determined. Normal growth must depend upon a proper balance between these different organs.”80 The introduction to the chapter now also featured some commentary on the influence of nutrition on growth.81 The eighth edition also maintained a conversation about the relationship between race and stature. While the text stated the relationship of weight

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to height was not overly influenced by race, the category served as an organizing principle in a chart featuring the averages of weight for height of boys. The chart included five growth curves identified by “race”—Japanese, Italian, American, Polish, and Russian—in order to show that Russians and Poles were “tall races” while Japanese and Italians were “short races.” In case the message was lost on the pediatrician, an explanatory caption was included.82 According to Holt’s textbook, race mattered when it came to averages and should matter to those in charge of assessing the health of children—pediatricians. Simultaneously, parents were also learning the value of weighing and measuring children and their role in this type of medical inspection. Baby books and health registers educated parents on the value of these tasks in that, if done properly, they could help catch the beginnings of malnutrition or a malady before it was too late. With an infant mortality rate that hovered around 150 per 1000 births during the 1890s, this type of effective surveillance seemed particularly important.83 While weighing was deemed most valuable in the supervision of minors, measuring their length was also considered to be significant but was not yet standardized. In Mother Stork’s Baby Book from the early 1900s, an entire page was dedicated solely to the recording of height from birth to two years. Other books, such as The Biography of Our Baby, allowed parents to record changes in height up until eight years of age. Sometimes parents were encouraged to log height and weight together, as was the case of Our Baby’s Journal. Other baby books—for example, Baby’s Record—kept height and weight separate.84 Even though it appears baby books varied in their approach toward recording measurements, many usually had designated pages to do so by the 1910s. At the same time, many of these books did not include charts or tables for parents to analyze their child’s statistics. This omission reaffirmed the role of the parent as a recorder of measurements but not the interpreter, which was the domain of the pediatrician.85 Beyond baby books, parent manuals and registers provided opportunities to track a child’s height. Their approach was often more long-term than the baby books’ and conveyed the importance of measuring infants, children, and young adults and sharing the data with physicians. For example, The Mother’s Register (an English translation of the French original) instructed mothers to record a series of measurements, developmental changes, and observations for the physician to interpret. Interchangeably using the terms growth and height, the register prompted mothers to note the growth of

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Figure 5. A completed record of height measurements for a child from age one to possibly age six, found in a baby book titled Baby’s Record: With Frontispiece in Colour and Thirty Illustrations in Black & White. From the History & Special Collections for the Sciences, University of California Los Angeles Library Special Collections.

their children by logging in height measurements from one to eighteen years of age; it also included a section where the women could include additional notes regarding growth. Some mothers took to the instruction and indeed recorded their observations. In one instance, a mother tracking the growth of her son used the additional space to mention that he was “rather short when a year and a half. After two years growth quite mixed.”86

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While the register encouraged the engagement of a mother in preserving the health of her child, it also endorsed the authoritative role of the physician by suggesting that “just as there is . . . danger in not calling in the physician until disease has crossed the threshold of the house, not otherwise must the mother’s observations begin, in some sort, from the first days of existence, and continue without interruption, so that she may have at hand the annals of the health of each one of her children, and need merely turn them over to the physician when he has been summoned in consequence of some indisposition.”87 Based on this register, the mother still had a very important role in the monitoring of her child’s health, namely, to collect the data needed for the physician’s use. At the same time, The Mother’s Register was not the only medium touting the benefits of weighing and measuring babies and children. During the early twentieth century, child betterment campaigns further promoted these practices.

Does Your Child Pass? While it is difficult to tabulate how many parents owned and/or used baby books or registers to record their children’s growth and development, the practice of measuring of infants and children and the use of averages as healthy norms grew in popularity during the early twentieth century, in part due to two large public health programs. These campaigns—the National Year of the Child (1918) and the annual Child Health Day (beginning in 1923)—were organized by the federal agency most influential in the promotion of children’s health during the first half of the twentieth century, namely, the US Children’s Bureau. They succeeded in making the quantification and assessment of the height and weight of children commonplace, a development that provided the framework for the modern stigmatization of short stature. Launched in the midst of America’s involvement in World War I, the National Year of the Child’s mission was to save “100,000 lives ordinarily sacrificed to infant disease.”88 The first phase of this campaign was the “Weighing and Measuring Test,” which was a nationwide effort to weigh and measure minors under five years of age (understood as a sort of “stock taking”). This was followed by a “Recreational Drive”—which advocated for more designated play spaces for children—and a back-to-school and stayin-school project.89 During the first phase, great lengths were taken to examine as many infants and children as possible, which involved opening

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special clinics in New York City and sending equipped trucks to rural areas in Ohio, Michigan, and Connecticut.90 Every possible institution was recruited, and by mid-year even churches were asked to designate Sunday, August 4 as “Children’s Sunday” to help carry out the measuring effort.91 Mothers belonging to parishes were encouraged to have their children measured for their well-being and “to conserve the lives and health of the children of United States” as a measure of national defense.92 The health of the next generation of soldiers and leaders had to be safeguarded, a point drilled home by the war raging overseas and articulated by President Woodrow Wilson in a letter to his Secretary of Labor. In the letter, the president wrote that “next to the duty of doing everything possible for the soldiers at the front, there could be, it seems to me, no more patriotic duty than that of protecting the children.”93 During this first phase of the Year of the Child, the US Children’s Bureau distributed 7,606,303 forms “for recording and reporting the height and weight of America’s children” in an effort to expedite and standardize the process.94 Half of the form consisted of a report card to be retained by parents; it bore the title “DOES YOUR CHILD PASS?” The card was perforated with space on one side to record the weight and height of the child. The other side featured a growth table to assess the normalcy of the measurements on the other side.95 The examiner was instructed to first weigh and measure the child and record the results on the card. The front side of the card provided space for this data and included two prompts regarding growth (“Are the child’s height and weight above, below, or equal to the average for his age?” and “Is the child’s weight above, below, or equal to the average weight for his height?”), which encouraged the recorder to assess the child’s measurements using the height and weight table on the back.96 Only one combination of height and weight for boys and girls was listed as the normal measurement for each age. The other portion of the form was referred to as a “record.” Although it asked for much of the same data as the card, the record also included prompts for identifying the parents’ country of birth and race. It also asked if the child was “apparently healthy and free from serious defect.”97 Upon completion of the exam, the record was sent to the bureau allowing for this test to do double duty—provide public health information about the health of the population and to serve as an important tool in the medical surveillance of an individual child.98 The growth table featured on the health report card instructed parents, educators, and public health officials not only to gather data but also to

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assess the measurements. The norms featured in this chart were derived from various sources, including the 1916 version of Holt’s Diseases of Infancy and Childhood; Holt’s personal communication with the Children’s Bureau about the average measurements of three-month-old boys; Bowditch’s 1875 Boston Growth Survey; and a collection effort by statistician and race suicide aficionado Frederick S. Crum, which entailed gathering measurements from Baby Health Conferences sponsored by the American Medical Association.99 Together, this hodgepodge of data served as standards, and examiners were encouraged to advise parents to take their child to a family physician if a serious deviation from the standards was found.100 Later on, the Children’s Bureau did call attention to the inadequacies of this diagnostic tool, and offered an alternative—a new set of height and weight tables for white children under six years of age. The new tables were based upon the measurements of 167,024 white children selected from the two million records the bureau had collected and included data about the offspring of “native mothers,” British, Irish, Scandinavia, Italian, and “other racial stocks.”101 According to the Children’s Bureau, the data’s racial exclusivity was due to the low return rate of cards from exams conducted on non-white children.102 The Year of the Child campaign was followed by an annual celebration intended to “express in a public way the importance of child health and the need of its conservation.”103 Beginning in 1923, Child Health Day (May 1) recognized all of the adults working together to ensure the health of America’s children and celebrated good health and healthy habits. During the 1920s and 1930s Child Health Days featured “maypole dances, plays, pageants, marches, band music, games, and health drills,”104 prompted teachers to “inspect the physical examination records, note physical defects of their pupils and urge the parents to have the defects corrected,”105 and provided an opportunity for volunteers to coordinate children’s health events. The American Child Health Association and the Children’s Bureau recommended a series of Child Health Day festivities that placed value on the weighing and measuring of children. Inspired by these suggestions, women’s clubs hosted medical examination days as public relation events gearing up for May 1. For example, in 1925 mothers at an endorsed event in Hollywood, California were instructed about how to take care of their children, and their babies were given “a thorough mental and physical test,” which included weighing and measuring. The exams were scored and the results “sent to the mother so that she may know the defects that need correction.”106 Even

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some department stores got in on the act and capitalized on Child Health Day’s emphasis on medical exams by featuring trained nurses weighing and measuring babies in display windows.107 Child Health Days celebrated both the medical surveillance of minors and perfect health. The eugenic undertones of its programs are undeniable, as contests and other events often rewarded children and infants determined by experts to embody perfect health or showing improvements from the previous year’s examinations. In addition, Child Health Day linked into existing pro-health activities, including better babies contests. Better babies contests had originated at the Iowa State Fair in 1911, after a clubwoman urged for babies to be assessed like cattle and created scorecards for this purpose. The widely read magazine Woman’s Home Companion created a similar nationwide campaign a few years later, and various women’s groups throughout the nation hosted their own better babies contests. In turn, the Children’s Bureau began participating in these contests and, concerned over a lack of standardization in scoring and needless competition, convinced the AMA to work with it in creating standards. In the end, a form was developed that helped contest judges assess health examinations. Henceforth conducted by physicians, the examination was divided into four tests—”mental and developmental measurements, physical examination, oral and dental examination, and eye, ear, nose, and throat.”108 The baby with the best score was awarded the title of “Better Baby” and frequently had his or her photo published in the newspaper. During the 1920s better babies contests often took place during the week around Child Health Day. Their public displays of health examinations educated onlookers, parents, and siblings about the importance of measuring a baby’s length. The winners of the contests served as examples of infants with perfect physical traits, including height.109 Thus during the early decades of the twentieth century, physical examinations of well-babies and healthy children became a part of American culture. School activities on Child Health Day also praised flawless bodies. In 1928 New York City’s celebration included the crowning of a girl who was deemed in perfect health by Dr. J. L. Blumenthal, Director of Child Hygiene of the Health Department as the Queen of May.110 In the city of Mansfield in Richland County, Ohio, where Child Health Day was transformed from a one-day festival into a year-round program during the early 1920s, a blue-ribbon project was developed to celebrate healthy children. In order to receive a blue-ribbon award, a child had to be “mentally normal, free from

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Figure 6. Companies—such as Fulton Park Dairy—capitalized on the growing popularity of weight and height tables and well-baby examinations to help sell their products. Baby book, Growing Up (Salem: White Publishing, c.1923–1930) n.p. From the History & Special Collections for the Sciences, University of California Los Angeles Library Special Collections.

physical defects, reasonably cooperative in the practice of healthy habits, and satisfactory in his behavior and attitude in the school environment.”111 Each child awarded a blue-ribbon award was registered in the town’s Blue-Ribbon Book and paraded through the streets of Mansfield on Child Health Day “wearing blue-ribbon badges on which appeared the legend, ‘First Premium for Health.’”112 Defect-free, robust, and similar, these bodies conveyed normalcy and health and served as visual representations of somatic standards. Nationwide annual campaigns to conduct health examinations of children received ongoing support and endorsement throughout the 1920s by funds made available by the Sheppard-Towner Maternity and Infancy Protection Act (1921). The Act subsidized a large number of public health programs and the creation of numerous infant welfare clinics, which provided year-round services to poor and middle-class families located in rural and urban areas.113 Numerous and popular, infant welfare clinics developed services known as the “well-baby conference”—a series of tests to

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examine the development of a healthy child. The tests further solidified the scientific management of child growth and thereby reinforced the regular weighing and measuring of children and the reliance on growth charts to interpret weight and height.114 Staffed by pediatricians and nurses, infant welfare clinics provided an opportunity for parents to have their children’s health routinely monitored by medical experts trained in accurately weighing, measuring, and charting growth, a procedure introduced en masse in 1918.115 Medical staff of infant welfare clinics recommended that patients make repeated visits and recorded a child’s growth and development over a series of years, establishing a required regimen in measuring height.116 The clinics transformed the annual measuring of a child into part of a routine examination intended to help the pediatrician keep a watchful eye on the health of the well child. They also converted the quantification of children’s height and weight—and the use of growth charts to analyze the gathered measurements—into essential components of the medical management of a child’s growth and development. Even though welfare clinics served valuable roles in connecting private practice with public health, they lost funding when the US Congress decided not to renew the Sheppard-Towner Act. Historians have noted that the American Medical Association contributed to the failure of the Act’s renewal by criticizing the law and the programs it funded. The AMA’s opposition to the Act caused a split among members of the American Pediatrics Society, the official AMA subcommittee for pediatricians, and inspired the creation of a rival pediatric professional association, the American Academy of Pediatrics (AAP) in 1930. The AAP maintained a public health sensibility until it buckled under the pressure of professionalization and played a role in the closure of more than four thousand well clinics. According to historian Alexandra Minna Stern, the end of the well clinics symbolized the growing divide between public health measures and private practice and the increasingly limited access poor Americans would have to private preventive care during the remainder of the twentieth century.117 In part due to this development, medical inspections conducted in schools became vital components in the surveillance of seemingly healthy children.

The Medical Inspection of Students School medical inspections were not new to the 1930s. In the nineteenth century, as schools had served as important sites for growth surveys, they

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had also become meaningful places in the prophylaxis of outbreaks and contagions. At the turn of the century, Board of Health reports regularly noted a rise in the rates of measles, diphtheria, scarlet fever, and whooping cough in children at the beginning of the school year. They also emphasized the effectiveness of medical inspections in detecting sickly children and curbing infection.118 Physical defects were also a concern. The eyesight and hearing of schoolchildren were often checked for deficits. In fact, by 1909 Massachusetts, Vermont, and Connecticut required the medical inspection of pupils while New Jersey and California had laws permitting the practice. In all, around one hundred US cities conducted regular physical examinations on children by 1910. Still, the United States lagged behind European nations, in particular Germany where around 600 cities medically inspected pupils on a routine basis.119 The most emulated inspection program in Germany was the Wiesbaden system. Examinations were not compulsory, although most parents consented to their child being inspected during the first, third, fifth, eighth, and last years of school. Health cards filled out with quantitative data followed students throughout their educational careers. Teachers were responsible for weighing and measuring pupils in the middle of the school year, while physicians took care of more nuanced measurements—for example, chest circumference—and interpreted the cards. While the curbing of infection due to contagious disease was always a pressing issue at this time, this tracking of growth and development also allowed the school physician to provide advice to the child’s parents about a future trade or career.120 Overall, much attention was given to the growth and development of German boys and girls. Thomas Denison Wood detailed the benefits of the Wiesbaden system and of health education in general at the 1910 meeting of the National Society for the Study of Education. He saw teachers as gatekeepers of children’s health and good health as imperative for the future success of pupils. A professor of physical education, Wood was an influential educator and played a leadership role in health education in American public schools throughout the first decades of the twentieth century, particularly when he served as the chair of the Joint Committee on the Health Problems in Education (renamed in 1921 to the Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association) from 1911 to 1938.121

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The Joint Committee was formed in 1911 after the American Medical Association’s president appointed a group of physicians to visit the 1911 annual convention of the National Education Association in order to recommend the creation of an organization dedicated to the overall health of school children. Once organized, the committee spearheaded, among other things, the standardization of the medical inspections of children, the recording of the gathered measurements, the selection of norms to be used in the preliminary interpretation of students’ data, and the development of health education curricula.122 Similar to the Wiesbaden system, the Joint Committee’s health program included the weighing and measuring of pupils by teachers and school nurses. It was recommended that children should be weighed once a month and measured every three months. The data was to be recorded on either a general report card or a separate health card. If any abnormality was indicated then the child was to be referred to a physician.123 In 1918, the Joint Committee’s efforts were helped by the establishment of another organization, the Child’s Health Organization (CHO). L. Emmett Holt served as its chair and sat on its executive committee, along with Thomas D. Wood. CHO’s motto was “health in education and education in health;” according to historian Richard Meckel, its goals were to “promote normal growth and development—as indicated by height and weight gains . . . and develop and popularize a method of health, education, along with appropriate materials and guides.”124 CHO advocated for standards of nutrition and growth in order to facilitate the surveillance and instruction of children’s health. The organization suggested that a child should be weighed at least once every three months and that height should be taken “in the fall and spring.”125 The record should follow the child throughout his or her educational career and any measurements were to be compared to averages on tables created by Thomas Wood. These tables were the foundation for the 1920 Baldwin-Wood Weight-Height-Age Tables, which were popular diagnostic tools for the medical inspection of children for more than a decade. How often schools complied with the Joint Committee and CHO’s recommendations regarding medical examinations is difficult to determine. In 1922 a committee report presented data from questionnaires filled out by 341 school superintendents from cities throughout the country about their experiences with medical inspections in their schools. When asked about the frequency of “health or physical examination to discover defects that may be present,” 323 superintendents responded. Asked about the

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frequency of examinations, 61 percent of them answered one per year, 17.3 percent twice a year, and only 4 percent said they had no health or physical examination.126 Asked who conducted examinations, 82.6 percent of superintendents reported that it was a school physician, nurse, or both. When reporting on which items were included in the health examinations, eyes ranked first at 89.3 percent, followed by ears (82.9 percent), and then teeth (74.3 percent). Height ranked fourteenth and was tied with the nervous system at 34.5 percent.127 Throughout the 1920s CHO (which merged in 1923 with the American Child Hygiene Association to become the American Child Health Association) continued to work alongside the Joint Committee on promoting the medical inspection and health education of children even though compliance was not complete. In 1930 their efforts were bolstered when the White House Conference on Child Health and Protection championed the weighing and measuring of students.128 The fact that many physicians, educators, and public health officials supported the measuring of height as a quick and easy way to assess a child’s health did not preclude a pushback or criticism of the mechanisms used. There was ample discussion about the lack of attention given to the rate of growth by the charts and tables employed.129 There was also debate, particularly in the 1920s, about what stood for normal in these diagnostic tools.130 Interestingly, these discourses took a certain shape in the South. There, some public health practitioners took issue with the fact that the data from which average curves emerged came exclusively from white children. For example, during the development of a child health program in Rutherford County Tennessee, there was a call for a separate set of standards and charts to be developed for black children. Based on a growth study conducted locally, it appeared that black children were heavier and taller than their white counterparts until the end of adolescence. The organizers of the study could not understand how this could be, especially considering their assumption that black children lived in unfavorable environments and experienced higher rates of rickets, which was known to stunt growth and development.131 Some Southern public health practitioners suggested that black children had different growth cycles and therefore required their own set of tables on the basis of which to be assessed.132 It was not the diagnostic use of averages that was in question; it was the selection of averages and whom they were applied to—black children who were consistently exceeding expectations. Framed by race or otherwise, critiques of growth charts and their use continued to percolate throughout the twentieth century.

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Conclusion Despite the criticisms, promoting children’s health remained a national priority, even through the Great Depression. In fact, “the health protection of every child” served as the slogan for the 1937 Child Health Day, organized once again by the US Children’s Bureau. The Bureau hoped the day would serve, as it had for over a decade, as a “climax to the year’s health program in the form of festivals, athletic contests, and special programs and exhibits featuring the growth and vigor of children and their safety from health hazards” and encouraged state health officials, educators, and community groups to get involved.133 In anticipation of the May 1 event, Franklin D. Roosevelt called upon “the people of the United States  .  .  . to consider and appraise child-health conditions and the community organization for child health and to plan for health protection for every child during the coming year.”134 As the nation struggled to climb out of the Depression and questioned the progress made by New Deal legislation, FDR remarked on the strides made in child health services and stressed the importance of “safeguarding the health of children” in “protecting the vitality of the nation.”135 The theme of health protection set the tone for the day’s promotional activities and was reflected in one of its promotional materials featuring a smiling toddler being supervised by older children, his parents, and a nurse and physician.136 This carefully constructed image conveyed the Child Bureau’s vision of what healthy children looked like: clean, smiling, white, and exceptional in their sameness. The toddler serves as the central figure; his happiness is conveyed by his smile, his able-bodiedness by the steps he is taking, and his health by his robust stature. Meanwhile fertile rolling hills provide a backdrop and visually connect the health and stature of the toddler to the health of the country.137 This image not only depicts perfect health but also perfect surveillance of a seemingly healthy child. Everyone in the image is appropriately supervising the health and development of the toddler. His older brother is getting him to walk by luring him with a baseball, while his sister supports him as he takes his first steps. The parents play their role from a distance, with the mother looking down lovingly at the children and the father staring straight ahead. The physician and nurse stand opposite to the mother and father and are dressed in uniform, communicating their professional roles as overseers of children’s health.

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In the end, this image of optimal health and surveillance made as much sense to its intended audience as did the photo of Charley and Floyd. Both depictions made use of and contributed to the medicalization of height and the modern stigmatization of short stature. They also spoke to the vulnerability of white bodies to the perils of modernization. During the early twentieth century, the betterment of the nation was linked to the health of a particular youth population—native white Americans. Reformers, educators, and medical specialists were motivated by this population’s need for protection. Thus, the “every child” called out in the 1937 Child Health Day slogan was not necessarily a universal category; in fact it was quite exclusive. In this context, short stature stood out as an indicator of being in poor health and susceptible to the grim realities of industrialization. Hence, short stature was code for racial degeneration at a time when the preservation of whiteness was being linked to national security.138 Without its correction, the future of the child—and perhaps the nation—appeared bleak.

2

The Era of Early Growth Hormone Therapy in the United States Walter Bodin and Burnet Hershey’s 1934 book, It’s a Small World: All About Midgets, begins with a vignette detailing a day in the life of Tom, a male “midget” performer. His morning commences with a telephone call from his fiancée, Marian.1 The two quickly get into an argument about women picking him up, literally. Tom exclaims, “you know how it is with us midgets. Never any peace . . . if you are going to take on like this every time some girl picks me up what will our married life be?”2 After self-reflecting on the party the night before that led to the argument, Tom proceeds to get ready for his day with the assistance of a series of accommodations, namely, a bath stool used to reach the light and then a chair enabling him to access a dresser drawer. Having completed his daily routine, Tom sets off to a local diner, where he wolfs down his usual order of “a slice of melon, eggs, fried potatoes, a double order of bacon, and three cups of coffee.”3 Tom’s breakfast ends with a lavish tip to the waitress and a slap to her behind. From there, his day is filled with drinks, gossip, and several daydreams of Adele, the woman Marian had found him with in a secluded corner of the party the night before. He happily reflects on how Adele is even taller than Marian and on his plans to see her the following day.4 Next, Tom heads to a midnight show, where he and other small-statured entertainers are set to perform. Minutes before going on stage, Tom shows his gentle side by holding hands with a fellow female entertainer. He no longer has to perform the rough manly exterior that had gotten him through his day. According to Bodin and Hershey, backstage “Tom closed his eyes. He sighed contentedly. He was at home, among his people.”5 Published in 1934, It’s a Small World received favorable reviews by the Chicago Daily Tribune and the New York Times.6 The Tribune reviewer commented that Bodin and Hershey’s book was a “tell all about phenomena which have fascinated millions,” and included “everything about midgets’

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life, liberties, and pursuit of happiness.”7 Indeed, It’s a Small World was meant to be an exposé of the secret life of small-statured people. At the same time, Bodin and Hershey attempted to satisfy their readers’ multiple curiosities about small-statured folk, which, by the 1930s, included questions about a medical explanation for their size and possible remedies. The New York Times reviewer commended the authors’ tackling of the scientific aspect, specifically for “tell[ing] with satisfactory fullness the story of medial research into the causes of midgetism and explain[ing] that the reasons for the condition are to be found in the pituitary gland and its secretions, the gland in them being incomplete.”8 In providing these explanations, It’s a Small World was a product of the modern impulse to diagnose abnormal-looking people, even those who were famous and even admired for their physical exoticness.9 This impulse—referred to by some scholars as the medicalization of “freaks”—mirrored the trajectory of the professionalization of scientific medicine and points to a more significant development whereby disability became pathologized. This transformation was slow and at times uneven.10 Even so, according to disability studies scholars, the “medical model” of understanding disability as diseased, undesired, and in need of a cure assumed cultural hegemony in the early twentieth century and validated the stigmatization and dehumanizing treatment of people with complex embodiment.11 “Midgets” found themselves squarely in the middle of this process during the 1920s and 1930s, a time period when endocrine research “was likened to a ‘goldrush,’” according to historian Alison Li.12 By then, therapeutic strides made in endocrinology had become part and parcel of the promise of scientific medicine and supported the idea that “midget” entertainment should not be tolerated by a modern society. It was argued that modern advances in hormone technology meant that certain “freaks,” including giants and “midgets,” were relics of the past and slated for extinction. At the same time, medicine failed actually to develop effective growth hormone therapy before the 1950s. This does not mean scientists and physicians did not try to treat short stature and their disappointing attempts were not seen as advancements. They were. During the first half of the twentieth century, while scientists and surgeons sought to unlock the physiological mystery of human growth, pharmaceutical companies and academic scientists developed growth-promoting hormone extracts that ended up being therapeutically unreliable, impure, and inconsistently effective. Even so, failed attempts at developing hormone therapy began to reorient the

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Figure 7. “A Midget’s Morning” in Walter Bodin and Burnet Hershey, It’s a Small World: All About Midgets (New York: Coward-McCann Inc., 1934), 14.

medical gaze on short stature and the popular understanding that growth hormone therapy cured “midgets.”13 Interpreted as hurdles and not as dead ends, clinical failures were seen by scientists as challenges to overcome in the laboratory. As researchers struggled to develop effective growth hormone therapy, small-statured men’s ability to make reasonable fortunes solely on cultural presumptions about their masculinity was coming to an end. By 1940 modern science was understood as a force eliminating “blunders of nature,” including male “midgets,” who had become discursive sites of the cultural

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assumption that small stature compromised masculine promise.14 This chapter builds on the history of the modern medicalization of height by exploring both the developments in scientific medicine that brought forth growth hormone therapy and the ways in which they contributed to the pathologization of small stature. It considers the gendered framework of clinical endocrinology, the history of male “midget” entertainment in the United States and its relationship to changing notions of manliness, early attempts to therapeutically use growth hormone, mainstream media’s interpretation of the development of growth hormone therapy, and the ways in which male “midget” performers dealt with the popularization of the pathologization of their short stature and their ailment’s supposed cure—GH. The attention given in this chapter to small male entertainers is not a gimmick. Instead, these performers serve as interpretive sites of the pathologization of short stature, then and now. They were victims of not only the medicalization of their smallness but also of the fledging promise of growth hormone therapy. The chapter argues that by the 1940s, being a short man was less acceptable than it had been previously because short stature was understood as a visible but treatable symptom of a hidden disease, a new conceptual construct that compromised the viability of male “midget” entertainment and a short man’s masculinity.

Making Old Men Feel Young and Fat Women Thin The human growth hormone industry derives from modern endocrinology, a field of scientific medicine founded on the discovery and clinical application of hormones. Since its inception, the therapeutic potential of hormones has often outshined actual efficacy. For example, even before British physiologists Ernest Starling and William Bayliss coined the term “hormone” in 1905, medicine was swept away by the promise of endocrinology when world-renowned French physiologist and neurologist CharlesEdouard Brown Séquard reported to the Société de Biologie de Paris that he had successfully cured himself and other men from the fatigue, physical weakness, poor urination, and constipation brought on by his old age by injecting himself and the others with “a liquid obtained from the testicles of animals” in 1889.15 Brown Séquard postulated that the diminished action of the spermatic glands in older men caused a host of problems, and that the therapeutic application of crushed testes replenished the body and helped

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men once again experience the benefits of youth. According to historian of medicine Merriley Borell, Brown Séquard’s report “generated an immediate and widespread interest in the use of testicular extract.”16 During the 1890s physicians experimented with sterile preparations of testicular-based substances made possible by pharmaceutical companies.17 Interestingly, these early attempts to use and manufacture testicular matter predate the isolation of testosterone by decades. As in the case of “testicle extracts,” pharmaceutical companies contributed to the practice of providing patients with rejuvenating hormones even before these internal secretions were adequately identified and discovered. Based on the premise that extracts from organs must have some therapeutic value, commercial offerings made claims that were sometimes difficult to prove but seemed to be substantiated by recent endocrine research.18 But the mixed therapeutic results of these preparations contributed to the demise of organotherapy beyond a few exceptions, namely, thyroid and adrenal extracts. Despite the broad failures of organotherapy, pharmaceutical companies kept organ-extract medicines in their repertoire, in the hope of finding another successful exception. In 1917 a Parke, Davis and Company business plan outlined the strategy it took when marketing glandular substances. The company decided to “aggressively promote” certain preparations, including pituitrin and corpora lutea, “without any misgivings.” In addition, they planned on “quietly” introducing several new medicines, including “pituitary, whole gland desiccated,”19 into the market with the hope that, “sooner or later one of these obscure glandular extracts will swing into prominence and usefulness.”20 Parke, Davis was confident that if a substance could make up “for a deficiency by supplying the needed amount of hormone which the patient requires, but which his own gland fails to elaborate in adequate quantities,” then it would be successful.21 There was no mention of the importance of the Parke, Davis Research Laboratory discovering or isolating of any specific hormone, as this type of long-term pursuit was left to academic scientists due to the meticulous attention needed for this endeavor. During the first two decades of the twentieth century, scientists on both sides of the Atlantic established endocrine societies and founded journals dedicated to a newly specialized medical field focused on hormone research.22 As scientists reported on their findings, they often found that their work put them into contact with for-profit companies. Yet, instead of singing

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the praises of pharmaceutical companies, medical researchers often pointed to the commercial undercurrents of the pharmaceutical industry’s interest in endocrinology. During the 1920s and 1930s the scientific community became downright critical of the industry. In 1921 American endocrinology pioneer Harvey Cushing cautioned endocrinologists to “look out for the character of its clinical advance agents” because he felt they were rushing the scientific process in order to get products to market.23 Cushing argued that pharmaceutical companies, eager physicians, and rush-to-judgment researchers had actually slowed down progress in the field by getting the medical press to intermix their “advertising leaflets” with abstracts from medical experts.24 It soon became difficult to decipher the difference between descriptions crafted by pharmaceutical companies and reports on medical research containing what Cushing called information with “actual value.”25 According to Cushing, this type of advertising encouraged “the administration of pluriglandular compounds” for a “multitude of symptoms, real and fictitious.”26 He was particularly critical of how corporate-funded research on the pituitary gland had caused the pathologization of normal variance in humans: “suddenly before our eyes there was found to exist a large group of individuals whose physical peculiarities, previously regarded as within normal physiologic limits, were due to a disordered function of this obscure gland.”27 Still, Cushing partook in corporate-funded research, including the clinical application of early growth hormone preparations manufactured by Parke, Davis.28 Cushing was not alone in offering internal criticism to the field of endocrinology. Other scientists argued that endocrinology was prone to for-profit pursuits and that researchers therefore risked the danger of taking shortcuts when developing therapeutics and skewing etiology. In 1933 Herbert Evans, a scientist engaged in endocrine research used this criticism in a presentation at the Congress of American Physicians and Surgeons meeting in Washington, DC. According to witnesses, he “received a round of laughter after suggesting that ‘to be an endocrinologist’ meant too often to be primarily concerned with making fat ladies thin.”29 Modern clinical endocrinology, a field that had been catalyzed by the rejuvenation of impotent old men, was now ridiculed for its ability to provide similar gendered excellence to women. During the early twentieth century, clinical endocrinology was valued for its attempts to fix gendered character flaws, a trait that inspired the future negative framing of short stature due to a hormonal dysfunction and led to the development of growth hormone therapy.30

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Modern Masculinity in the Making During the late nineteenth and early twentieth centuries, the understanding of what constituted gendered character flaws changed along with cultural notions of femininity and masculinity in the United States. Predicated on the self-definitions of the burgeoning middle class, the gendered ideals promoted during the nineteenth century exhorted women to be pious, virtuous, and domestic and men to exercise self control and protect and direct those subordinate to them—namely, children, wives, and employees. Yet, according to historian Gail Bederman, these principles were seriously contested by the end of the century.31 As sociologist Michael Kimmel has suggested, by 1900 the confluence of financial uncertainty, increasing political pluralism, and the closing of the frontier meant that white men could no longer perform manhood by evoking “economic autonomy,” “political patriarchy,” and the “dominance of the west.”32 In addition, white male supremacy appeared compromised by a public sphere that was becoming increasingly diverse and feminine due to massive waves of immigrants and the emergence of working and politically savvy women.33 Even though, as historian John Kasson argues, “manliness is a cultural site that is always under construction,” the turn of the century marked a time when it seemed to be under siege, especially in the case of white middle-class men in the United States.34 While scholars disagree on whether this period in fact saw a “masculinity crisis” in the United States, it is true that white men were negotiating new strategies to hold onto their power.35 Some men celebrated “all things male,” including fraternal orders. Others focused on mentoring the next generation of men—boys—by organizing campaigns, for example by calling for more male schoolteachers. Simultaneously, there was a rise of appreciation for and participation in sports and bodybuilding.36 Within this context, the American white male body proved potent in framing notions of masculinity.37 According to Kasson, it “expressed the meaning of manliness in this emergent urban, industrial order” and served as the male counterpart to the “New Woman.”38 In particular, a muscular, strong, white male body came to stand for modernity and its positive impact. The entertainment industry both reflected and influenced this corporeal development. “Popular spectacles” of the male white body expressed deep “fantasies and anxieties” surrounding manliness. These included “strength and vulnerability” along with “discipline and erotic fantasy.”39 And while

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scholarly consideration has been given to those who set the standards—men including Theodore Roosevelt, Harry Houdini, and Edgar Rice Burroughs (author of Tarzan of the Apes)—other lesser-known celebrities also played roles in the cultural construction of the white male body.40 During this time of increased body awareness and masculinity construction, small-statured entertainers exploited social anxieties and expectations around manliness by playing upon size-related assumptions through hyper-masculine performances, including feats of strength and abrasive behavior. However, as medicine’s pathologization of short stature progressed and the promise of growth hormone therapy became more well known, the hyper-masculine persona traditionally adopted by small-statured male entertainers in their performances was no longer possible because these performers were now seen as reluctant patients rather than admired men in miniature. The hyper-masculine persona adopted by male “midget” performers pre1940 was first developed by Charles Sherwood Stratton, also known as General Tom Thumb (a name given to him by P. T. Barnum after he recruited Charles at an early age for his museum in New York City). Stratton also received an official description of a “perfect man in miniature, not an illformed, offensive-to-look-at-dwarf.”41 Thumb’s decades-long career was impressive. Audiences flocked to Barnum’s museum to watch the tiny-sized entertainer impersonate historical figures and reenact past battles, including the biblical conflict between David and Goliath. Newspaper reviews raved about his exceptionally small stature, impeccable charm and ability to impersonate well-known figures, especially Napoleon. Those who saw his rendition of the French emperor loved the way Thumb would stay in character and over-emphasize mannerisms. Hyper-imitating Napoleon, with his war-like sensibility and allegedly small stature, Tom Thumb surprised his audiences, who did not expect that such a tiny man would be capable of belting out such a big performance. Tom set the bar for future performers, as this Napoleonic theme of “little-man big-personality” reverberated in male “midget” entertainment throughout the nineteenth century and early decades of the twentieth century.42 Charles Stratton was not just an entertainer—he also was a celebrity.43 His personal life garnered as much media attention as his performances, although with P. T. Barnum as his manager there was often a fine line between public spectacle and private moments. Tom Thumb’s fame reached new heights in the early 1860s when the media reported that he had decided to wed Lavinia Warren, another small-statured entertainer. A

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poignant heterosexual ritual reifying Tom’s manhood, the ceremony took place during the Civil War on February 10, 1863, at New York City’s Grace Church. It was reported on as “the grand national event of the season,” as thousands of onlookers tried to get a glimpse of the wedding party—”General Charles Thomas Thumb Stratton, Miss Lavinia Warren, Commodore Nutt, and Miss Minnie Warren”—all “midget” performers.44 After the wedding, the four entertainers toured the world together as the General Tom Thumb and Company, singing, dancing, and performing skits. Their tour was a success, and the four of them received accolades for their rare and remarkable stature and ability to entertain. At this stage in social history, they were not “freaks” but rather prized women and men in miniature.45

The Medicalization of “Midgets” Indeed, during Tom Thumb’s heyday, “freak” entertainment was socially popular and its entertainers were not yet pathologized by medicine. Later on, however, Stratton experienced a dip in his fame and fortune. Although he was able to grow his theatre company into a fifteen-member troupe, its hegemonic status in “midget” entertainment was shaken by the loss of Nutt (who decided to pursue his own career) and Minnie (who died while giving birth in 1879).46 When Charles Stratton died in 1883, Lavinia was left with only a fraction of the wealth they had once shared, which forced her to remarry another male “midget” performer and start an “all-midget” traveling opera company, the Lilliputians.47 Her decision to go on the road to showcase her talents was in part due to a slump in the popularity of “freak” performers and changing popular tastes. During the late nineteenth century, newspapers started reporting on the declining interest in “freak” entertainment, most notably exhibits. In 1894 a Washington Post journalist used an interview with two veteran showmen, Dale Armstrong and Frank Willis, to describe this loss in popularity. In the article, Willis claims that he “never cared much about putting deformed people on exhibition” and that audiences were “repulsed by them.” Armstrong, on the other hand, provided a more optimistic perspective and spoke about the growing popularity of vaudeville. He suggested that “a fat woman must be able to sing serio-comic, skeletons should have an iron jaw for lifting heavy weights, giants should learn to do a neat song and dance, Albinos do magic, midgets to play musical instruments, and so along the list.”48 Many “midget” performers answered the call of vaudeville, including

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staging hyper-gendered performances and “all-midget” revues.49 One of the more popular shows was put on by the Rossow Midgets. Touring the country at the turn of the century, these two performers, Carl and Franz Actermeier, entertained audiences with impersonations, musical numbers, and a final act comprised of a boxing match between the two. A theatre poster depicted the brothers as ready to fight each other and claimed that the Rossow men were “the smallest and greatest fighters in the world.”50 While one Washington Post journalist called the match “amusing,” the bout clearly demonstrated the brothers’ ability to play with cultural notions of masculinity that pertained to size and strength. Due to their size, Carl and Franz were not necessarily seen as serious boxers by their audiences; rather, they were entertainers willing to risk their masculinity to please those who paid to watch them perform.51 Male “midget” performers did not have to box each other in order to get the attention of scientists. At the turn of the twentieth century, advocates of scientific medicine were enthralled with trying to make scientific sense out of human curiosities. The year 1896 saw the publication of the popular edition of Anomalies and Curiosities of Medicine. Written by doctors George M. Gould and Walter L. Pyle, this text intended to scientifically identify and historicize human peculiarities, many of which were often on display at sideshows, dime museums, fairs, and vaudeville acts. Gould and Pyle championed the study of the anomalous, believing that “to know extremes give directly some knowledge of means.” They also posited that science had been founded on the study of the abnormal.52 The book’s layout indicates their intent. The headings, including “genetic anomalies”, “major terata,” and “anomalies of stature, size, and development,” provide structure to the featured depictions. There is no doubt that classification, not diagnosis, was the authors’ goal.53 This categorization of human oddities is significant as it marks a change in how science made sense out of abnormalities. It was at the turn of the century when someone with complex embodiment was no longer seen as a “freak” of nature or lusus naturae; rather, the person was interpreted as a specimen of pathology. In early 1908 an anonymous contributor to the editorial section of the New York Medical Journal commented on this change. In an article titled “The Pathology of Circus and Museum Freaks,” the author contemplated the scientific value of “freaks,”54 suggesting that they “add to our knowledge of development of normal types and may possibly illuminate many difficult and obscure problems in pathology.”55 The editorial also

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Figure 8. H. C. Miner Litho. Co., The Rossow Midgets, Star Specialty Co., 1897. From the Theatrical Poster collection, Library of Congress.

pointed to the example of a certain Dr. E. C. Seguin, who used a “freak” entertainer—the “blue man”—to teach his students about the health effects of the prolonged administration of silver nitrate.56 At the same time, the author advocated for the end of the museum “freak,” noting with approval that most “civilized countries now had laws forbidding public exhibiting of monsters and revolting deformities.” In addition, he argued that what made these entertainers abnormal might also be prematurely killing them. The article did name one entertainer who was an exception to this rule: the “robust and virile” General Tom Thumb.57 Stratton’s hyper-masculine persona remained provocative and protected him against a medical diagnosis. To use a modern metaphor, the New York Medical Journal editorial went viral after it was published. It was reported on by the New York Times later the same month; the Times article was then reprinted in the Washington Post on March 15.58 In it, the journalist commended the original article’s prediction of the passing of “the profession of museum freak” and championed vaudeville as “a more elevated form of public amusement” than the traditional static exhibit or display. In April, the article was reprinted in the Scientific American Supplement.59 Not only did the reprint bring the anonymous journalist’s voice to a larger readership, a title change furthered the

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medicalization of “freaks.”60 While the original editorial was titled “The Pathology of Circus and Museum Freaks,” the new version sported the title “Circus and Museum Freaks. Curiosities of Pathology.”61 Although the logic behind the retitling of the article is difficult to determine, it is still significant as it transformed entertainers from having a pathology to being pathology. Alongside this subtle but important shift in the cultural conception of “freak” entertainers, a major development took place in one of the venues best known for showcasing them: the Barnum and Bailey circus, which recently had been bought by the Ringling Brothers. In March 1908 P. T. Barnum’s successors, Tody Hamilton and Willard D. Coxey, announced that “freak” entertainment would no longer be part of their circus. Coxey suggested that “circusgoers were tired of freaks and that they long ago ceased to amuse even the youngster.” He also informed future attendees that “freak” entertainment would be replaced by a tropical garden with the “finest specimens of the animal kingdom and birds of every hue.”62 Hamilton and Coxey were true to their word, for the most part. When the New York Times reported on the circus’s opening night at Madison Square Garden the article was titled “New Feats Startle at Circus Opening: Audience Thrilled by Horse Ballonist and Autos that Pass in the Air. FREAKS BARRED THIS YEAR. African Midget Queen Reigns Alone in the Menagerie—All the Other Circus Favorites in the Arena” (all caps are in the original). The Times explained that while there had been reports that Hamilton and Coxey had reconsidered their decision, only one “human oddity remained,” “a tiny dwarf woman from Africa, who sat complacently on a little platform and rocked herself to and fro in a doll’s armchair while the onlookers stared and commented.”63 While her real name was Hattie Williams, the small entertainer’s stage name was Princess Weenie Wee and she was billed as the littlest “midget” in the world.64 It was not until 1913 that all “freak” entertainers were reintroduced back into the Barnum and Bailey circus. The New York Times reported “the management had decided that, after all, the old idea of having the human grotesques on exhibition is the right one” and that much care had been taken to not include those “considered repugnant of offensive.” Their return was often seen as a nod to the nostalgic with the intent of stirring up memories of the older audience members. Back was the sideshow of their youth, just as they remembered it. Even though the sideshow had returned, it was considered old-fashion and an artifact of yesteryear.65 There was much speculation about the fate of “freak” entertainment

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and the reasons for its deletion from the circus before its return in 1913. A March 1908 article in The Nation suggested that it was time to drive “freaks from their comfortable position” and that their social demotion had in part to do with patrons realizing that the human oddities were “all victims of rare diseases with ten-syllabled names of Greek origin, and that, in all probability, other sufferers, who are unwilling to exhibit their afflictions, are under treatment by physicians, these, too, lose most of the fascination.”66 A 1910 Washington Post reprint of a New York World article mentioned a “slump in the freak market.” The Post reprint ended with a quote from “an old showman” stating, “the only way for a freak to make a living now is with the doctors.”67 The value of human oddities to scientific medicine did not go unnoticed in the popular media nor did the medical diagnoses of these entertainers. While “midget” performers along with other “freak” entertainers fought for their reentry into the circus, “midget” performers faired well on the vaudeville circuit. At the turn of the century, “midget” entertainers sought work in vaudeville or created “all-midget” troupes. One of the most popular “all-midget” revues during the first half of the twentieth century was the Singer Midget Troupe. Named after its manager, the troupe originated from an exhibit in Vienna called “Liliputstaadt” and toured Europe until World War I broke out in 1914. In the United States, Singer’s Midget Troupe played to packed theatres across the nation. The group was known for its elaborate programs, which included hyper-masculine performances such as small-statured male entertainers boxing and tossing around fellow performers on stage, and “pocket size cowboys” riding miniature horses and forming human pyramids.68 The Singer “midget” performers were also able to adopt another attention-getting strategy: they claimed a fairytale temporality. The assertion that its talented members were part of an ancient race was central to Singer’s Midget Troupe’s fame. Newspaper reports on their performances often mentioned the troupe’s members having “slipped from between the covers of a volume of fairy tales.”69 This dual citizenship between the modern and ancient allowed “midget” performers to set a temporal stage for their audiences and to position themselves outside of modern medicine’s assessment and suggested therapeutics. Beyond vaudeville, “midget” entertainers also performed at amusement parks and fairs. For example, from 1904 to 1911 Coney Island’s Dreamland was home to one of the earliest “midget” exhibits in the United States. This

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was an elaborate recreation of a miniature city featuring a fire department with little fire engines, a small stable with “diminutive horses,” and a theatre with “midget” performers, including Charles Stratton’s widow, Lavinia.70 With its estimated thousand “tiny inhabitants,” “Midget City” emphasized the grouping of small-statured men and women. Its success attracted interest from other amusement parks and attractions—including Atlantic City in New Jersey and the Louisiana Purchase Exposition in St. Louis—and set a precedent for future “midget” exhibits at parks and fairs, with its attention to detail, robust population, and theatre featuring topnotch entertainment.71 Americans could and did catch “midget” performances even as media scrutiny and medicine’s purview became increasingly critical of the former during the early decades of the twentieth century.72 Try as they might to avoid it, “midget” entertainers often found themselves the targets of public inspection or lumped in with other “freak” performers receiving similar attention. To make matters worse, the use of scientific authority to pathologize complex embodiement and recommend possible treatment for “freak” performers intensified during the 1920s. In a 1922 Illustrated World article, E. Leslie Gilliams declared the end of the era during which categorizing medical curiosities was considered a hobby. He also claimed that “to the scientist there is no such thing as a freak of nature”73 and argued that science was “ready to explain how all . . . so-called freaks are in reality extreme types of various diseases.”74 Gilliams informed his readers that when it came to short stature, medicine not only understood its underlying cause but it also offered a cure for this affliction. According to the article, short stature was due to “abnormal activity of certain organs in the brain called pituitary glands,” of which “midgets” could “be cured by treatment with pituitary gland extract.”75 Next, he accused small statured performers of deciding not to seek therapy because for them “lack of inches means more money.”76 However, not all scientists engaged in growth-promoting hormone research were eager to treat small-statured entertainers, even if someone was diagnosed as having a glandular deficiency causing short stature. Such was the case of Dr. Hans Lisser, chief of the Ductless Gland Clinic at the University of California Out-Patient Department in San Francisco and pioneer in growth hormone therapy.77 After over a decade of trying to harness GH therapeutically, Lisser seemed well aware of the earning potential of small-statured performers. In 1936, he postulated that for some it was “more profitable to be very small” and that “growth-stimulating treatment

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by pituitary extracts” was not intended for individuals wishing to commercially benefit from their small stature.78 Somehow, Lisser’s sensitivity to small-statured entertainers’ earning potential did not receive the same media attention as advances made in growth-promoting hormone therapy.

The Promise of a Growth Hormone Hans Lisser was part of the initial group of researchers who were simultaneously excited and troubled by the promise of growth hormone. Throughout the early twentieth century scientific medicine struggled to develop effective growth hormone therapy. Part of the problem had to do with basic science’s difficulty in proving the existence of a singular growth hormone. In the United States, Harvey Cushing was first to postulate that a singular growth hormone located in the pituitary did in fact exist. In 1909 he presented findings substantiating his hypothesis to the American Medical Association’s annual meeting and was quickly recognized as one of the leading authorities on the pituitary in the United States.79 Patients suffering from possible pituitary disorders flocked to be treated under his care, providing Cushing with ample opportunities to further his research.80 Although Cushing did not discover GH, his speculation that it existed sent researchers on a hunt that would span most of the first half of the twentieth century. This hunt was complicated by GH’s location, the pituitary gland. Known as the master endocrine gland, the pituitary gland plays a pivotal role in the hormonal regulation of many physiological processes throughout the body. Located at the base of the brain and weighing 0.02 ounces, it is composed of two lobes, the anterior and the posterior. The posterior pituitary is an extension of the hypothalamus and stores and secretes the hormones oxytocin and vasopressin, which it receives from the hypothalamus. The anterior pituitary stores and secretes many hormones, which regulate several physiological processes, including growth and reproduction, and is regulated by neurosecretory cells in the hypothalamus.81 The pituitary gland’s plethora of hormones and its location in the brain obscured early efforts to fully understand its specific contents and physiological roles.82 Herbert Evans, one of the hormone hunters inspired by Cushing and not deterred by the complicated nature of the pituitary gland, came across the latter’s work on GH while attending medical school at Johns Hopkins University and eventually became a prominent figure in experimental endocrinology. In 1915 Evans took the position of the chair of Anatomy at the University of

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California, Berkeley. During his tenure at Berkeley, he created what would become one of the most dynamic laboratories working on hormones and vitamins during the first half of the twentieth century.83 There, in collaboration with his colleague Joseph Long, Evans began conducting experiments to show that there was a growth factor located in the anterior pituitary by injecting rats with pituitary extracts.84 Evans and Long observed that rats administered a posterior lobe substance did not grow, but that rats given an anterior lobe material did. They concluded there must be a growth factor of the pituitary located in the anterior lobe, and that the overgrown rats provided proof of the existence of a growth hormone. The rats catapulted Evans’s career in experimental endocrinology, although it would take him and his lab over twenty years to isolate GH itself.85 Until then, the scientific debate raged on about the existence of a single growth hormone.

The Promise and Mixed Potential of Commercial Growth Hormone While Evans and his lab spent twenty years trying to convince naysayers of growth hormone’s existence, pharmaceutical companies focused on developing commercial growth hormone products with the assistance of academic researchers including Lisser. At first, instead of hunting for a single hormone, they tried to harness the growth-promoting potential of the anterior lobe of the pituitary gland in the hopes that the successful results would demonstrate the existence of GH and the potency of their medicines. Unreliable, impure, and inconsistently effective these extracts were made accessible to physicians by pharmaceutical companies engaged in a continuous effort to perfect them. However, none of these products offered clinical-grade effective growth hormone for humans because growth hormone is species-specific whereas preparations at this time were composed of pituitaries extracted from various cattle and swine so they were unable to function in humans. During the 1920s, 1930s, and most of the 1940s, no one knew that these medications were doomed to fail. Therefore, when a patient who was taking anterior lobe pituitary gland extracts grew, researchers and physicians reasonably surmised that it was due to the therapy. At this time, several anterior lobe preparations were made available to clinicians and scientists by pharmaceutical companies, including Burroughs Wellcome, Armour, Squibb, Wilson Laboratories, and Parke, Davis.86 Further investigating

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Parke, Davis’s Antuitrin-G will provide a glimpse into the development stages of pituitary gland extracts featuring GH at this time. Parke, Davis began offering growth promoting hormone-based therapy as early as the 1910s, by using an anterior lobe preparation during a time when pituitary therapy was notoriously unpredictable. The company funded research into the identification and isolation of a growth hormone while offering to the public an organotherapeutic option in the meantime. In 1916 T. Brailsford Robertson, a professor of biochemistry and pharmacy at the University of California, suggested progress in the quest to locate a growth hormone in the anterior lobe of the pituitary gland, reporting that he had isolated a substance from the anterior lobe that had promoted certain growth changes in young rats and could possibly facilitate rapid wound repair.87 Robertson named this substance Tethelin. Excited about this possible endocrinological breakthrough, Parke, Davis tested its commercial anterior lobe preparation for Tethelin but found very little of the substance.88 In the end, this failure was due to poor science rather than a weak drug. By 1922, Tethelin’s existence was seriously questioned by the scientific community due to the impure product researchers obtained when following Robertson’s method and its poor performance in experiments.89 Meanwhile, Parke, Davis was researching the therapeutic value of another drug in development, Antuitrin. Two different versions of the drug— Antuitrin A and B—were to be given to patients who were diagnosed with hypopituitarism. Before Antuitrin went commercial, Parke, Davis distributed it to physicians in order to test it on their patients and continued to research its potency and effectiveness in its laboratory. Physicians who received the experimental drug wrote short reports of their experiences for Parke, Davis.90 While some physicians sent in favorable findings, others were cautious in their assessment because of the short amount of time they had to conduct the tests on their patients. One physician stated, “anyone who reports on the physiological effects of Antuitrin ‘A’ and ‘B’ in such a short space of time is guessing.”91 In the end, Parke, Davis decided that the clinical results were inconclusive and that more laboratory research on this anterior pituitary product was needed.92 Even so, physicians would not have to wait until Parke, Davis figured out if Antuitrin was effective. Antuitrin-A was made available (even though it was not heavily advertised) before more trials were conducted.93 However, a pure growth hormone drug proved more difficult to manufacture than an anterior pituitary extract claiming a growth-promoting

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quality. Pharmaceutical companies could not absolutely guarantee the purity of growth hormone products, as scientists were unable to isolate growth hormone itself until 1944.94 Nevertheless, Parke, Davis remained hopeful, as an article in a scientific journal reporting on Evans’s success in promoting the growth of hypophysectomized tadpoles with a growth-promoting product gave Parke, Davis’s researchers reason to believe they could make a potent commercial GH drug.95 In 1924, Dr. Thomas B. Aldrich, a Parke, Davis scientist, tried but failed to imitate Evans’s successful experiment.96 Subsequently, the company decided it needed to work with experts in the field and began collaborating with scientists (including Harvey Cushing) conducting research on the pituitary to develop a potent sterile growth extract.97 In the fall of 1930 Parke, Davis employee Dr. Edwin P. Bugbee reported on the company’s progress in hormone development at the American Chemical Society meeting. Parke, Davis had made impressive strides with hormones from the anterior lobe of the pituitary gland and Bugbee detailed how experiments on animals had shown eleven distinct activities of the anterior pituitary, with one stimulating growth. Bugbee also informed his audience that Parke, Davis had managed to create a potent growth hormone product for human use. According to Bugbee, Parke, Davis researchers had in “our hands . . . the most potent preparations of the growth hormone.”98 This new anterior pituitary extract was named Antuitrin-G and was the product of several collaborations between Parke, Davis and academic researchers. Before Antuitrin-G went commercial, Parke, Davis distributed samples to physicians for ad hoc clinical trials and continued conducting laboratory tests to determine its purity and potency. Initial results were good. In a 1932 internal memo from Park, Davis’s department of experimental medicine, Elwood A. Sharp reported to Dr. William Lescohier the excitement exhibited over Antuitrin-G by two physicians, Robert L. Schaefer and William Engelbach. Sharp stated, “Dr. Robert L. Schaefer addressed the Noon Day Study Club of the Wayne County Medical Society . . . and was on the program of the Grace Hospital staff meeting . . . he stated that it (Antuitrin-G) is the only effective growth hormone available and contains about 15 percent of the standard of experimental preparations developed by Evans and Smith. He showed clinical records of patients who had been effectively stimulated by Antuitrin.”99 Dr. William Engelbach, an associate of Schaefer’s was reported to be “very anxious to pursue his clinical observations with growth hormone.”100 However, other physicians reported on their frustrations over not being

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able to duplicate successful results with Antuitrin-G. In a Parke, Davis internal letter from July 23, 1932, Dr. Wilbur F. Kamm informed Bugbee that “no one (including Dr. Cushing) seems to be getting any results and we are almost forced to admit that there is little effect of our extract upon experimental animals.”101 As time went on, even Schaefer could not give the glowing report he and Engelbach had hoped for. Their clinical trials were inconclusive, and Schaefer believed this had to do with the loss of potency in the growth hormone they administered to patients.102 Frustrated by these results, Parke, Davis researchers began to wonder whether a recently discovered new hormone actually stimulated growth or, alternatively, if they needed to make changes to the processing of the finely ground beef anterior pituitaries that made up Antuitrin-G.103 Despite the inconclusive data, the clinical experiments continued, as Parke, Davis tried to improve its product by tweaking both it and the instructions for its use, which included encouraging physicians to give patients larger dosages of the drug. Their advice did not work. Letters continued to come into the company’s offices reporting on physicians’ dismal results. One letter from an Oklahoma doctor demonstrates the frustration clinicians experienced with Antuitrin-G: “I wish you would advise me what clinical response some of the other men are getting from Antuitrin-G, as I am not at all satisfied with the results I have obtained.”104 By the end of 1933 Parke, Davis scientists concluded that the “old extract was rather weak but that really potent extracts can be prepared,” and went back to the laboratory to revamp Antuitrin-G.105 By 1935 Parke, Davis had a new and improved version of the drug and was finally ready to commercialize its growth hormone product. Wanting to separate its product from the pack of other commercial anterior pituitary concoctions, the company emphasized Antuitrin-G’s purity and potency. Parke, Davis promised that its pituitary extract containing growth hormone was prepared “in a highly purified form, which when administered to adult rats in amounts of 0.5 milligram daily results in appreciable growth,” and it was “entirely free of gonadotropic, thyrotropic, and adrenotropic factors.”106 The purity of the drug was important to those physicians wishing to treat pituitary dwarfism (short stature due to growth hormone deficiency). If other hormones were present in the product, they could ultimately stunt growth instead of promoting it. However, the promise of purity was impossible to make, given that growth hormone had been discovered but not yet isolated. Antuitrin-G was never pure or potent, and all attempts to make it so

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failed. Unaware that a more pure growth hormone product would be unable to ensure potency since GH is species specific, Parke, Davis’s scientists went to great lengths to make Antuitrin-G potent by adding more animal hormone. Preparations sometimes included chunks of animal pituitary glands, and there were reports that when the powder was added to the solution for injection, it appeared cloudy and “unsatisfactory” in appearance. The chemists responded by claiming that undissolved hormone remains guaranteed potency.107 They were wrong. No matter how chunky or cloudy Antuitrin-G was, it could not promote growth in humans. Failing to consistently deliver growth, anterior pituitary preparations elicited “widespread skepticism” among physicians.108 Even so, some doctors searched for value in growth-promoting hormone therapy. Such was the case for A. Wilmot Jacobsen and Arthur J. Cramer. In 1937 they promoted combination therapy of pituitary extract featuring growth hormone and thyroid extract in their report highlighted ten cases in which they used Antuitrin-G in combination with thyroid extract to treat various conditions, such as “dwarfism, infantilism, and hypogonadism.” They had decided to use combination therapy “after demonstrating the lesser effects of either product when used alone” and where somewhat happy with their results, especially when it came to treating pituitary deficiency resulting only in short stature.109 While Antuitrin-G became part of this recommended drug regimen for patients, Parke, Davis still wanted to create a growth hormone product that could spur growth on its own. In 1938 the company decided to collaborate with Dr. Quentin R. Bartz from the Institute of Experimental Biology at the University California, Berkeley. The collaboration brought forth a new version of Antuitrin-G in 1939 that touted potency but not necessarily purity.110 In an internal letter, the new Antuitrin-G was described as a growth hormone product not “substantially free” of thyrotrophic and gonadotropic hormones; it was noted that its impurity did not have much therapeutic significance.111 In fact, it was significant: the thyrotrophic and gonadotropic hormones were probably the only substances making Antuitrin-G clinically effective, although no one knew it at the time.

Growth Hormone Therapy During this era of early growth hormone therapy, scientists working both on their own and commercial preparations believed that early growth hormone

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therapy was effective in treating some of the ill-effects of growth hormone deficiency—most notably, short stature. Up until the 1960s physicians used symptoms and signs as keys determinants of growth hormone deficiency, since the immunoassay (in this case, a procedure used to detect and measure GH levels inside the body) was not developed until 1963. It is true that those deemed cured by GH therapy were often in their teens. As new preparations of growth hormone therapy were developed and needed clinical testing, physicians suggested young adults and children from among their patients as possible participants in the trials. The physicians who conducted tests of commercial growth hormone preparations on young patients were part of a new breed of doctors engaged in the biochemical turn taken by investigative pediatrics during the inter-war period.112 Investigative pediatrics focused on specific issues, such as dehydration and the hormonal regulation of children’s growth, and contributed to the development of a series of pediatric subspecialties, including pediatric endocrinology. But the founding of the latter field was a slow process. While its origins can be traced back to the 1930s, pediatric endocrinology’s first textbook, The Diagnosis and Treatment of Endocrine Disorders in Childhood and Adolescence, was not published until 1950, and a pediatrician could not receive an American Board of Pediatrics’ special pediatric certificate in endocrinology until 1976.113 However, various medical practitioners dabbled in investigative pediatrics and in particular growth hormone research and the administration of growth hormone therapy to children, even though there was no protocol.114 Pediatricians took up the cause in part because it was up to them to diagnose and treat hormonal disorders in children. In a 1924 address to the Portland Academy of Medicine, Dr. Hans Lisser remarked, “the pediatrician is frequently confronted with preadolescent disturbances of glandular function.”115 When it came to treating “skeletal undergrowth due to a lack of anterior lobe hormone,” Lisser was cautious in recommending commercial anterior lobe substances, which existed in tablet form. He deemed non-commercial anterior lobe substances effective in the “hands of trustworthy clinicians” but not on a consistent basis. If a clinician decided to give anterior lobe therapy a try, Lisser was adamant that therapy must continue for more than just a few weeks or months.116 Lisser’s preference for non-commercial preparations was the closest thing to a protocol in pediatric growth-promoting hormone therapy until 1930, when Dr. William Engelbach became the first physician to inject anterior pituitary extracts into undersized children to stimulate their growth.

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Figure 9. An example of early clinical growth hormone research conducted by Hans Lisser using Parke, Davis and Company’s Antiutrin G and other hormone preparations to treat hypophyseal infantilism. An increase in height was used as a main indicator of therapeutic effectiveness. Hans Lisser, Lectures on Clinical Endocrinology (San Francisco, 1939), 30.

In June 1931, at the Fifteenth Annual Meeting of the Association for the Study of Internal Secretions, he described the treatment of the first human to receive treatment consisting of Evans’s growth hormone preparation. The patient was a nine-and-a-half-year-old girl whom Engelbach had diagnosed with hypopituitarism by comparing her measurements with standard measurements he had collected. Engelbach was able to rule out a thyroid condition because of her “normal intelligence.” He oversaw her treatment for almost a year. During that period, this nine-and-a-half-year-old girl grew 2.7 inches in height, 7.5 pounds in weight, 0.6 inches in head circumference, 1.7 inches in the chest, and 1.3 inches in the abdomen after years of “arrested physical development.”117 Engelbach was pleased with these results and collaborated with Robert Schaffer on clinically testing Parke,

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Davis’s Antuitrin-G until he himself became terminally ill in the summer of 1932.118 Two years after his death, an article in the Journal of the American Medical Association demonstrated the minimal success Engelbach and Schaffer experienced with their human subjects. They tested seven children from ages seven to eighteen (who were diagnosed with hypopituitarism, hypothyropituitarism, and hypopituitarothroidism) with Antuitrin-G. Out of the seven patients they experimented on only one, the eighteen-year-old with hypopituitarothyroidism gained a half of an inch in height.119 These results were pretty common in growth-promoting hormone research and led to uncertainty in the field. By 1936 there were thirty-six proposed published protocols of growth hormone therapy and no definitive answer as to a preferred preparation, dosage amount, or duration of treatment.120 Even so, most researchers favored laboratory preparations concocted by academic scientists over commercial anterior pituitary extracts because, as Lisser had suggested earlier, commercial products struggled with providing effective therapy while academic researchers were able to demonstrate some success with non-human laboratory subjects.121 Still, the scientific community’s overall faith in pituitary extracts featuring GH seemed to waiver during this time period, as evidenced by Lisser’s 1936 unenthusiastic recommendation to clinicians to “utilize what we have, and do the best we can.”122

Growth Hormone in the News Generally, scientists’ frustration with harnessing growth hormone remained unreported in the mainstream media. Instead, journalists focused on the positive. For example, the discovery of the anterior pituitary gland’s ability to promote growth was discussed in a 1923 Los Angeles Times article titled “Doctors Hear Gland Talk: Convention Told Height and Weight Can Be Regulated by Hypophysis Organ.” The journalist distilled Herbert Evans’s paper on this scientific milestone, explaining that “the gist of it was to the effect that recent experiments with life forms ranging from tadpoles to rats and rabbits have given foundation for the belief that the size and form of the human body may in the near future be regulated by the feeding of secretions of animal hypophysis gland.”123 Similar treatment was given to Evans’s 1932 experiment with tadpoles that enabled him to “discover” growth hormone in a Chicago Daily Tribune article titled “Medicine Gets New Place in Gland Control: Perfected Extract Used to Guide Life.”124 These and other

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articles reporting on growth hormone research emphasized endocrinology’s scientific milestones and their future medical applications. Clinical successes were also reported on in a celebratory fashion. A 1931 New York Times article titled “Chemist Discovers ‘Growth Hormone’— Dwarfs are Aided by Extract of Pituitary Gland, Buffalo Convention is Told” described William Engelbach’s work on treating undersized children with injections of anterior pituitary extracts in a way that made treatment seem possible and effective.125 Two years later, reports surfaced of more than two hundred children being successfully treated for “arrested growth” with “extracts of ductless glands” by a Dr. Theodore Zuck of the Brush Foundation in Cleveland. Zuck’s proof lay in “a boy who grew 8½ inches in twenty-one months. When the treatments started, he was 15 years and 4 months old, but his height average was only that of a boy 8 years and 7 months. Now his height is average for a boy of 13 years and 1 month and he is still growing.”126 Later that decade the promise of growth-promoting hormone therapy was substantiated by the story of Eula Herbert. Her two-year-long growth-stimulating therapy at New Orleans Charity Hospital was detailed in a Time magazine article titled “Cornstalk.” Eula, a teenager at the time, was given daily doses of thyroid and pituitary extracts after she had stopped growing. The results were noteworthy, as the magazine article remarked that Eula shot up like cornstalk. Described as a “shy little dwarf,” Eula demonstrated her pride in her newfound height by stating, “I’m taller than Helen Hayes” (although according to the article this was technically untrue).127

Victims of the Medical Gaze The triumphant reports in mainstream media depicting growth-promoting hormone therapy’s successes further established science’s ability to cure “midgets.” No longer did growth-promoting hormone therapy seem merely experimental; rather, it had proven to be successful and accessible. By the late 1930s small-statured entertainers had to deal with these reports along with the growing popularization of scientific medicine’s interpretation of somatic abnormalities as pathological. Throughout the late nineteenth and early twentieth centuries, the medical model had slowly transformed “freak” performers, including “midgets,” from entertainers with wonderful and fantastic pedigrees to potential patients riddled with deficiencies. A 1937 Collier’s Weekly article titled “SideShow Diagnosis” by Hannah Lees demonstrates the mainstreaming of this

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stigmatizing interpretation of complex embodiment.128 Lees suggested that all of the real “side-show freaks” could be “fitted snugly between the pages of some medical textbook” because, while they may be curiosities, they were “more certainly  .  .  . sick.”129 With the help of medical professionals who joined her at a circus sideshow, Lees proposed diagnoses for a list of typical “freaks” one would see there, including “The Leopard Man” (vitiligo), “The Elastic-Skinned Woman” (skin tumor), and “The Blue Man” (argyria). Every oddity, it seemed, had a medical explanation. According to Lees, dysfunctional glands provided “the bread and butter of any side show” by creating the “Fat Lady, the Bearded Lady, the Midgets, the Giants and even the Ugliest Woman in the World.”130 Throughout the article, Lees’s accusatory prose pulled back the curtains and exposed the supposed reality behind every “freak” show—namely, pathology.131 “Midget” entertainers attempted to persevere in this changing cultural climate, in which they were forced to take more responsibility in manufacturing enchantment for their audiences and distracting them from adopting a medical mind-set. They did this by continuing to claim a fairytale pedigree and offering hyper-gendered entertainment. During the 1930s, fairs, intended to uplift the spirits of Americans in the throes of the Depression, proved to be the perfect mediums for this strategy, as most of them featured amusement areas where the small-statured entertained. Still, by the end of this decade, entertainers found themselves pigeon-holed by a fairytale temporality, as their performances provided an existential contrast to the science and medicine hailed at these fairs. In the end, “midgets,” including those famous for their complex embodiment and talent, embodied the antithesis of science’s core values of innovation and progress, especially given their supposed resistance to therapy.132 During the 1930s “midget” exhibits at fairs across the country served as an antique counterpoint to the celebration of scientific progress that was helping the United States out of the Great Depression. One of the most elaborate examples of these displays of modern achievements could be seen at Chicago’s Century of Progress World’s Fair in 1933.133 Promoters advertised the fair’s cutting-edge flare. They hailed the fact that it was set up on “made land” stretching three miles in length and celebrated all things modern through a series of exhibits demonstrating the promise of technology and scientific innovation.134 Fair attendees were encouraged to bask in the glory of modernity by visiting the House of Tomorrow, touring the Electrical Building, and viewing the unique architecture of the Travel and Transport

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Building.135 When they needed to relax from this immersion in modernity, visitors could stroll the midway area. The most popular section of the fair, the midway hosted the entertainment, which included a “freak” show, a “plantation negro show,” and the “Midget Village.” In displaying oddity, the “hottest colored band from Dixie,” and an ancient race, each of these exhibits served as a direct contrast to the Century of Progress.136 As an antique counterpoint to modernity, the “Midget Village” lived up to the bill. It was a replica of a fourteenth-century walled Bavarian village built on small scale and described as “an old-world scenic glory miniaturely designed for midget inhabitants.”137 Once visitors passed “four towering giants” standing guard, they entered an enclosed space about a city block in size.138 Ten to twelve feet high walls encompassed a public square with a fountain. Along the perimeter were shops and buildings, which housed facilities for the village “inhabitants,” including a mayor’s office, police and fire departments, and a jail. In an effort to provide visitors with a behind-the-scenes feel, the village offered opportunities for people to view “wee families at rest and leisure.”139 The exhibit also included an open-air theater where entertainers performed hourly.140 While the village let visitors feel as though they had walked into the past, the Modern Lilliputians—as they were called in a souvenir brochure—were to be seen as contemporary incarnations of an ancient race. The brochure claimed that the goal of the exhibit was to allow for normal sized attendees to see these “midgets” “as real human beings intent on their own tiny-world social, artistic, cultural and economic ways.”141 It assured readers that the village’s inhabitants were not “infantile freaks” but rather “pure midgets,” that is, “well formed and healthy.”142 Attendees were to marvel at both the stature and the ability of these individuals. The brochure suggested that many of them had “extraordinary strength in lifting heavy objects,” lived longer than most people, and were smarter than many “larger folks.”143 In short, these Modern Lilliputians were “modern” in their similarity to the normal-statured visitors and “Lilliputians” in ancient extraordinariness. “The Midget Village” provided the perfect respite for visitors who needed a break from the chiseled architecture and sleek exhibits celebrating scientific advancements on display throughout the fair. Several subsequent world’s fairs (including the Century of Progress the following year) made sure to include “midget” exhibits in their landscapes for a similar effect. Throughout the 1930s “midget” performers entertained patrons of the California Pacific

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Figure 10. The entrance of “Midget Village” at the Chicago’s Century of Progress World’s Fair, 1933. The village returned with the fair in 1934. Courtesy of the Wisconsin Historical Society.

International Exposition in San Diego (1935–1936), the Texas Centennial Exposition (1936), the Great Lakes Exposition (1939–1940), the Golden Gate International Exposition, and the New York World’s Fair (1939–1940).144 Although the “midget” exhibits were constructed for entertainment purposes only, they were occasionally transformed into makeshift scientific laboratories for the further investigation of these small-statured individuals. For example, at the Century of Progress’s “midget exhibit” in Chicago, Professor Paul A. Witty, head of the psycho-educational clinic at Northwestern University, spent time assessing the small-statured performers’ psychological health through mental tests. Harvard University’s, Dr. L. W. Wilkins and C. W. Dupertuis also visited the exhibit, measuring and prodding several of the inhabitants and including the results in their large anthropometric display, which was also at the fair.145 The work they conducted at “Midget Village” had a lasting impact as the means derived from these data appeared in the 1940 version Holt’s Diseases of Infancy and Childhood in the section “Dwarfism.”146 Chicago’s Century of Progress “Midget Village” also hosted eugenicist Harry Laughlin. The Eugenics Record Office was intrigued by the inheritability of short stature, and Laughlin collected his own series of measurements of the entertainers for his single-trait research. So pleased was

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Laughlin with this opportunity to mine data from the “midget” population, that he sent a personal letter to the managing director of “Midget Village,” Nate T. Eagle, thanking him for “the splendid collaboration which you and your staff gave to our investigators who are making research on anthropometric measurements and family histories of midgets. You have doubtless assembled the largest and most interesting collection of midgets ever brought together in one place.”147 These scientific efforts at “Midget Village” demonstrate how “midget” performers found themselves in the purview of medicine even while they were entertaining.

Medicine, Munchkins, and Manhood Ironically, the silver screen provided a type of respite for entertainers who might have felt stifled by the increasingly critical medical gaze of amateur and expert. In particular, two male “midget” entertainers, William “Little Billy” Rhodes and Kurt Schneider (Harry Doll/Earles), were able to find roles pretty early on in the motion picture industry. Their performances often successfully played upon the cultural assumption of a causal link between stature and masculinity as evidenced by the positive reviews they received. For example, “Little Billy” Rhodes received rave reviews for his portrayal of a boxer’s manager and mascot who pretends to be a little girl in order to impress a wealthy old aunt in Oh Baby! (1926). The New York Times reviewer commended Rhodes for his ability to maintain a “masculine posture” and then quickly turn into a “gentle affectionate little girl” who was quick to give kisses to young ladies.148 Rhodes’s performance in The Sideshow (1928) also tugged on the intersection of masculinity, stature, and normative heterosexuality. In the film, “Little Billy” plays the character of P. W. Melrose, a “midget” who owns a sideshow being sabotaged by a rival circus. While trying to figure out which of his performers was working against his sideshow, P. W. falls in love with the new trapeze performer, Queenie Parker. Even though Parker helps Melrose figure out who was to blame, she does not have the same feelings for him. In the end, the sideshow is saved but Melrose’s heart was broken.149 Kurt Schneider (Harry Doll/Earles) received similar accolades for his work. Like Rhodes, he depicted characters impersonating a young person, for example in the comedy That’s My Baby (1926). Featured in the second half of the film, Earles’s performance was the comic relief to an otherwise unfunny movie, according to one reviewer.150 However, Earles’s most

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memorable work can be found in The Unholy Three (1925 and 1930) and Freaks (1932). Directed by Tod Browning, The Unholy Three and Freaks feature Earles as a sideshow performer with an unexpected dark side. In The Unholy Three, Earles plays Tweedledee, one of three “freak” performers (the others being a ventriloquist, and a strongman) who commit a series of robberies that escalate in magnitude.151 Tweedledee comes off as the worst of the bunch, which would have been a surprise to audience members who would have thought that his short stature would compromise Tweedleee’s bravado. “Hapless,” “greedy,” and “cruel,” Tweedledee is even able to persuade the strongman to commit a murder.152 The New York Times review highly recommended The Unholy Three and remarked on the leading male actors’ performances, especially Earles’s evocative portrayal of a “vindictive, tiny specimen of manhood.”153 Yet, Earles is probably best remembered for his portrayal of Hans, a small male entertainer in the cult classic Freaks. This 1932 film tells a dark tale of deceit, love, loyalty, and the perils of short stature. The setting is a traveling sideshow where a short-statured male entertainer named Hans falls in love with a female entertainer named Cleopatra. At first, normal-sized Cleopatra mocks Hans for his crush on her until she learns from his small-statured fiancée Frieda of his pending inheritance. Scheming with the man who plays Hercules in the sideshow, Cleopatra marries Hans and tries to poison him. Hans’s friends—fellow “freak” entertainers—uncover her plot, inform Hans, and together seek revenge by transforming Cleopatra into a ducklady. The makeshift operation takes place in the woods and is conducted by Hans and his friends armed with shanks.154 Browning might have pushed the boundary of what had become acceptable behavior by the 1930s with Earles’s depiction of Hans in Freaks. Even before its release, it became clear that this movie was going to be a hard sell. Stories leaked that during the preview horrified viewers had ran out of the theater.155 Producers successfully pressured Browning to remake the ending, and the advertising campaign tried to heighten interest while quelling the concerns of potential moviegoers. For example, one poster played on cultural notions of masculinity, stature, and heterosexuality by featuring a non-threatening Hans sitting on Cleopatra’s lap in an embrace. It posed the rhetorical question, Can a full grown woman truly love a midget?156 The assumption behind this poster was that the potential patron knew the answer was “no.” Due in part to his small stature, Hans was not man enough to get Cleopatra to love him. To emphasize the depth of his inept masculinity,

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Hans’s small stature and tiny voice were contrasted to Hercules’s height, muscles, and deep voice throughout the film. Whether the public called for it or not, movie producers felt an increasing need to moderate the bravado of their small-statured male entertainers. Rhodes and Earles finally worked together on a project in 1938. Both of them—along with over a hundred other small statured men, women, and children—were contracted by Metro-Goldwyn-Mayer (MGM) to star in a film adaptation of L. Frank Baum’s The Wonderful Wizard of Oz. Unlike previous movie versions of the novel (The Wonderful Wizard of Oz, 1910 and The Wizard of Oz, 1925), the 1939 version featured Munchkins, the race of “midgets” depicted in Baum’s novel. The decision to include Munchkins was made in part because of Walt Disney’s $8 million success with Snow White and the Seven Dwarfs. MGM executives wanted to profit from the popularity of small-statured men157 and L. Frank Baum’s novel gave them the “midget race” they were looking for, although his description of Munchkins was not particularly evocative and called for some tweaking.158 MGM decided to take some artistic license and gave this race of small people a makeover. For the movie, their original drab blue garb was transformed into elaborate and colorful costumes. Their homeland was also magically transfigured. Shot in Technicolor, Munchkinland appeared to be pure fantasyland as this technology allowed for the suspension of modern temporality and the insertion of an enchanted one where seemingly perfectly proportionate “midgets” lived, worked, played, and—especially—sang and danced. This depiction clearly emphasized how distinctly isolated Munchkins were, being so far away from the modern era, and encouraged audiences to consider these small people as “objects of spectacle,” much as the inhabitants of an isolated Tiny Town had been depicted in the “all-midget” western musical The Terror of Tiny Town a year earlier.159 Unlike the use of “midget” entertainment in Oh Baby! and The Unholy Three, The Wizard of Oz employs a classic “all-midget” troupe approach by emphasizing the large number of talented small-statured men and women. One of the film’s most memorable musical numbers, “Ding Dong the Witch is Dead” is performed by Munchkins. Treated like children, the Munchkins are instructed by Glenda the Good Witch to “come out to play” after Dorothy’s house fell on the Wicked Witch of the East and killed her. The Munchkins obey and appear en masse to celebrate her death. Demonstrating their talents, these “midget performers” portray a happy race of small people by marching, dancing, and singing for joy.160

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MGM also intended to repeat the success of Snow White, leading the producers to depict male Munchkins as similar to the seven male dwarfs in the cartoon. In The Wizard of Oz, male Munchkins are portrayed as emasculated small men grateful for Dorothy’s courage and heroism. The “midget” actors were not asked to play the roles of “freak” entertainers with a dark side or men impersonating young children for financial gain; instead, they portray people from a fantastic, colorful place called Oz who are thankful for Dorothy’s unintentional murder of the Wicked Witch of the East. During the Munchkins’ formal greeting of Dorothy, the heroine is approached by three men in child-like costumes and with odd-sounding voices. Representing the “Lollipop Guild,” they welcome Dorothy with song and dance and a giant lollipop. The most seasoned actor of this trio was Freaks actor Kurt Schneider (Harry Doll/Harry Earles). Other male munchkins emerge from the masses to greet and thank Dorothy, including the Munchkin Barrister played by William “Little Billy” Rhodes. Members of the League as well as the Barrister are portrayed as being in debt to Dorothy, a young woman, for murdering their villain. She had done what they either could not or did not do—save their women and children from evil.161

Conclusion In many ways, The Wizard of Oz was a swan song for “midget” troupe entertainment and what was left of small-statured male performers’ masculinity. By the 1940s, scientific medicine interpreted short stature caused by a glandular dysfunction as an affliction in need of a remedy, which made a “midget” less of an attraction and more of a subject for medical research. It was believed that, as Bodin and Hershey suggested in It’s a Small World, “when the scientists have learned all the secrets of our mysterious glands it is not improbable that midgets . . . will go the way of the dodo, the dinosaur and the pterodactyl, themselves the victims of faulty glands, into oblivion.”162 Even Singer’s Midget Troupe was unable to weather the storm of the popularity of the scientific interpretation of “midgets” and their fate as it and most “all-midget” revues ceased to exist by the 1950s.163 The pathologization of small stature hit male performers particularly hard. No longer could small male performers choose to play hyper-masculine roles. Their stature was not seen as a natural wonder and their proportionate bodies were no longer admired. Instead, their shortness defined them as diseased and therefore curable. In essence, short stature

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had been transformed into a symptom in need of treatment. In addition, as the modern notion of masculinity coalesced, to be obviously shorter than most women compromised one’s manliness. It made the question “Can a full grown woman ever love a ‘midget?’” not only good copy but also the basis for a rhetorical question to which the answer was “never.” At the same time, growth hormone therapy appeared less promising than ever. The painstaking pursuit of discovering and then isolating a pituitary-derived singular growth hormone proved to be extraordinarily difficult and eluded scientists until the mid-1940s. Meanwhile, treatment was not always effective and proved to do more for the pathologization of normal variance in stature than offer a cure. Medical experts’ faith in the available GH also seemed to teeter during this time period. They tried to remain steadfast in their support for growth-promoting hormone therapy in cases of small stature, but with inconsistent success it was difficult to do so. Even so, hope persisted. On August 1, 1937, the New York Times reported on well-known endocrinologist Dr. Oscar Riddle’s proclamation that “hormones from the pituitary gland might be used in the near future to overcome inferiority complexes and possibly develop backward, retiring individuals into geniuses.”164 According to the article, a remedy was needed, as psychiatrists recently discovered that short stature hindered people from fully utilizing their natural intelligence and drive. Riddle confidently postulated the possibility of self-help through systematic injections of growth hormones. These injections would “convert the individual from a mediocre worker into a competent, confident person able to use his intelligence, which might be that of a genius, to its maximum possibilities,” with the only missing link being a therapeutically potent growth hormone preparation.165 But with no isolation of GH and no agreement among scientists as to if a single hormone was even solely responsible for stature, it appeared as if Riddle’s proclamation was less grounded in scientific achievement and more of a product of wishful thinking.

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Short Stature as a Psychosocial Risk Factor in Need of an Effective Cure In 1947 the popular magazine American Weekly reported on new developments in growth hormone therapy and research with an article by Allen Greenacre called “We’re GETTING BIGGER Again.” Greenacre suggested that the recent increase in height among Europeans and Americans had to do not only with a change in diet but also with a physiological change in the level of growth hormone secreted by the human pituitary gland. He went on to wonder what the future held for individuals who desired to be bigger and then shifted his focus to the therapeutic future of growth hormone. Greenacre informed readers about science’s progress in harnessing the therapeutic power of GH by describing a clinical experiment Dr. Choh Hao Li was conducting: “For one year he (Li) injected it (GH) three times weekly in a 10-year-old Hawaiian girl who was only as tall as a child of four. In that time she grew two and a half inches, but her mother took her back to Hawaii and he doesn’t know what has happened to her since.”1 The reader was left to wonder not only about the girl’s ultimate fate but also about when potent growth hormone would finally become available to patients. This was not the first time journalists heralded an impending breakthrough in effective growth hormone therapy for short stature. Throughout the first several decades of the twentieth century, medical experts conducted human experiments hoping to develop a pituitary extract featuring GH strong enough to increase the height of their patients. While physicians and medical researchers were rattled by the continuous mixed results of clinical trials, Dr. Li’s 1944 isolation of growth hormone from the pituitary of an ox gave them and drug companies hope that a potent and pure pharmaceutical was in their grasp. However, their optimism was quickly crushed when refined growth hormone preparations did not yield positive clinical results.2 In fact, medicines touting purity performed worse in clinical trials then earlier pharmaceuticals had.

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As cynicism over the therapeutic potency of growth hormone drugs grew, so did the perceived public need for them. During the 1940s psychology texts and advice books for parents popularized the psychoanalytical notion that biological deficiencies in children—including short stature—caused inferiority complexes. As infant mortality rates declined during the first three decades of the twentieth century, child experts’ concerns over children’s health shifted from life and death issues to psychosocial adjustment and normal physical growth. Psychoanalysis highlighted the interrelationship between the two, reframing the meaning of biological variation and inspiring a continued holistic approach in the field of pediatrics. Although pediatric endocrinology and psychoanalysis are usually considered separate medical fields, they converged on short-statured, male, youthful white bodies in the post-World War II era and together transformed short stature into a psychosocial risk factor in need of treatment. This chapter aims to pinpoint the moment at which growth-promoting hormone therapy became synonymous with treating short boys in the hopes of making them tall. Existing scholarship on the history of the human growth hormone industry has underestimated and miscalculated the roots of the gender disparity in GH therapy.3 Since the 1940s boys have been targets for growth-promoting hormonal therapy as gendered growth charts, diagnoses, and treatments have all played a role in the medical quest to treat short-statured male youngsters. By 1945 gender trumped race and class when it came to the assessment of children’s height. Indeed, the various growth charts used by pediatricians, public health officials, and school administrators segregated data by sex, and norms for boys were less forgiving of small stature than comparable measurements for girls. Gender also mattered when it came to medical diagnoses, as pediatric textbooks placed special emphasis on boys afflicted with recently-named physiological disorders causing short stature. Even treatment was gendered. By 1950 pediatric endocrinologists advised the use of the male hormone testosterone in cases of short stature due to an anterior pituitary hormone deficiency. Their official recommendation contributed to a synergy between treatment and patient and solidified the notion that a surge of masculinity would save boys from the perils of short stature. Even once medical experts figured out how to use cadaver human growth hormone to treat short stature and cHGH replaced testosterone as the preferred medical regimen, the link between boys and growth-promoting therapeutics did not waiver. In fact, the human growth hormone industry would end up depending on it.

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Pathological Height During the 1940s an increasing number of child experts observed, debated, and theorized about what constituted a “normal” childhood. In an article for the April–May 1943 issue of the Ciba Symposia, Wilton Marion Krogman, an associate professor of anatomy and physical anthropology at the University of Chicago, commented on the cacophony generated by the many experts weighing in on the modern study of human growth. According to Krogman, “growth was conceived by an anatomist, born to a biologist, delivered by a physician, left on a chemist’s doorstep, and adopted by a physiologist. At an early age she eloped with a statistician, divorced him for a psychologist, and is now being ardently wooed, alternately and concurrently, by an endocrinologist, a pediatrician, a physical anthropologist, an educationalist, a biochemist, a physicist, a mathematician, an orthodontist, a eugenicist, and the Children’s Bureau!”4 Even across this wide spectrum of experts, most agreed that a child was “not a small replica of the adult.” Instead, his physical composition, mental faculties, and behavior separated him from his older counterparts.5 While variations of rates in the rate of development of physical growth, motor skills, and personality were acknowledged, certain milestones were identified and deemed as markers of a normal and therefore healthy childhood. It was expected that most children would get their first tooth by eight months, refine their walking skills when they were two to three years of age, and sexually mature in their teens.6 Deviation from this schedule signaled a possible pathology.7 Pediatricians were mindful of these milestones and regarded the monitoring of stature as an important measure in assessing the health of a child. For these doctors, short stature suggested a possible serious physiological disturbance, a chronic or acute illness, or inadequate nutrition, all of which could affect normal growth and development. While pediatric textbooks recommended that doctors routinely take a series of measurements—including body weight, height, chest, and head—at every examination, the height and weight measurements were considered the “fundamental base for the appraisal of development and physical condition.”8 Height and weight were charted over time and assessed using norms represented on growth tables and charts. Even though these tabulations were already common fixtures in pediatric textbooks in the 1930s, their presentation continued to evolve. In the early twentieth century, textbooks had featured growth charts and tables

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depicting averages based on data from anthropometric surveys. Those who had conducted the surveys were often credited in the tables and variations in measurements between studies were discussed in the text surrounding the graphics.9 Possible factors such as race, class, and whether the children attended public or private school were sometimes given consideration as having an impact on growth. Attention was also given to the problematic aspects of offering pediatricians average measurements to use as norms in assessing a child’s health.10 While human variation was acknowledged, growth charts and tables featured in pediatric textbooks displayed averages based on data from various growth surveys as healthy norms, a feature that had been a part of these diagnostic tools since their inception but had become even more non-contexualized during the mid-twentieth century. In part, this trend might have been due to the increasing complexity found in textbook descriptions of growth and development. Take for example the 1940 edition of Holt’s Diseases of Infancy and Childhood.11 No longer was the section dedicated to growth and development primarily focused on weight and height; instead, it also discussed and charted other topics, such as “the growth of organs of the body”12 and “chemical growth.”13 Even so, height and weight charts and tables intended to serve as diagnostic tools maintained a level of simplicity. At the same time, the textbooks developed in the 1940s devoted more attention to how the measurements were taken rather than to where the data came from. This subtle but meaningful alteration disengaged measurements collected from growth surveys from their origins and further presented the data as generically normal and healthy rather than pertaining to a certain population. Ironically, gender was the one factor that remained linked to the measurements, and the continuance of gender-specific standards had tremendous implications on the treatment of short stature in children because it took less variation for boys to be considered pathologically short than for girls. With growth charts acting as diagnostic gateways in pediatric care, the detection of abnormal growth would be followed by an examination for chronic infections. In addition, parents would be questioned about their child’s diet. If constitutional and environmental culprits of short stature (i.e., race, social class, hereditary factors, and environment) were ruled out and illness or a nutritional problem seemed not to be implicated, a hormone deficiency was considered. Pediatricians understood that growth continued as long as the thyroid and growth hormone were active and the gonads were

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not.14 Skeletal growth ended when gonadal activity caused epiphyseal closure.15 Any irregularities in this hormonal trifecta resulted in growth abnormalities, including delayed sexual maturation and short stature. Medical experts speculated that hormonal irregularities were caused by lesions hindering the production or release of a growth-promoting hormone, though verification of this type of obstruction could only be made postmortem. Thus, physicians had to rely on the body for clues. In order to investigate possible endocrine disorders, pediatric textbooks-recommended physicians conduct a physical examination, take x-rays of various skeletal sites—including “the skull, sella turcia, long bones, and wrists”—and take blood and urine samples to determine basal metabolism and blood chemistry.16 Since these tests could not definitively determine if the child had a severe or mild growth hormone disorder, diagnosis involved a process of elimination.17 If no other underlying deficiency—such as diabetes, hypothyroid, precocious puberty, and non-pituitary forms of dwarfism—was identified as the reason for the short stature, physicians could consider an anterior pituitary hormone disorder. Anterior pituitary deficiencies causing a delay in growth and development were known as pituitary dwarfism, but there was a series of sub-categorizations further classifying this dysfunction. A cluster of disorders (including Fröhlich’s syndrome and congenital pituitary dwarfism, otherwise known as Levi-Lorian dwarfism) was characterized by delayed sexual maturation, pudginess, and short stature, all of which resulted in a type of endocrine infantilism. While these diagnoses were not necessarily sex or race specific, afflicted white boys feminized by their infantilism were highlighted in textbook descriptions. The race of these males fell in line with general practices at this time, as most case studies depicted in pediatric textbooks were white. However, not all them were boys. It is fair to speculate that the gender imbalance existing in the portrayals of pituitary dwarfism was due to either the assumption that boys appeared more victimized by symptoms or because the condition appeared to be more prevalent in males. In the case of Fröhlich’s syndrome, boys were thought to experience more severe problems than girls because the condition problematized their masculine traits. Boys diagnosed with the syndrome usually produced “female contours,” and their voices stayed “soprano,” while the growth of the penis, testicles, and scrotum was considerably delayed and sometimes buried in fat.18 Perhaps the most ambiguous description of a growth disorder causing short stature was the acquired form of anterior pituitary deficiency of

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growth. A description of this disorder from a 1942 pediatricians’ textbook reveals the fluidity of the diagnosis: “The acquired form of anterior pituitary deficiency of growth is characterized by a short stature, which ranges from marked dwarfism to moderate stunting, depending upon the severity of the damage and the age of the onset. The general appearance varies from one stimulating the congenital type to that of a normal child who looks younger than his age. The child may be obese, thin, or normal in nutrition. Bone development and sex development may be normal or retarded.”19 The one identifiable constant characteristic of this type of pituitary dwarfism was short stature of varying degrees, which appeared gender neutral. However, diagnosis of a child suspected of this deficiency would include the use of charts featuring sex-segregated height and weight standards that were more restrictive for boys.20 Hence, both a gender bias in the portrayal of endocrine disorders linked to the pituitary found in pediatric textbooks and the use of gender-specific charts by pediatricians reified the perils of short stature for young boys.

The Complexity of Growth Hormone While classifications of growth hormone disorders causing short stature evolved, effective treatment was in a state of flux by the mid-1940s.21 Debates about the effectiveness of anterior pituitary compounds as a viable mode for treating delayed growth and pituitary dwarfism persisted. With no definitive resolution, growth hormone manufacturers continued to sell their products and donate them to medical research. For example, during the 1940s the growth hormone producer Armour Laboratories published an informational booklet intended for practicing physicians titled The Pituitary Gland. The pamphlet was intended to be an instructional piece teaching the physicians about the pharmaceutical products offered by Armour, including Growth Complex and Anterior Pituitary Powder and Tables, as well as about the “pituitary gland, its functions, disorders, and therapy.”22 The names of the medicines offered by Armour were typeset in all caps, making them pop out of the text describing clinical conditions warranting their use. Armour marketed Growth Complex and Anterior Pituitary Power and Tablets as preparations intended to treat short stature caused by pituitary dwarfism (Lorian-Levi type). Growth Complex contained adrenotropic and lactogenic factors, which Armour deemed “essential to body growth, and normal development.”23 As with the anterior pituitary preparations Evans

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had used in his experiments, Growth Complex was intended to promote only stature and not sexual maturation. In fact, the advertisement at the end of the book stressed that it was stripped of gonad and thyroid hormones and was therefore “suitable for children when skeletal and visceral growth” were the desired outcomes.24 Results in growth were predicted “within two or three months.”25 Armour’s advertising of its Anterior Pituitary Powder and Tablets addressed scientists’ shared opinion of the ineffectiveness of orally administering anterior pituitary preparations by claiming that their products were “still employed extensively and with apparent success as a means of accelerating growth and development in the pituitary types of retarded growth or dwarfism prior to the closure of the epiphyses.”26 To ensure success of these treatments, the ad recommended the extracts be taken in conjunction with either a vitamin-rich diet or vitamin supplements.27 Parke, Davis was also still active in the growth-promoting hormone business. During the 1940s the company’s research laboratories were busy at work with Dr. Quentin R. Bartz in improving the process of manufacturing Antuitrin G.28 As discussed in the previous chapter, Parke, Davis was struggling with what it internally called an “unsatisfactory product” by attempting to make its anterior pituitary extract powder more soluble, less irritable, and more potent.29 In March of 1944, an article in Science detailing Dr. Choh Li’s isolation of growth hormone inspired Parke, Davis researchers.30 Li’s research gave credence to the existence of a pure protein anterior pituitary growth hormone and provided hope to Parke, Davis Research Laboratories in its twenty-year quest to create an effective commercial growth hormone product. Researchers at Parke, Davis duplicated portions of the process articulated by Li in manufacturing Antuitrin G; however, Li’s method to isolate GH did not yield large enough quantities needed for clinical and basic research, let alone pharmaceutical manufacturing. In 1948 another medical expert in growth hormone, Dr. Alfred E. Wilhelmi, spearheaded research that offered a new preparation providing enough GH for scientists, clinicians, and pharmaceutical companies alike.31 However, it didn’t matter. Parke, Davis, along with other GH manufacturers, continued to produce growth hormone pharmaceuticals that were ineffective due to the hormone’s species specificity, a quality of growth hormone that only became understood later. For a time, Li’s isolation of GH brought hope to those suffering from short stature. Some individuals were so eager for a pure and effective growth hormone drug to reach the market that they personally contacted Li.

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Figure 11. Growth Complex, Armour Laboratories, The Pituitary Gland: Clinical Application of Its Hormone Factors, Revised Edition (Chicago: Armour and Company, 1944), 65.

In October 1945, he received a letter from a self-identified Chinese-American engineering graduate student, inquiring about his research. She wrote, “I know you and your scientific associates haven’t yet figure out the molecular stucture of the pituitary growth hormone, I am afraid of using these

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Figure 12. Anterior Pituitary Powder and Tablets, Armour Laboratories, The Pituitary Gland: Clinical Application of Its Hormone Factors, Revised Edition (Chicago: Armour and Company, 1944), 64.

pituirty hormone extracts on the market for it might do more harm than good.” Standing at five-foot-two, she confessed: “I am just dying to grow taller. Its agonizing to be short.”32 Ironically, the isolation of GH and the further refinement of the

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purification process did not lead to a more therapeutically potent growth hormone drug. Therefore, even though pharmaceutical companies refined their products and sent them to scientists and clinical researchers to determine their effectiveness, the results were not good. For example, in 1949, Armour Laboratories asked several research teams to study a refined version of a growth hormone preparation, but none of the researchers were able to report positive findings.33 Researchers claimed that Armour’s GH products did facilitate “linear growth, weight gain and nitrogen retention”34 in laboratory experiments involving rats and dogs, but they did not do the same for people. In some cases the treatments caused patients to lose their appetite and made them experience “listlessness, vomiting, malaise, nausea, negative nitrogen balances and other toxic effects.”35 These negative findings were a huge blow for growth hormone manufacturers and pediatric endocrinologists eager to help their patients grow taller.

The Power of Pediatric Endocrinology Faced with the therapeutic failure of a purer-form of GH, pediatric endocrinologists privileged alternative therapies to promote growth and shared their recommendations with other pediatricians at the 1946 annual American Pediatric Association’s meeting. For example, William C. Deamer of the University of California Medical School read a paper detailing his success in promoting growth in under-statured boys with hard tablets of testosterone that were supplied to him by Ciba, the same pharmaceutical company that funded the endocrine clinic where he worked. Deamer reported that he led a team of researchers in treating five boys with divergent bone and chronological ages with testosterone, and that each of the subjects grew. According to the report, researchers, parents, and children alike were pleased with the results of treatment. Deamer commented, “each time the patient’s trousers had to be lengthened was an occasion for rejoicing.”36 First identified in 1935, testosterone was quickly synthesized and used in clinical trials to treat various ailments by the end of the 1930s. However, treating short stature with testosterone was somewhat tricky since it caused some patients to become aggressive, develop masculine sex traits, and experience an early closure of bones, which ended the growth process. Deamer addressed some of these side effects by suggesting they were to be welcomed. In his report, he remarked on the increased aggressiveness of two boys in the study as “a desirable feature of the treatment.”37 A leader in the

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field of pediatric endocrinology, Deamer inspired others to officially endorse testosterone as the preferred treatment for short children, even though girls were ostensibly left out of the picture with this medical recommendation.38 At a 1949 American Academy of Pediatrics-sponsored roundtable discussion of endocrine therapy in childhood, leaders in the field—William C. Deamer, William A. Reilly, and Lawson H. Wilkins—recommended the “male hormone” for “symmetrically understatured” children.39 In the case of short stature due to a growth hormone disorder, the effectiveness and appropriateness of the available treatment made boys appear as the ideal candidates. Boys’ bodies responded better to testosterone therapy than girls, as there were fewer complications, more benefits, and more appropriate somatic results. Also, the social problems boys had with being short were seen as more pressing for them and their parents than for girls. Pediatric endocrinologists’ recommendations carried weight because, by the 1950s, they were becoming the undisputed experts in treating short statured resulting from hormonal disorders. In part, this was because pediatric endocrinology had at last grown into a respectable specialty within pediatrics. Its professionalization was marked by the publication of the first edition of The Diagnosis and Treatment of Endocrine Disorders in Childhood and Adolescence in 1950.40 This textbook provided descriptions of common pediatric endocrine disorders, diagnostic criteria, and therapeutic options. Other editions followed, and additional reference books were published in order to disseminate up-to-date information to pediatric endocrinologists, pediatricians, and general practitioners. While pediatric endocrinology publications provided a more precise understanding of growth disorders linked to anterior pituitary hormones, they were unable to offer a diagnostic test for determining growth hormone deficiency, besides the collection of body measurements. The best they could do was rule out other possible causes for short stature, including low ACTH levels or insulin intolerance. If the specialist did suspect a growth hormone deficiency, not much could be done.41 During the 1950s, experts were keenly aware that pituitary growth hormone was “the only agent known to be capable of stimulating growth without at the same time accelerating skeletal maturation,”42 but they struggled with its clinical inconsistencies. Therefore, they continued to recommend testosterone, even though it accelerated epiphyseal closure, and caused female patients to take on masculine traits, including the growth of mustache hair, enlargement of the clitoris, and “hoarseness of the voice.”43

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The Use of Growth Charts in Medical Surveillance Without a laboratory test for growth hormone, growth charts served as the fundamental diagnostic tool for anyone concerned about children’s health, from the pediatric endocrinologist to the school physician. As in the early decades of the twentieth century, schools remained important sites in the medical inspection of seemingly healthy children during the 1940s and 1950s. School physicians, nurses, and teachers were charged with the responsibility of identifying children suffering from malnourishment or an invisible physiological disorder; they relied on the recording, tracking, and assessing multiple measurements to help them with this task. In addition, the Joint Committee on the Health Problems in Education of the National Educational Association and American Medical Association continued to assist schools in medical inspections as it had done earlier. By the late 1940s, the Committee decided it would be in the best interest of the children to update protocols relating to the measurements recorded, the procedures followed during the physical, and the norms used in interpreting the data. The result was an instructional booklet titled Physical Growth Record, which allowed school physicians and nurses, physical education instructors, and even rural schoolteachers to systematically record and interpret height and weight measurements of pupils in elementary and secondary schools using an identical format.44 The Physical Growth Record was a four-page, sex-specific booklet with charts intended to record a child’s growth in height and weight from four to eighteen years of age. Developed by Dr. Howard V. Meredith of the Iowa Child Welfare Research Station and Dr. Harold C. Stuart of the Department of Maternal and Child Health at the Harvard School of Public Health, the booklet was intended to aid school programs aimed to keep a watchful eye on pupils’ growth and health. A child’s height and weight were to be measured at least three times a year and recorded in his or her booklet. The data was placed on the booklet’s charts, which featured “five normative zones— Tall, Moderately Tall, Average, Moderately Short, and Short.”45 A child had to fit into one of these normal growth zones in order to be considered healthy. Failure to do so and to consecutively stay in a zone often meant a referral to a pediatrician. Based on body measurements taken on white children attending the University of Iowa’s experimental elementary and high schools during one or more years from 1930 through 1945, the charts featured in the Physical

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Growth Record were limited in scope. This fact was not lost on its creators. Stuart and Meredith tried to compensate for the shortcomings of their data. In the footnotes of an article explaining the Physical Growth Record, Meredith cautioned against the universal use of their charts because the data sample was composed of “white children of northwest European ancestry living under better-than-average conditions” and did not represent a large swath of America’s population.46 He suggested school programs make their own charts when assessing non-white children or employ additional charts. Meredith specifically referenced two studies for the latter endeavor. One was a growth study of Los Angeles school children conducted by Orren Lloyd-Jones. Working through the Work Project Administration and in collaboration with the Los Angeles Board of Education’s School Health Aid Project, Lloyd-Jones oversaw the measuring of over 163,008 children representing various “races,” including “White, Mexican, Negro, and Japanese” in order to create standard height-weight-age tables for the use of LA schools.47 The second study focused on a different part of the country, Minnesota. The populations consisted of school-aged boys of Finnish and Italian ancestry, which were understood as two separate ethnic groups representing two “series of physically normal white boys.”48 In addition to these recommendations, Meredith was comfortable with the use of his charts when measuring working-class children. He, like others in the field, believed that the exclusive data set did not inappropriately skew the normative curves. Rather, the upper-class white children provided a type of optimal norm.49 The Stuart-Meredith charts had a profound impact on the measuring of children. Also known as the Harvard-Iowa charts, these diagnostic tools became common fixtures in schoolrooms, pediatric offices, and public health clinics. Up until the mid-1970s school programs continued to rely on the Harvard-Iowa charts in health examinations. Pediatricians also gravitated to them as diagnostic tools, as they were familiarized with the charts during medical school. Pediatric textbooks during the 1950s, 1960s, and 1970s included their own variation of the Stuart-Meredith charts. Different from those featured in The Physical Record, height and weight charts found in pediatric textbooks employed percentiles represented by curved lines or standard deviations instead of zones to represent normal theoretical growth patterns, allowing for a more rigorous analysis of measurements. In the pediatric textbooks, charts for pre-school aged child and infants used data from Stuart’s growth surveys and the Harvard School of Public

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Health Longitudinal Studies. Ironically, the Harvard Study was based on values from working-class Boston children and not middle-class children from Iowa, which in some way diversified these data overall but also added to the confusion because the norms seemed disjointed between infants and children. Even so, the Stuart-Meredith charts were used by physicians and public health officials in the United States and around the world for nearly thirty years.50

The Growing Problem of Short Stature Still other charts and methods offered additional analyses or diagnostic tools, including William Sheldon’s body type formula and Norm Wetzel’s grids. According to historian Heather Munro Prescott, psychologist William Sheldon’s method of sizing up adult body type and predicting personality was a popular technique that had been adapted to the measurement of children by the mid-1950s. Sheldon suggested that everyone could be categorized into one of three basic body types—endomorph (fat, round), mesomorph (muscular), or ectomorph (skinny)—and that each body type had its own personality (fun-loving, aggressive, and sensitive).51 Pediatric textbooks in the 1950s and 1960s featured images illustrating Sheldon’s classification. A boy with a pudgy middle exemplified endomorphy, a proportionate boy represented mesomorphy, and a fragile small boy served as the example of ectomorphy. The text linked each body type to a specific growth speed and height. Endomorphs matured early and were tall into late childhood, ectomorphs developed later and remained shorter longer, and mesomorphs were somewhere in the middle.52 While some child development experts took issue with Sheldon’s theory being applied to children and adolescents, his three categories considered an overall composite instead of analyzing single measurements, and insinuated a correlation between stature and personality. The classification system interpreted short statured boys as sensitive, fragile, late bloomers. For its part, Wetzel’s method stressed a holistic approach to evaluating growth and development. Since the 1930s, Dr. Norm Wetzel had been a vocal opponent of the current practice of measuring children against charts because most of them did not adequately consider growth speed and failure. Using complex mathematical equations, Wetzel had created grids that were composed of channels instead of single curves to represent normal growth. The Wetzel Grid was meant to correct the above-mentioned deficiency in

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that it accounted for measurements that indicated a child’s growth speed, size, and shape.53 While the Wetzel Grid offered a new way to think about normal growth, it endorsed a preference for the average and a negative attitude toward the short. In an April 1950 Life magazine article titled “How Children Should Grow: Grid Discards ‘Average Size,’ Charts Progress of Seven Body Types,” images served to help the reader gain a better sense of the Wetzel method, including one featuring a replica of the grid with children standing on it to represent the seven different channels (A1-A3, M, and B1-B3).54 The better-looking child represents “M” or the average channel while the short stocky child represents “A1,” a less desirable norm.55 Another image further stigmatizes “Channel A1” with a short stocky child. A photo of female pole climbers is meant to represent the relationship between stature and physical performance. The girl representing the average channel performed best, while the girl standing in for “A3,” the channel of the stocky, was unable to get off the floor. Although Wetzel aimed to even out the playing field when it came to interpreting a child’s growth as normal and healthy, the descriptions of the channels revealed his bias for the average.”56 Even though the Stuart-Meredith charts beat out Sheldon’s system and Wetzel’s grid in terms of longevity and use, the latter two tools spoke to an interest in the causal relationship between mental health and physical growth dating back to the pioneer of educational psychology, G. Stanley Hall.57 While Sheldon contributed to the discussion about the relationship between personality traits and stature, Wetzel directly addressed the surveillance of children’s health by suggesting that his grids worked “as a sort of alarm box for many physical defects,” because they took into consideration growth speed and therefore were able “to prove for the first time that normal physical growth can actually be retarded by emotional disturbance.”58 Unfortunately, the cumbersome mathematical demands required by the Wetzel grid along with a couple of miscalculations he had made sealed the doom of his system.59 Nevertheless, the association between growth and one’s psychological state continued to be a hot topic in the field of child development, in part because of the growing popularity of psychoanalysis. In mid-twentieth century America, a psychoanalytical revolution in the understanding of human behavior emphasized a body-mind connection. This inevitably contributed to the reframing of short stature in boys as a psychosocial risk factor. Alfred Adler was first to postulate that a stunted child could suffer from an inferiority complex. A practitioner and theorist of

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the “new psychology”—psychoanalysis—Adler had worked with Sigmund Freud in Vienna before establishing a rival school based on the idea that people are driven by a sense of inferiority and not the libido. Adler’s psychoanalytical theory of the human drive was known as individual psychology.60 He suggested that communal living lead to a sense of inferiority because group dynamics cause each person in the group to strive “for a measure of security and totality which shall make continued existence tolerable, a fate which is inextricably linked to the fate of his group.”61 According to Adler, feelings of being inferior begin in infancy and continue throughout one’s life. If not dealt with appropriately, this powerful agent in personality development could create what he called an “inferiority complex.”62 Adler was particularly interested in early childhood development and his interpretation of how children dealt with inferiority complexes changed the way Americans understood, treated, and dealt with biological differences in children.63 He argued that children were not immune to inferiority complexes. Like other psychoanalysts, Adler believed that by age five, a child was set “toward success or failure,” which for him meant that an inferiority complex in childhood could have a lasting impact throughout one’s life.64 The child, according to Adler, was a prototype, which was “like an unripe fruit, if there is some trouble with it, if there is a worm, the more it develops and ripens the larger the worm grows.”65 Children with biological deficiencies were particularly prone to a disastrous adulthood if they did not deal with their inadequacies with the help of a professional psychologist. According to Adler, “the child who is born with imperfect organs . . . immediately feels inferior, feels always in danger, hesitates to meet any new situation and is anti-social.”66 These children, just like anyone facing feelings of inferiority, had two options. They could either address their emotions by working with a professional who would help them get to the underlying issue, or overcompensate for their perceived inadequacy by succeeding at something other than what was causing them to feel inferior. Adler championed the former.67 Interestingly, Adler’s example of what not do to when dealing with an inferiority complex ended up having a profound impact on people’s perception of short boys. In his book The Science of Living, Adler describes a case study of a short boy acting like Napoleon in order to compensate for his feelings of inadequacy. According to Adler, this boy’s inferiority complex manifested in his sleep, as he slept “with arms crossed on his breast, like Napoleon.”68 Researchers had observed the boy’s unusual bedtime posing during a sleep study and, after investigating further, realized that “the boy was actually

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imitating his teacher that he adored but due to a lack of funds he was not able to continue his education.” Once he left school his family made him work in a restaurant “where the patrons had all derided him because he was undersized.”69 The boy’s inferiority complex was rooted in his small stature, and he had attempted to escape feelings of humiliation in his sleep by acting like his favorite teacher, who happened to have similar mannerism to Napoleon. The boy’s actions, the researchers’ interpretation, Adler’s assessment of this boy’s behavior, and his previous psychoanalytical interpretation of Napoleon as having a psychological complex could possibly be the inspiration for the phrase popularly used to express short men’s angst-driven behavior: the Napoleon complex.70

Parenting Advice and Psychoanalysis The inferiority complex, the Oedipus complex, and the Castration complex— psychoanalysis claimed to reveal hidden dangers to a person’s development lurking in childhood. Beginning in the late 1930s, as infant mortality rates continued to decline, parents worried increasingly about their children’s mental health and the impact that childhood experiences had on the latter’s adult lives—a trend complimented by this new psychology. A 1951 comic from Los Angeles Times made light of how psychoanalytical notions reframed parental concerns over parent-child relations. In it, the father rolls up his sleeve with the intention of disciplining his son for making a mess, but his facial expression shows he is worried about the repercussions. The short little boy reminds his dad that hitting him would cause an inferiority complex. The comic’s caption reads, “go ahead, go ahead, give me an inferiority complex!”71 Psychoanalysis suggested that one wrong parental move could damage the child forever. This parenting trap vilified common childrearing actions and piled new stress on first-time parents. In a 1950 Life magazine article titled “How to Survive Parenthood,” journalist Robert Coughlan played off psychoanalysis’ popularity by calling the palpable level of parental anxiety prevalent in post–World War II America “neuroses-neurosis.”72 By 1950 psychoanalysis had ushered in a new era of expert parenting advice in the United States. Previously, at the beginning of the twentieth century, experts had suggested that mothers—due to their intuition and Christian ethics—knew best when it came to parenting. A mother was told to trust her instincts, conduct her affairs in an honorable way, love her children, and reward good behavior and pray for “divine intervention” when these tactics

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failed.73 In the 1910s the tide began to turn. Experts urged mothers “to put their children on a strict schedule and to punish them when they were wrong.”74 During the 1920s and 1930s these ideas were elaborated and made more rigorous by John B. Watson, a behaviorist and psychiatry professor at Johns Hopkins. After observing children in the field, Watson conducted an experiment on a child to determine the possibility of conditioning children. Known as the “Little Albert experiment,” Watson’s experiment on the son of an employee of the Harriet Lane Home for Invalid Children led him to postulate that the human infant was born with three emotions—fear, love, and anger—and that the rest of the child’s personality was a result of his upbringing. Through the many articles he wrote for popular journals and his 1928 book, The Psychological Care of Infant and Child, Watson encouraged parents to treat their children like young adults, teaching them how to adhere to a strict schedule, giving them handshakes instead of hugs, and letting them resolve difficult moments on their own. Their success in adult life depended on them learning independence and adhering to schedules. Watson speculated that this type of parenting would be successful because children were universally all the same and predicted that if parents adhered to his program its success would bring an end to marriage and would foster communal living.75 While parental advice based on behaviorism found an audience in women’s magazines during the 1920s, its popularity started to decline during the 1930s. According to a study published in the Journal of Pediatrics in 1950, 100 percent of the articles featured in three of the most popular women’s journals (Ladies Home Journal, Women’s Home Companion, and Good Housekeeping) during the 1920s advocated some form of behaviorist advice for parents. By the 1930s the tone of the articles changed. Only 75 percent of the articles featured any type of “let-them-cry-it-out theory,” and by 1945 no article advocated an upbringing inspired by the theories of behaviorism.76 A kindler and gentler approach began to prevail during the 1930s, as some advice books promoted hugs instead of handshakes, stressed happiness over regimen, and celebrated the differences found in children. In a 1936 advice book titled Health: Physical, Mental, and Emotional, the authors declared that “there is no average baby . . . the individuality of each one is manifest both in his physical and mental growth and in his development . . . What a stupid world it would be if every child conformed perfectly to a set pattern! A healthy baby is a happy baby.”77 The book stressed the importance of providing the right guidance to children so they could learn to

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make healthy choices. The focus was to guide the parent in taking care of the child and was inspired by psychoanalytical theory. Psychoanalysis favored understanding over training when it came to helping children learn from challenges that arose due to biological deviations. In Health: Physical, Mental and Emotional, instruction pertaining to physical difference stressed that “whether he is hard of hearing, cross-eyed, lame, undersize, or deformed in some way  .  .  . the child may become extremely sensitive regarding the handicap, and feel inferior because of his inability to compete on an equal basis with his companions.”78 Hence, it was up to the parents to get the child to “reach the point of appreciating his abilities and trying to use them in the best way, and of admitting his shortcomings and trying to improve.”79 Throughout the 1940s and 1950s experts continued to stress the link between psychological troubles and physical disabilities and to champion a level-headed approach when dealing with biological deficiencies. They emphasized parents’ responsibility to teach and allow the child to be happy so he or she would grow to accept his or her somatic reality and not become a neurotic adult. Psychoanalysis caught the attention of child development experts eager to offer parents a modern way of childrearing that valued personality development and emphasized good emotional health through the feeling of security.80 The widely popular Common Sense Book of Baby and Child Care by Dr. Benjamin Spock fell into the psychoanalytical genre and also espoused the importance of personality development. Mothers and fathers were to help their children grow by making them feel safe and loved. Written in a conversational tone, the book began with the phrase “trust yourself, you know more than you think” and empowered parents, in particular mothers, by reminding them of their natural talent to nurture without usurping the expert role pediatricians played in childrearing.81 Spock’s approach was extremely traditional in that it encouraged mothers to respect and rely on a pediatrician’s authority in children’s health. He stated, “don’t be afraid to trust your own common sense. Bringing up your child won’t be a complicated job if you take it easy, trust your own instincts, and follow the directions your doctor gives you.”82 First released in 1946, Common Sense quickly became a best seller by 1950, with over a million copies sold annually.83 Its whirlwind popularity might have had something to do with new moms looking for new parenting techniques. In post-World War II America, what historian Elaine Tyler May has called “family fever” swept the United States. Women and men were getting married and becoming parents at a

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younger age than their own parents.84 According to historian Rima Apple, many young mothers found words of wisdom in The Common Sense Book of Baby and Child Care and praised Spock’s efforts to help them in dealing with the challenges of parenthood, even writing laudatory letters about the doctor to the Children’s Bureau.85 While less is known about how Spock’s doctrine was received by men, Common Sense spoke about how both parents should deal with biological abnormalities. Spock’s set of guidelines for parenting children who were biologically different—including short-statured boys— privileged patience and acceptance. Parents were advised not to overcompensate for any deficiencies and to teach their children to accept their own bodies. Although he acknowledged “a defect quite naturally upsets the parents to some degree,” he still suggested that parents must “treat him naturally.”86 This psychoanalytical approach encouraged parents not to overreact to a physical disability for fear the child might develop a complex. In Spock’s view, a parent’s failure to accept a child’s biological abnormality had disastrous effects on that child’s emotional health. He illuminated the importance of parents being accepting of their children’s “handicaps” in an example highlighting how a mother and father influenced their short son’s self-perception. The story featured a ten-year-old boy who was shorter than his eight-year-old sister. According to Spock, the parents saw this vertical difference as “a real tragedy,” and took their son to a series of doctors who agreed that their the boy was short for no pathological reason. The parents overreacted by making their son eat more, shielding him from his true stature in relation to his sister or other boys, and reminding him of his intelligence.87 Instead of accepting his height and addressing his short stature directly, the parents projected how devastated they were about their son’s height. Spock suggested, “there is enough rivalry among boys so that an individual who is short feels some disappointment, anyway. But the two factors that made the biggest difference were the boy’s general happiness and self-confidence, and how easily the parents accepted his shortness.”88 Spock also cautioned concerned parents about blaming a son’s short stature on a glandular disturbance. He suggested, “some people who have read popular articles on glands assume that every short person, every slow pupil, ever nervous girl, every fat boy with small genitals, is merely a glandular problem who can be cured by the proper tablet or injection. This enthusiasm is not justified by what is known scientifically at the present time.”89 Even though Spock was correct to advise parents to be skeptical about

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available therapies, scientists—backed by pharmaceutical companies—were close to a breakthrough that would make the glandular myth a reality in the case of GH.

Effective Human Growth Hormone Therapy The 1950s saw a flurry of drug company-backed research dedicated to making a viable growth hormone preparation. Pharmaceutical companies—including Parke, Davis, Eli Lilly, Armour Laboratories, and Merck Sharp and Dohme—supported leading researchers in the field, in particular Maurice Raben from Tufts University, Choh Li from University of California (Berkeley and San Francisco), Alfred Wilhelmi from Emory University, and Ernst Knobil from Harvard University.90 The corporate backing these researchers received was neither unique nor exclusive to growth hormone research. For example, Dr. Li was granted $25,000 by Merck for his work on ACTH and so-called “other hormones,” while also receiving support from Eli Lilly for his research on GH.91 In the case of growth hormone, because corporations and academic scientists were motivated to figure out why the therapy yielded inconsistent results, their mutual interests facilitated collaborations similar to the ones that had characterized the 1930s and 1940s.92 These relationships were bolstered by additional funding from newly established federal agencies, including the National Institute of Arthritis and Metabolic Diseases, leading to progress in GH research during this time period. In part, this had to do with new and better procedures in crystallizing GH that were developed by Wilhelmi and Raben, in 1948 and 1951 respectively.93 With more of the hormone to go around, researchers examined the metabolic effects of beef and pig GH on man in order to determine if they indeed activated growth. Initial findings were mixed and interpreted in various ways.94 For example, when researchers at Johns Hopkins reported on the failure of beef GH to promote consistently specific metabolic changes in patients, they suggested that it “may be the result of improper dosage, the development of an allergic state,” or “a species peculiarity.”95 As the data continued to be inconclusive, scientists turned their attention to other types of GH, namely human and monkey. Researchers obtained human pituitaries from local pathologists and monkey pituitaries from pharmaceutical companies engaged in the poliomyelitis vaccine program. Drug companies, including Parke, Davis, Eli Lilly, Pitman-Moore and Co., Wyeth Laboratories, and Merck Sharp and Dohme, possessed left-over simian

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pituitaries and distributed them to scientists—including Knobil, Wilhelmi, and Li—per their requests.96 Their research yielded positive results and supported the speculation that GH was species specific. With Eli Lilly backing his research, Li wrote an article for Science in 1956 elaborating this theory. “Preparation and Properties of Growth Hormone from Human and Monkey Pituitary Glands” postulated that beef growth hormone had failed to work in humans because it was chemically and physically different from the one found in men.97 More specifically, Li suggested that while various growth hormones have similar cores their outer parts were different, accounting for previous inconsistencies in GH therapy. Other scientists agreed. In fact, Knobil had presented a paper earlier that year at the thirty-eighth meeting of the Endocrine Society detailing the possibility of GH’s species specificity. Titled “Some Physiologic Effects of Primate Pituitary Growth-Hormone Preparations in the Hypophysectomized Rhesus Monkey,” the paper demonstrated a marked difference in monkeys’ responses to various growth hormones, although it did not explain why this was the case.98 These experiments using human and simian growth hormones facilitated a better understanding of the biochemistry of GH in general. After species specificity was established, researchers embarked on developing effective human growth hormone therapy. In the United States alone, several clinical trials took place during the late 1950s. In 1958 scientists began reporting their positive results. One of the first reports was presented in June of that year at the Endocrine Society’s annual meeting, as a team of scientists led by Philip H. Henneman from Massachusetts General Hospital and Harvard Medical School detailed the prolonged administration of Human Growth Hormone in three patients with panhypopituitarism.99 The next report came later in the summer of 1958, when Choh Li informed attendees of the Conference on Chemical Organization of Cells of his successful therapeutic use of HGH on a patient whose pituitary was still intact. Li collaborated with John Hutchings, Roberto Escamilla, and William Deamer on this study; the human subject was an eleven-year-old girl whose growth had been compromised by a prolonged infection at six months of age. She had first been seen at the University of California Medical Center in San Francisco in 1955, when she was eight-and-a-half years old. She was diagnosed with “pituitary dwarfism secondary to encephalitis,” with “mild residual optic atrophy.” At first no treatment was given to her; subsequently, physicians placed her on a thyrotropic hormone.100 For the study, she was readmitted in 1957 and treated with human growth hormone for

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nine months.101 Very quickly after treatment began, she started to grow and experienced metabolic changes, leading researchers to believe that human growth hormone was the causative agent.102 While at the time Henneman and Li received much attention for their work, they were quickly overshadowed by Maurice Raben who, on March 10, 1958, submitted a letter to the editor of the Journal of Clinical Endocrinology and Metabolism that documented his effective clinical application of HGH. On August 1, just three weeks before Li’s presentation and a little over a month after the Endocrine Society’s annual meeting, the journal published the letter with the title “Treatment of a Pituitary Dwarf with Human Growth Hormone.”103 Based on his ongoing work with pituitary dwarfs at the New England Center Hospital, Raben used the epistolary medium to publicize the first successful clinical case of HGH therapy. He reported that, after ten months of human growth hormone therapy, a seventeen-year-old male pituitary dwarf had grown 2.1 inches in height.104 Raben was able to establish that HGH was indeed the causative agent for his growth by documenting that the boy’s “levels of serum inorganic phosphorus and alkaline phosphatase” were similar “to values characteristic for growing children,” and that side effects often associated with testosterone therapy—including advance in bone age or signs of growth associated with puberty—were not reported.105 These success stories ushered in a new era in growth hormone therapy, as cadaver-HGH replaced testosterone as the drug of choice for treating short stature. Even though clinicians no longer had to rely solely on testosterone to promote growth in underdeveloped children, growth-promoting hormone therapy continued to harbor a firm gender bias. Boys remained targets for GH therapy, as gendered growth charts, diagnoses, and treatments framed the medical tendency to treat short-statured children along gender lines as they had done before. At the same time, psychoanalysis continued to make inroads in the field of child development, in particular child psychology, which further underlined the hardships of being small. As evidence from experts mounted, parents continued to worry about their sons’ short stature. But now medicine offered them a possible cure: cHGH. And with the availability of theoretically limitless supplies—made possible by the extraction of pituitaries at autopsy—the future of treating short boys in the hopes of making them tall appeared bright.

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On August 22, 1965, the cover of the Parade Magazine section of The San Diego Union featured a smiling boy with the tagline “THIS BOY IS A DWARF” together with a declaration in its banner claiming “WE CAN END DWARFISM!”1 Journalist Lloyd Shearer reported on cover boy Harold Riley as one of the lucky “little people” being “treated with human growth hormone.”2 A junior in high school, Harold had “top grade” health and intelligence but was only four-foot-five, even after having grown more than five inches in the last two years due to the “miracle hormone” cHGH.3 Harold’s treatment had begun after his mother first noticed that his clothing size had not changed in years. Concerned, she took him to physician after physician, until a pediatrician finally diagnosed him with growth hormone deficiency. The pediatrician referred Harold to a doctor who had a friend who worked at the National Institutes of Health. The insider was able to connect the Riley family with a medical expert who had access to human growth hormone for the purposes of clinical research from the NIH-affiliated National Pituitary Agency. Once treatment began, Harold experienced a two-year growth spurt. According to the article, an avoidable limited supply of HGH had hindered the treatment of children like Harold. Shearer argued that unfettered access to a bountiful supply of HGH could cure the estimated 10,000 children in the United States whose “height-shortage was caused by a dysfunction of the pituitary gland.” Contemporary therapy often experienced a series of abrupt stops due to unnecessary HGH shortages, as in the case of Harold. In the article, Mrs. Riley expressed her frustration over the sporadic supply: “if we can just get a steady supply of it, he stands a very good chance of growing another eight, ten, maybe twelve inches. Whenever I get a supply from the agency, I give him the shot myself . . . Harold is so close to making five feet, I just know he will. There’s nothing I wouldn’t do to normalize his life.”4

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The Parade Magazine human-interest story gave readers hope and dispensed advice on how they too could help needy short children by willing their own pituitary glands to the NPA and encouraging friends and relatives to do the same. Readers were also encouraged to volunteer to work with pathologists in their local neighborhood hospitals in soliciting pituitary gland contributions. The article pointed out that approximately 1,500,000 people had died in 1964, yet only 50,000 pituitaries were collected. Shearer pleaded with his readers to donate, stating, “if you can, won’t you please help, especially before it’s too late, and the bones of some undersized boy or girl have fused, forcing the poor child into a life of hellish dwarfism.”5 In addition, the Parade article demonstrates that the success of HGH therapy for growth hormone deficiency was measured by vertical inches gained. A large photo of Harold standing between two boys aged fourteen and seventeen respectively displayed both Harold’s success and his need for further treatment. The article also says much about cultural beliefs regarding the adversity brought on by short stature. In order to encourage readers to donate their pituitary glands, Shearer emphasized the “waves of anger, pain, and supersensitivity of a child who is not like other children” and other hardships of being small.6 Unlike the period between the 1920s and early 1940s (when pituitary extracts featuring GH were abundantly available) and the early 1950s (when physicians preferred to treat short stature with testosterone), the era of clinical-grade cadaver human growth hormone that began in 1958 experienced limited supply despite theoretically bountiful resources. In their campaign for the harvesting of pituitary glands during this time period, promoters and practitioners played into cultural fears of short stature. They did so by drawing on a growing body of scholarship documenting the disabling nature of short stature. During the 1960s and 1970s child psychologists confirmed that short stature had a damaging effect on children’s school performance and self-identity; at the same time, sociologists honed in on the discrimination short adult men faced in the United States. In turn, journalists repackaged the findings from these studies as a type of collective common knowledge regarding the hardships confronting short-statured boys and men. As psychologists, sociologists, and journalists continued to substantiate and articulate cultural concerns over stature through studies and ever more precise terminology, the category of short stature received scientific clarity when the federal government funded and spearheaded the creation

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of a unitary set of growth charts for infants, toddlers, children, and teens. The 1977 National Center for Health Statistics (NCHS) growth charts were to serve as public health instruments and diagnostic tools for nearly thirty years. As new standards further defined shortness and slow growth in children and as evidence proving the negative consequences of short stature was mounting, HGH therapy seemed to be the only way to save small individuals from a life of “hellish dwarfism.” This chapter sheds light on the synergy between the availability of effective HGH therapy, the creation of national growth standards, sociologists’ increased interest in heightism in America, and the upsurge of child psychologists’ concern over short stature in childhood from the early 1960s to the early 1980s. It also examines the beginnings of the human growth hormone market in the United States and the ways in which the social stigmatization of short stature framed this development. The chapter concludes by considering the implications of the Creutzfeldt-Jakob disease outbreak linked to cadaver human growth hormone therapy in 1985 and of the FDA approval of the first synthetic human growth hormone product (Genentech’s Protropin) on the making of the HGH industry. It does so by exploring the availability of treatment, messages in pharmaceutical advertisements, consumer outreach strategies employed by companies, and concerns over therapy before and after 1985. While the existing literature addresses various elements of human growth hormone therapy during the cadaver growth hormone era, it undervalues how developments during this time period influenced the contemporary HGH industry and overemphasizes the revolutionary impact of Protropin by suggesting that cHGH’s demise was due to the FDA approval of the new drug. The literature either focuses on the making of the deadly version of HGH produced by the NPA or concentrates on how Protropin remedied the short supply of the cadaver hormone, a problem which had historically plagued HGH therapy in the United States, (even though the shortage had been alleviated before Protropin was made available).7 However, if one looks at this period from the vantage point of the 1950s, a different picture emerges. By 1960 many medical experts assumed that while it was difficult to access, a cure had been found for the short stature caused by growth hormone deficiency. It was at this time that the quest to synthesize HGH and a public relations campaign persuading people to contribute to the supply began. Medical experts played into pre-existing

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Figure 13. A portrait of a therapy recipient of cadaver human growth hormone, Lloyd Shearer, “We Can End Dwarfism!” San Diego Union, Parade Magazine August 22, 1965, cover, MSS 72, Box 13, Folder 1, Mandeville Special Collections Library, University of California, San Diego. Courtesy of Athlon Media Group.

cultural notions of masculinity and its relationship to stature in order to encourage people to consider posthumously donating their pituitary glands. In short, those engaged in curing short children believed that modern medicine could and should end dwarfism and undertook vigorous steps to ensure that this dream became reality.

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Figure 14. In the article, “We Can End Dwarfism!” the National Pituitary Agency’s donation card was featured with the caption “Copy of simple will form issued by National Pituitary Agency. You or your relative can make a contribution to science.” San Diego Union, Parade Magazine August 22, 1965, cover, MSS 72, Box 13, Folder 1, Mandeville Special Collections Library, University of California, San Diego. Courtesy of Athlon Media Group.

The National Pituitary Agency Although mainstream media and scientific journals reported on cases of successful cHGH therapy during the late 1950s, pediatric endocrinologists and medical researchers struggled to provide patients with treatment and laboratories with enough product for research because human growth hormone was difficult to collect and required an expensive purification process. Few institutions had the funds, personnel, or facilities to purify growth hormone for clinical therapy or research.8 Laboratory researchers and clinicians had to personally request cHGH from those who had the means to prepare it and were required to collect the pituitary glands on their own.9 While each phase of the process of producing clinical-grade or research-grade HGH posed a host of problems, the collection of glands

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was the most unpredictable stage because “growth hormone was available only through individual arrangements” between practitioners and pathologists.10 Dr. Solomon Kaplan, a pioneer pediatric endocrinologist, later remarked that the process was “haphazard” and often provided only “limited amounts of growth hormone to treat the vast number of patients available and in need of this beneficial treatment.”11 Instead of working in the lab or treating patients, Kaplan had to spend time reminding pathologists of his request, sending them pre-paid mailing containers, and placing follow-up calls to make sure they were sending the glands.12 Collection efforts were complicated even further as some researchers chose not to provide others access to their inventories and “private entrepreneurs” vied for a portion of the reserves.13 For example, Dr. Choh Hao Li, who was then the director of the Hormone Research Laboratory at University of California in Berkeley and later in San Francisco, “always had a group of West Coast hospitals collecting fresh frozen glands for him” and gained a reputation for not sharing.14 Although Li had lost the race in publishing the first article detailing effective human growth hormone therapy, he began collecting human pituitaries during the late 1950s and established the first pituitary bank in the United States in 1960.15 The bank’s goal was to streamline the collection process; throughout the 1960s and 1970s it collected pituitaries for basic research and clinical care from hospitals in the San Francisco Bay Area and from “foreign sources,” including hospitals in “Hong Kong, Manila, Mexico City, and Panama City.”16 While Li’s bank was exceptional in scope, it was not the only such enterprise in the United States during the early years of the cHGH era. But with no standard procedure for procuring glands and not enough to go around, the collection of human growth hormone became downright “chaotic” by the early 1960s.17 Concerns about the development of a black market and frustration over a lack of available hormone plagued cHGH therapy. Medical experts most active in basic and clinical research involving pituitary hormones held meetings sponsored by the NIH to swap techniques for extraction, share research results, and discuss the possibility of creating a nationwide agency. In 1962 a group of these experts decided to join efforts to coordinate pituitary collection, extraction of hormone, and hormone use. Doctors Alfred Wilhelmi of Emory University, Robert Blizzard of Johns Hopkins University, Cho Hi Li of University of California, San Francisco, Maurice Raben of Tufts University, and Mr. Morris Graff from the National Institute of Arthritis,

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Metabolism, and Digestive Diseases (NIAMDD) created the National Pituitary Agency.18 Receiving contract support from NIAMDD and backing from the College of American Pathologists, the NPA standardized the collection, production, distribution, and use of human growth hormone in the United States and Canada from 1963 to 1985.19 At each stage of this process, emphasis was placed on the exclusivity of cHGH, which inadvertently universalized the notion that cHGH availability was limited and treatment was selective. The NPA developed its own standards for the collection, storage and shipment of human growth hormone. The agency’s director Robert Blizzard and its Medical Advisory Board created plans to deliver cHGH therapy to patients through clinical investigations.20 Meanwhile, the organization orchestrated an outreach campaign combining a minimal financial reward ($2 per pituitary gland) with an emphasis on the clinical use of cHGH on hypopituitary dwarfs to encourage pathologists to retrieve human pituitary glands at autopsies.21 Twice a year during the 1970s the chair of the NPA wrote an appeal letter emphasizing how pathologists’ efforts in gland harvesting would help dwarfed children.22 For example, the 1973 letter from NPA chair Dr. Salvatore Raiti remarked how the increased number of glands translated into more children treated and thanked the pathologists for a job well done on behalf of “the hypopituitary dwarfs of the United States.”23 Parents of growth-hormone-deficient children also helped in the collection of pituitary glands. During the twenty-eight (1958-1985) years of cadaver human growth hormone therapy, it took anywhere between fifty and two hundred extracts from human pituitary glands to provide one child with a year of treatment. Parents of potential candidates for the therapy scrambled to help clinical researchers—serving in effect as their HGH providers—in order to secure enough supply for their own children.24 In 1965 a group of these parents came together and created Human Growth Inc., which was later renamed the Human Growth Foundation (HGF).25 Their goals were to provide a support system for families, educate the public on growth and development, keep current on the scholarship of human growth hormone therapy and the psychological impact of short stature on children, and help increase the supply. Members encouraged local hospitals, pathologists, and friends to donate pituitaries for the cause and participated in a national hand-delivery service. Delivery was facilitated by two of the founders of HGF, Fred and Gwen Mahler. The Mahlers worked for Trans World Airlines and were able to persuade their employer to provide its planes for the rounding

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up and delivery of glands to the NPA.26 During the 1960s and 1970s Human Growth Foundation chapters sprouted up across the country, their members joining the ranks of volunteers transporting glands. Their efforts were invaluable to the collection of the pituitaries, as HGF members routinely collected batches of glands from morgues and then stored them in their personal refrigerators until they were able to ship them in special containers to the National Pituitary Agency.27 Once glands were accumulated, they were collected, processed, and distributed by one of four NPA affiliated laboratories—Dr. A. Wilhemi’s lab at Emory, Dr. Maurice Raben’s lab at Tufts University and the New England Medical Center, and Dr. B. B. Saxena’s lab at Cornell University in New York City.28 While Li’s pituitary bank did distribute human growth hormone, it did not do so through the NPA. Not all of the labs working with the NPA extracted HGH from pituitary glands throughout the entire duration of the cadaver human growth hormone program, with Wilhelmi’s lab being the most productive. It was common practice to pool glands and make batches of cHGH, with little recording of the origins of the glands and of the final destination of the batches. The hormone was extracted from the pituitary glands and reconstituted into a powder. Hyland Laboratory in Costa Mesa, California, carried out the vialing of HGH for clinical use.29 Since there was no standard method for creating the preparation, each procedure yielded different grades of cHGH. Wilhelmi’s procedure produced preparations with considerable physicochemical heterogeneity.30 The variety of storage techniques added to this problem, as some were preserved in acetone, embalmed, or frozen with dry ice. While the use of fresh frozen glands would have yielded more growth hormone and physiochemical homogeneity, the National Pituitary Agency worried that a restriction placed on the type of storage would “seriously complicate the collection process.”31 With various processes and preserves in play, NPA-cHGH varied in biological potency and number of antibodies. All NPA growth hormone preparations were antigenic (antibody producing), and more than half of the patients treated with them for eighteen months or longer developed antibodies that bound to the cHGH. While some pediatric endocrinologists who received clinical grade cHGH from the NPA further processed the contents of their preparations, official accounts indicated that the number of patients who became resistant to NPA-cHGH was relatively small.32 In fact, initial reports estimated that only 5 percent of NPA patients had developed such a high number of antibodies that the HGH was neutralized.33 Wilhelmi also

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responded to researchers’ dismay over the purity of his product by claiming that antibodies could be found in most human growth hormone recipients regardless of what preparation the GH had gone through. Technically, he was correct. Yet the most popular method in Europe—the Roos Method— did not yield the same high rate of antibodies as Wilhelmi’s. Wilhelmi continued to use his own method for nearly fifteen years, and his version of cHGH was distributed throughout North America and the world. Finally, in December 1976, shortly before he retired, he changed to the Roos method— which included an important step in purification known as gel filtration— and the NPA as a whole moved away from embalmed glands since they yielded little to no viable HGH.34 After Wilhelmi retired, the process moved from Emory to the University of California, Los Angeles and was placed under the supervision of Dr. Albert Parlow. Changes in procedure and in the selection of glands were more important than anyone had predicted. In 1978, two years after the Roos method was adopted, Wayne V. Moore and Paula Leppert—pediatric endocrinologists at the University of Kansas Medical Center and themselves past recipients of NPA-cHGH—wrote an article in the Journal of Clinical Endocrinology and Metabolism claiming that NPA-cHGH contained only about 30 percent effective growth hormone, which meant that 70 percent of the drug given to children probably did not help augment growth. While Moore and Leppert’s report questioned the potency of the administered HGH, it also raised the question of what else was lurking in the injections. In fact, the drug contained some amount of unidentified material, which in some batches turned out to be deadly. The contents of some of NPA-cHGH included prions, folded brain proteins that cause Creutzfeld-Jakob Disease. They do so by causing normal proteins located nearby to misfold and poke holes in the brain, causing rapid mental deterioration. While the incubation period can last up until thirty years, CJD is always fatal.35 According to the National Endocrine and Metabolic Diseases Information Services, all of the twenty-nine cases of CJD caused by NPA-cHGH in the United States were linked to batches produced before 1977.36 For decades, the government agencies, pharmaceutical companies, and pediatric endocrinologists distributed that administered cadaver HGH to children were unaware of the potential dangers. Most of the cHGH distributed by the National Pituitary Agency went to “investigative therapy.”37 Researchers had to apply for batches of cHGH, even if they themselves were producing and distributing it through the NPA. The application included

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a description of the project and human subjects involved. It also allowed applicants to request which laboratory they would like their HGH to come from. Two subcommittees reviewed these applications and recommended those they found worthy to the director.38 While projects varied in scope and content, many focused on treating growth hormone deficient children for their short stature. Getting cleared for treatment was no easy task. While provocation tests for HGH deficiency evolved between the 1960s and 1980s, they often required hospitalization, the repeated drawing of blood, a risky hypoglycemic state, and yielded inconsistent results. In the meantime, if a child’s growth curve flattened, the physician was advised to consider a series of diseases and disorders including GH deficiency. In 1963 a new chemical method emerged to determine a child’s HGH levels. Children suspected of GHD were placed in a hypoglycemic state and their HGH levels were tested.39 This type of testing was risky and involved hospitalization. Sometimes the patients would vomit or go into extreme hypoglycemia requiring the administration of glucose. In the end, the blood tests often yielded false positives, as some children with normal growth hormone levels failed to respond to stimuli. Throughout the 1960s, 1970s and early 1980s other stimulants, such as estrogen, exercise, sleep, glucagon, and propanol were administered to encourage a release of growth hormone, all with varied results.40 Although a blood test result verifying a growth hormone deficiency brought a child one step closer to therapy, a determination of normal growth hormone levels was not necessarily exclusionary. Clinical studies and availability of cHGH played major roles in access to therapy. Children volunteered to serve as human subjects in clinical research in order to receive cHGH therapy. For the most part, the study lasted as long or longer than the therapy required, such as the National Collaborative Growth Hormone Treatment Project, which took place for more than ten years. While other clinical research endeavors were more short-lived, the end of these studies did not mean children were no longer treated for their GHD. Those who had served as subjects were allowed to continue to take cHGH as long as the hormone was available and they met the height requirments.41 They received cHGH from the NPA, free of charge, for eight months of each year following the study until they reached five feet.42 The five feet rule stayed in effect until the early 1980s.43 Once the supply of cadaver human growth hormone reached a non-critical state, this termination measurement was recalibrated. Boys were allowed to receive NPA-cHGH

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until they were five-foot-six, while girls were denied treatment once they reached five-foot-four.44 While this type of gender-specific guideline restricting girls’ access to cHGH was new to the NPA-HGH program, it spoke to a long-standing gendered approach to treating abnormal height in pediatrics. Cultural notions of masculinity and femininity had played roles in pediatric endocrinology’s approach to treating growth irregularities since its inception. Short boys were understood as the intended targets of growth-promoting hormone therapy, while tall girls faced possible growth-halting treatment, namely, estrogen therapy. During the 1960s and 1970s pediatric endocrinologists measured lengthy girls’ skeletal ages, predicted their end heights, consulted parents, and administered estrogen to promote rapid epiphyseal fusion, which would stop growth prematurely and help curb the supposed anxiety the girls endured due to their stature. This practice of halting tall girls’ growth was not seriously questioned by specialists until the early 1980s, when controversy grew over the inconsistency of estrogen therapy.45 A deeper analysis of the effect of heteronormativity and societal gendered expectations on decision-making in estrogen therapy did not occur among pediatric endocrinologists. For these specialists, the problem was medical and not cultural.46

Public Service Announcements, Growth Hormone, and Disabling Short Stature “Hellish dwarfism,” “painful life,” “bombarded with taunts”—depictions of the disabling nature of short stature were a staple of human-interest stories serving as public service announcements to raise awareness of human growth hormone therapy during the cHGH era.47 The information campaign in large part had to do with a new need to locate growth hormone that could be made available for future use. During the era of cadaver human growth hormone therapy, clinical-grade cHGH was highly sought after, and stories about puny white boys who had been responsive to therapy bolstered pleas to the public to donate one’s pituitary gland to the cause. The campaign included press reports evoking disability as a compelling argument for care. They depicted sufferers (mostly boys) of short stature who were facing a life of doom if they were unable to receive treatment.48 For example, in a 1966 Los Angeles Times article, journalist Walter Alvarez reported on the horrors of short stature: “Obviously, a lad who is only four feet tall is going to be terribly handicapped and unhappy for the rest of his life, and

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hence everything possible should be done to make him grow as he should.”49 Sometimes the disabling nature of short stature was understood as more immediate, as in the case of fourteen-year-old Erick Carstensen. His story was featured in a May 7, 1973, Time magazine article titled “Helping the Little People,” according to which the youth felt alienated from other students who excluded him from games. Furthermore, he was discriminated against by teachers who mockingly called him “shorty” and harassed “him for his inability to keep up with his classmates in physical education.”50 Short stature was also depicted as a perpetual disability in a 1978 Chicago Tribune article titled “Hormone Means Life is Looking Up for Short People.” In it, journalist Robert Steinbrook elaborated on the hardships of the short-statured boy as thus: “At school he is bombarded with taunts of shrimp, small fry, midget, and dwarf.”51 Steinbrook also predicted his bleak future, suggesting that he will lead “a painful life as a loner, fraught with incredible anxieties about sex and success at work or school.”52 These stories were intended to convey to readers how terrible it was to be short, and stressed that medicine could save those children whose disability was caused by growth hormone deficiency. If only they could be given they opportunity! Holding up GHD boys as poster children for growth hormone therapy, press reports like these quantified their cure in vertical inches, contributing to the understanding that short stature was a disability that could be corrected through added height. In short, growth hormone therapy worked because it enabled boys to grow taller. Greater height meant increased happiness, improvement of performance at school, and general normalcy. For example, in a 1966 article titled “Their Hope Grows by the Yardstick,” journalist Carolyn Lewis conveyed the benefits of growth hormone therapy by interviewing a father of a boy in treatment. The man reported on his son’s progress by stating, “his face just lights up whenever he learns he has grown an eighth of an inch.”53 The power of height was also evoked in the disability narrative of Virgil Anderson, Jr., a young man who received cHGH therapy under the care of Dr. Willard Vanderlaan, head of the Division of Endocrinology at Scripps Clinic of La Jolla in San Diego. Before treatment, Virgil was four-foot-four at age fifteen. His peers and adults taunted him, calling him nicknames like “shorty”; as a result, the teenager “was pretty unhappy with himself.”54 During therapy, Virgil grew eleven inches. By the time he turned twenty-two, it was argued that his life had changed because he was bigger. As journalist Leo Bowler suggested, at five feet three, Virgil was “a happy,

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productive man” who worked alongside his father as an operator of an aluminum shingle-manufacturing machine.55 According to this and other coverage, Virgil owed his joy and success to the cHGH he had received at Scripps Clinic, with one journalist quoting him as saying, “I would never have been able to make anything of myself without Dr. VanderLaan’s help.”56 Far from of exposing the flawed nature of cultural perceptions of height, the media reporting on growth hormone therapy referred to cHGH recipients as lucky individuals because they had a treatable form of short stature and were able to overcome discrimination through the donations of others’ pituitary glands. While these anecdotal stories of tragedy and promise promoted the medical correction of the body in the name of social acceptance and peace of mind, child psychologists were busy investigating the psychosocial impact of being small. Their research brought short stature’s etiology still further away from disease and closer to disability.

Psychologists Weigh In Initial findings from research in the field of child psychology revealed that short-statured children tended to act immaturely, suffered from poor self-esteem, and struggled at school. Unlike Alfred Adler—who had suggested that short children suffered from an inferiority complex based on his clinical observations—child psychologists tried to substantiate this through empirical scientific data demonstrating the psychological hardships brought on by being short. Their research focused on children and adolescents and aimed to identify the causes and the extent of the problems short children faced. Research into the psychologically disabling nature of short stature grew in the 1960s in parallel to the development of effective human growth hormone therapy. Sometimes these two scientific endeavors directly inspired one another. At Johns Hopkins University, Ernesto Pollitt and John Money saw the hospital’s new pediatric growth study (which included cHGH therapy) as an opportunity to conduct a longitudinal psychological study of small statured children. In 1964 they began publishing their findings about the psycho-social impact of short stature in order to later assess whether “physical benefits from growth treatment” corrected character flaws that were linked to short height.57 Based on their observations of seventeen children, Pollitt and Money reported that small stature was indeed a disability. They argued that it negatively impacted school performance, interpersonal relationships, and overall personality and furthermore that all of these

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hardships were interrelated.58 For example, short children seemed to be more interested in social acceptance than academic performance, and their quest to fit in with their peers interfered with their schoolwork.59 Pollitt and Money also suggested that short stature compromised the relationship between parent and child, especially when the parent babied the child. The dysfunctional relationship often produced a delayed “psychomaturation” and “personality disturbances.”60 The study’s findings went on to frame subsequent scholarship as researchers drew similar conclusions about short stature’s impact on “social competence, behavioral problems, self-esteem, and family functioning.”61 As evidence mounted indicating the hardships of being short, child psychologists also examined growth hormone deficiency. Throughout the 1970s and 1980s studies were conducted to examine a possible causal relationship between GHD, personality disorders, and learning disabilities. A study conducted by H. C. Steinhousen and Nikolaus Stahnke of Children’s Hospital at the University of Hamburg aimed to tease out the endocrinological component of negative personality traits they witnessed in small children and adolescents. Steinhousen and Stahnke found that these children were “less aggressive,” “less excitable,” “less conscientious,” “more tender-minded,” and “less shrewd” than their normal peers.62 Upon further investigation, these scientists concluded that the observed flaws were due to the children’s stature and not to GHD. It was their scientific opinion that the disability (short stature), and not the disease (GHD), was the medical problem.63 In fact, some studies demonstrated that short stature with no pathological origin was the most debilitating of all. In a September 1982 Journal of Pediatrics article, Dr. Michael Gordon, the lead investigator at the departments of psychiatry and pediatrics of the State University Hospital at the Upstate Medical Center in New York, reported on a study of twenty boys and four girls with constitutional short stature (CSS). The findings suggested that children with CSS had significantly more behavior problems and less self-esteem than a matched control group with normal height. These findings were in contrast to recent evaluations of children with growth hormone deficiency. Investigators postulated that children with CSS were more frustrated with being short because they did not know why they were short, while the GHD children understood the cause of their short stature, received medical care for it at top-notch universities, and remained hopeful that they would grow taller.64 By the mid-1980s the prevailing view in child psychology and pediatrics

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was that short stature, regardless of cause, was disabling. As Deborah Young-Hyman of University of Maryland Medical School remarked in 1986, “the psychological literature concerning short-statured children is remarkable in that, with few exceptions, the conclusion is that shortness is a handicapping condition. This conclusion has led to an extensive effort by pediatric endocrinologists to seek effective forms of treatment, and has motivated mental health professionals to study these children.”65 Even in an article that questioned how detrimental being small was for “short normal children,” the hegemonic notion of the disabling nature of short stature was not refuted.66 The Human Growth Foundation played a role not only in research conducted on the ill effects of short stature but also in studies on the benefits of HGH therapy. Throughout the 1960s and 1970s the organization continued to spread nationwide; by 1982 its membership included more than six hundred families spanning seventeen chapters. The foundation held national meetings, organized local get-togethers, hosted charity events, and provided social services for members’ children. HGF’s activities spanned the spectrum from hosting Super Bowl Sunday parties to coordinating conferences.67 In 1979 the Human Growth Foundation cosponsored a symposium in Galveston, Texas, with the University of Texas Medical Branch to examine the psychosocial aspects of short stature.68 HGF parents believed that medical professionals needed to both better understand the hardships their short-statured children endured and to do what they could to help improve the supply of HGH.69 HGF was uncritical of HGH therapy and member parents worked closely with the National Pituitary Agency to keep a steady stream of HGH injections available both for their children and for scientists conducting psychological research on the perils of short stature. For example, HGF partially funded a study conducted at the State University of New York at Buffalo and Children’s Hospital of Buffalo, New York that found that if treatment began early enough in childhood—and if patients did not suffer from multiple pituitary deficits—then the problems associated with short stature could be corrected.70 Another HGF-funded study orchestrated by the University of Virginia School of Medicine and Johns Hopkins University School of Medicine claimed that HGH treatment “could be introduced in late childhood with positive psychological as well as physical benefits to many patients.”71 With this growing body of scholarship substantiating their children’s hardships, HGF members were sure they had the evidence

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they needed to convince and persuade others of the horrors of small stature and rally them to the cause of saving the unfortunate minors from needless turmoil. In combating GHD-induced short stature, pediatric endocrinologists and endocrinologists framed the history of growth hormone therapy with the understanding that this treatment focused more on saving children from short stature than from HGH deficiency. At the sixty-second Annual Meeting of the Endocrinology Society in 1980, Henry G. Friesen, a professor of medicine in the Department of Physiology at University of Manitoba, Winnipeg, presented a paper titled “A Tale of Stature” honoring the efforts of Maurice Raben. In it, he described how Raben was a pioneer in HGH therapy and had reported on the first case of effective human HGH therapy in 1958. Demonstrating the impact of this accomplishment and adding some levity to his talk, Friesben stated, “over twenty years he extracted over one and a half million U of GH which provided psychological and therapeutic benefit by adding 16,000 cm of height to all these short children. You must agree with me—that it is a giant contribution!”72 In the end, medical experts (albeit jokingly in this case), pediatric endocrinologists, journalists, child psychologists, journalists, parents, and children measured the success of HGH therapy by height gained.

Heightism: The Sociology of Stature Sociologists also explored the perils of being short, but instead of looking only at the individual, they suggested that public perception of stature was the source of troubles and discriminating practices. Heightism is the sociological term created to describe the social discrimination faced by short men and society’s preference for height. Sociologist Saul Feldman coined the term in a paper he presented at the 1971 meeting of the American Sociological Association titled “The Presentation of Shortness in Everyday Life—Height and Heightism in American Society: Toward A Sociology of Stature.”73 He argued that “American society is a society with a heightist premise: to be tall is to be good and to be short is to be stigmatized” and explored the nuances of this discrimination in language, male-female relationships, politics, economics, popular culture, and “degradation of self.”74 Drawing on the work of Erving Goffman, Fieldman demonstrated how men were most victimized by heightism in America, given the country’s

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idealized notions of masculinity. He quoted Goffman as saying that “there is only one complete unblushing male in America: a young, married, white, urban, northern, heterosexual Protestant father of college education, fully employed, of good complexion, weight, and height, and a recent record in sports.” According to Fieldman, being short was enough for a man to be “considered deviant” and less than ideal.75 Feldman’s sociology of stature intended to demonstrate the potency of physical stature in America rather than to assess the mental state of short individuals or to champion HGH therapy. Instead of blaming short people for not being able to overcome their deficits, Feldman pointed the finger at a society “directed toward overabundance and glorification of anything above average.”76 Feldman’s 1971 speech became the template for subsequent work and commentary. He argued that Americans’ disdain for shortness was pervasive and that it had seeped into our language. He cited examples: the term “short-sighted” for someone who lacked foresight; “short-tempered” applied to those with a quick tendency to get angry; “shortcoming” meaning a deficiency; “short-changed” when someone does not receive the entire amount he or she is due; and “the short end of the stick” for a situation in which someone receives the less-desirable outcome.77 For Feldman, these expressions spoke to a deep-seated discrimination against short people in America. The field of psycholinguistics took the argument even further and suggested the above-described sayings actually helped cause heightism.78 Either way, they served as evidence of a society critical of shortness. Feldman’s term encompassed a hegemonic heterosexual standard, which cast men as the most common victims of heightism. He postulated that out of the four possible stature situations, to be either a tall woman or a short man were the most limiting and linked this assessment to mate selection.79 While previous research in psychology and sociology had drawn similar conclusions, Feldman’s attachment of a term to height-based discrimination gave his analysis an effective punch, and also allowed him to reaffirm with certainty the daunting adulthood predicted for short-statured boys by child psychologists.80 Although Feldman presented his analysis as the sociology of stature, he focused exclusively on the hardships of short men. He argued, “no matter what his race, creed or financial status, the American male under 5 feet 8 inches—the height of the average American man—is a victim of discrimination.”81 He called attention to how size mattered for men in many facets of American life, including politics, making a strong argument for the role

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of height in presidential elections. In his 1971 speech Feldman pointed out that the taller candidate had won in seventeen out of nineteen presidential elections.82 This observation drew media attention and began a tradition of journalists reporting on the height of candidates during presidential races. For example, in 1976 Los Angeles Times journalists Garrison Nelson and W. Ross Brewer suggested, in this case inaccurately, that height could be a factor in the presidential election.83 Even though Jimmy Carter—the shorter candidate—won, sociologists continued to suggest that short stature compromised a candidate’s chance of being elected. In addition, Feldman suggested that the workplace, Hollywood, and sports all seemed to harbor discrimination against short men. He noted that tall men were “hired sooner, promoted faster and paid more than short men”84 and pointed to studies showing that tall men (six feet two and above) received a starting salary 12.4 percent higher than graduates from the same school who were shorter than six feet.85 Even when short men were able to beat the odds and do well in business, their success was often understood in the context of their stature. Feldman argued that “assumption of political or economic power for a tall individual is considered admirable, but let an individual of less than average stature, such as Andrew Carnegie or Fiorello H. LaGuardia, assume power and he is viewed as having a Napoleon complex.”86 Being short also hindered the careers and popularity of movie stars and athletes, Feldman observed. He reported on how short actors were often cast as villains or “buffoons,” while heroes tended to be tall.87 He also pointed out how heightism was pervasive in sports and argued that Americans favored sports that glorified height, such as basketball. When a shorter athlete was involved, as in horseracing, less attention was given to the athlete than in other sports. Feldman lambasted Americans’ refusal to follow jockeys’ careers as they did baseball players’. He pointed out that “a jockey’s face has never appeared on a bubblegum card . . . but (jockeys) do appear across the nation as plastic lawn ornaments.”88 Americans preferred tall men and the national pastimes reflected that preference. Feldman’s analysis shed light on what some considered to be invisible discrimination based on stature and exposed the problems boys would face in adulthood if they remained short. Furthermore, he postulated that because short men had silently endured barrages of insults, limited employment options, and hardships in dating throughout their lives, many of them internalized the social discrimination they faced and experienced a “degradation

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of self.”89 He suggested that they felt less in control, were hurt by the fact that others did not see them as manly, and blamed their own bodies for not measuring up to others expectations of how tall a man should be. While short stature negatively impacted men’s quality of life, self-confidence, and self-perception, the sociological discourse of heightism provided a medium and language for them to talk about it.90 Short-statured male journalists started to contribute to the growing commentary on heightism and spoke out against the mistreatment they faced in America. Instead of demanding a medical fix for their vertical realities or blaming themselves, they criticized the cultural biases pertaining to their height. During the 1970s and early 1980s the loudest voice from this pool of victims was Ralph Keyes’s. In addition to writing about heightism for various magazines, in 1980 he published Height of Your Life, which brought together a decade of his observations and analyses. The book’s tagline read, “Short or tall . . .Who’s really on top? The funny, fact-filled lowdown from salaries to sex and beyond.” In it, Keyes used a socio-biological framework to discuss the discrimination he had faced ever since he was a little boy and expounded on Feldman’s sociological interpretation of Americans’ preference for height. He claimed that the discrimination short men faced did not come from their being disabled or having an illness or disease. During the 1970s, while child psychologists were unable to come to a consensus on the long-term gain of increased height in children due to HGH therapy, the first-hand experiences of men such as Keyes and findings from sociological studies documented the pervasiveness of heightism in America and the hardships of being a short man. The heightist debate was in high gear when Randy Newman released his sixth album, Little Criminals in 1977. The first song made into a single from the album was called “Short People.” Meant to ridicule prejudice, the song’s lyrics included such lines as “Short people got no reason to live,” and “they got little noses and tiny little teeth . . . they wear platform shoes on their nasty little feet.”91 With controversial lyrics and a catchy tune, “Short People” shot up the charts, immediately inciting opposition. By early 1978 some radio stations refused to play Newman’s song, as short-statured people protested against the derogatory lyrics. This controversy made the song even more popular and, ironically, it was Randy Newman’s first song to reach number one on the charts. Newman was adamant that the true intent of “Short People” was to mock discrimination through satire and pointed to other songs from his decade-long

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career, including “Davy, the Fat Boy” and “Yellow Man,” as examples of his unique style of writing and cultural commentary.92 But it did not matter. The song continued to be misunderstood, and people publicly discussed the discrimination they thought it reflected. With titles such as “Short People Song Sets Off a Tall Furor” and “Certain Song Makes the Short People Stand Tall in Rage,” newspapers articles from the Wall Street Journal, Los Angeles Times, and Chicago Tribune reported on the opposition to the song, Newman’s intent, and its social impact. While the popularity of “Short People” provided an opportunity for people to discuss heightism, it also became its soundtrack. Carol Oppenheim reported in the Chicago Tribune that “taller youths are serenading the shorter ones with the song” at a junior high school in Manhattan as evidence of the cultural currency of “Short People.”93 Randy Newman could not override the potency of his prose, and his song provided bullies with yet another medium with which to taunt schoolyard victims about their short stature. What recourse did these harassed short children have? Their stature had made them prime targets for ridicule, which now had lyrics to go along with it. While their parents could have intervened and demanded punishment of the abusers, the victims remained defenseless in a society where to be tall was to be good and to be short was to be stigmatized. According to experts, their futures looked grim. If they remained shorter than their counterparts, they were destined to experience childhoods of continued trauma before growing into adulthoods with limited opportunities, especially if they were male. Perhaps their parents would consider taking their bullied children to the pediatrician for some guidance or treatment in order to avoid such a disastrous fate.

Federally Endorsed Growth Charts Medicine offered help for some short children with cHGH therapy but it also compounded the social reality of others when it helped the federal government create the first set of national growth charts for infants and children from birth to eighteen years of age, consisting of fourteen sex-specific tables. These diagnostic tools contributed to the pathologization of stature that did not measure up to the norms created by selective measurements. They quickly became ubiquitous fixtures in doctors’ offices across the nation and set the standard for children’s growth around the globe when the Centers of Disease Control (CDC) and the World Health Organization

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(WHO) adopted them in their efforts to monitor children’s health. In doing so, the CDC and WHO endorsed both the value of the measurements presented on the charts as normal/healthy and the medical practice of measuring children in pediatric care. The NCHS/CDC growth charts were the mechanism by which data about an individual could be compared to the population and interpreted in the context of accepted norms. Similar to earlier growth charts, they perpetuated and validated a medical sensibility of short stature, which contributed to its stigmatization at a time when there was a budding interest in its sociological and psychological impact on the quality of life, especially for males. The 1970s growth charts were developed in response to requests by both the public health sector and private medicine. In 1971 “a study group cosponsored by the American Academy of Pediatrics and the Maternal and Child Health Program, Public Health Service, and the Department of Health, Education, and Welfare (DHEW) recommended the development of national growth charts to be used for nutritional screening, public health assessments of populations of children, and clinical standards of children and infants.”94 In 1974 the National Academy of Sciences called for new growth charts to evaluate the nutritional health of America’s children and infants on a large scale. In 1975 a group sponsored by the National Institute of Child Health and Human Development made similar public health recommendations.95 By 1976 the demand for charts that would make use of new data collected and new graphing techniques fueled the development of a series of fourteen sex-specific growth charts by the National Center for Health Statistics (NCHS). They consisted of smoothed growth curves of plotted percentile points based on distributions of body size (weight, height, and head circumference) attained at specific chronological ages. The charts for children from birth to three years originated from the Fels Research Institute’s longitudinal study conducted from 1929 to 1975, while the set of charts for children two to eighteen years of age were based on data collected from Health Examination Surveys sponsored by the NCHS from 1963 to 1974.96 In both public health and private medicine, the birth to two years and adolescent charts drew the most criticism. The data for the latter charts were extremely limited, as they came from the Fels Research Institute growth study. The purpose of this study had been to examine the development of a small sample of people throughout their lives in order to get a comprehensive understanding of growth at an individual level; the researchers had

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never intended to collect massive measurements that could serve as healthy norms on charts. Consequently, the pool of subjects was small and only featured eight hundred sixty-seven middle-class, formula-fed children from white families who lived near Dayton, Ohio from 1929 to 1975. The NCHS defended its use of the numbers from the Fels study by stating, “there were no suitable alternative data for the first year of life.”97 Subsequently, this unique population served as the data for charts used throughout the world for over twenty years. Not all children lived up to the normal curves created from the Fels children’s measurements. At a public health level this could be beneficial because it suggested the need for better living conditions in impoverished areas, but the racial exclusivity of the subjects did not allow for practitioners and medical experts to rule out race-based explanations for measurements and growth trends. At a clinical level, these charts proved problematic because they reflected data from a very specific group and thereby skewed the clinician’s assessment of patients’ health. Medical experts also criticized the new adolescent charts, even though they were not based on data from the Fels Study but on more comprehensive NCHS surveys from the 1960s. British growth expert James M. Tanner was the most well-known critic of the use of the adolescent charts in private care. Co-developer of the standard five-stage clinical system for identifying normal pubertal development, Tanner claimed that the NCHS/CDC charts failed to reflect the variability of growth during adolescence because the data was based on cross-sectional measurements and not on the tracking of individuals’ growth over a long period of time.98 A leader in the field of growth and development, James Tanner was perplexed by the entire set of charts. He wondered how these diagnostic tools were going to answer the question: “What is the probability that this particular child belongs to the motley army of normal children, of so many shapes and sizes; and what is the probability that he belongs to another battalion altogether, the company of the sick?”99 The wide distribution of growth charts made possible by Ross Laboratories, one of the largest manufactures of baby formula, made matters worse in Tanner’s opinion.100 While the NCHS/CDC charts depicted average heights of children measured, they failed to authentically depict the rate of growth these young people experienced. Despite Tanner’s (and others) opposition, growth charts continued to operate as the initial diagnostic tool in determining the normalcy of a child’s growth and height and in the recommendation of growth hormone therapy. Pediatric endocrinologists recommended that physicians plot the height

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and weight of a child on a growth chart and compare his or her development to the normative curves. If a child’s growth sharply declined, stopped altogether, or appeared abnormal, then further tests were conducted; if a growth hormone deficiency was suspected, then the child would be referred to a pediatric endocrinologist, who often repeated these preliminary diagnostic tests in the quest to discover the cause of the failure to grow. A growth hormone provocation test would ultimately determine if the child was a candidate for cHGH therapy. If the child was found to be GH deficient, he might be eligible to serve as a subject for a clinical study and to receive growth hormone as long as it was available. As the “company of the sick” became more identifiable through national growth charts and growth hormone testing, medical experts and the National Pituitary Agency attempted to develop additional reserves of HGH. These efforts along with multiple professional pursuits pertaining to stature provided the perfect tableau for the next development in growth hormone therapy in the United States—the emergence of commercial cHGH.

From the Natural to Synthetic—The Rise of Commercial HGH in the United States The introduction of commercial cadaver human growth hormone into the US pharmaceutical market was an uneventful one. On July 30, 1976, the Food and Drug Administration approved two cadaver human growth hormone products—Serono’s Asellacrin 2 and 10—for the treatment of growth hormone deficiency.101 Serono was a pharmaceutical company based in Italy and was second to Sweden’s pharmaceutical giant, Kabi, in the European cHGH market. While one would expect Serono to try to quickly make inroads into the untapped American market in order to get a leg up on any commercial competition (especially from its rival), advertisements for Asellacrin did not appear in US medical journals until the 1980s. The same was true for Kabi’s Crescormon. Approved by the FDA on April, 6, 1979, Crescormon entered the market with little fanfare, although this lackluster approach on Kabi’s part might have had more to do with its collaboration with Genentech than with an unmotivated marketing department.102 San Francisco-based Genentech, Inc., was the first biotech start-up and the brainchild of Herbert Boyer (a professor in microbiology and biochemistry at University of California San Francisco (UCSF)) and Robert Swanson, a venture capitalist. Shortly after Genentech was founded in 1976 Boyer and

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his lab collaborated on DNA research with two Southern California scientists, Arthur Riggs and Keiichi Itakura, at the City of Hope National Medical Center near Los Angeles. Their goal was to create a gene not found in nature but able to act like the one whose design it copied. After a year of experiments and research, their efforts gave birth to the biotech industry. Using somatostatin (a human protein known also known as the growth-hormone-inhibiting hormone) as their muse, these scientists transformed the microorganism E. Coli bacterium into a functional, replicating protein generator.103 Although Genentech’s somatostatin was not bound for market, it caught the attention of Kabi Pharmaceutical’s Director of Research Hans Sievertsson. In 1977 Sievertsson visited San Francisco to meet Boyer and Swanson, and on August 1, 1978, Kabi and Genentech entered into an agreement over the development and distribution of a synthetic human growth hormone product. The contract gave Genentech two-and-a-half years to genetically engineer a bacterium capable of producing HGH. In order to reach this goal, Kabi provided Genetech’s scientists with human pituitary material, collaborators, and $1 million. In return, Kabi received exclusive foreign marketing rights and shared rights with Genentech in the United States.104 This contract not only signaled a pending change to the human growth hormone industry, according to historian Nicolas Rasmussen it also suggests that Genentech had no intention of marketing its product.105 But this does not mean that Genentech was not in a hurry to replicate HGH; it was. Fierce competition with Eli Lilly-backed rival scientists at UCSF had heated up by the summer of 1979. Both UCSF and Genentech claimed they had synthesized human growth hormone.106 It was difficult to tell which group of scientists was going to claim victory, in part because their announcements regarding scientific strides were framed by for-profit motives.107 Still, by late 1979 it looked as if Genentech had won out when it filed for a patent on its human growth hormone Protropin and renegotiated its contact with Kabi in order to have sole control over the US market.108 Kabi continued to have a presence in San Francisco and Genentech until mid-1980, when it moved the processing of its synthetic HGH to Sweden. But this is not to say that it left the US market. In 1981 Kabi began running ads in the Journal of Pediatrics and Journal of Clinical Endocrinology and Metabolism for its cadaver based human growth hormone, Crescormon. With Genentech in the early stages of FDA approval for Protropin, Kabi was competing with only one other commercial product—Ascellacrin—and the

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National Pituitary Agency’s cHGH. Kabi’s ads decidedly focused on competition with the latter with the taglines: “Now you can prescribe Somatropin. . . . We set the standard, you judge the need.”109 Even though a recent change in the NPA’s processing of pituitary glands allowed more cHGH to be yielded to such an extent that the agency announced the hormone’s availability for conducting research on its “use for burns, bleeding peptic ulcers, and other metabolic or clinical states,” physicians still had to fill out paperwork and receive the agency’s approval before receiving the product.110 Kabi hoped its ads would encourage pediatricians and clinical endocrinologists to forego the bureaucracy and choose Crescormon instead. At the same time, Serono also started advertising Ascellacrin in the Journal of Pediatrics and the Journal of Clinical Endocrinology and Metabolism. The reoccurring ad for Ascellacrin appealed to physicians by addressing the needs of both the doctor and the patient. While it spoke to the physician through its tag line (“The Miracle of Growth: When growth depends on Somatropin replacement, you can depend on Serono”), the majority of the ad featured the intended upper-class consumer of cHGH therapy—the prepubescent, white, affluent boy wanting to be taller. White, young, and not fully developed, the boy was full of linear promise, which could only be realized with the help of Asellacrin.111 The ads conflated notions of growth and height and provided a gendered and racialized perception of the presumptive patient and in doing so capitalized on the two decades of press materials created around cHGH therapy, findings from child psychologists about the hardships of short stature, and parental anxieties over heightism. Serono also advertised the potential use of Ascellacrin through another of its products: a diagnostic service to predict height. Ads for Serono’s Theoretical Growth Evaluation (TGE) featured a young prepubescent white boy wearing a man’s dressy shoes.112 Marketing for TGE used the familiar rhetoric of growth and development and the growth chart genre to provide pediatricians with height predictions for their patients. Serono’s evaluation service was different from the other more traditional medical examinations that featured measuring: it was personalized, used more measurements, and was technologically more advanced in its composition. TGE marketing also stressed the need for early diagnosis, the availability of cHGH treatment, and the promise of height. Running repeatedly in medical journals, Asellacrin and TGE advertisements made growth hormone therapy synonymous with treating short white boys in the hopes of making them taller.113 Genentech also started running ads for its HGH product in the early

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1980s. The first such ad ran in 1983 and was three pages in length. The first page remarked, “Soon. Very soon . . .” and featured a large image, part of a computer-generated-looking sphere. The following two-page spread kept the words and visuals to a minimum. The sphere was more complete and on the top of the sphere was an outline of a person. The tag line read, “The new era in human growth hormone. From Genentech Inc. The world leader in biotechnology.”114 Serono directly and indirectly responded to Genentech’s ad campaign by sponsoring psychologists researching short statured children and emphasizing the naturalness of Asellacrin in its advertising. In 1984 it collaborated with the Human Growth Foundation in organizing an October symposium in Washington, DC on the psychosocial aspects of growth delay and sponsored the publication of papers presented at the conference. While the conference did not directly promote HGH therapy, it did provide a venue for experts in the field of child psychology to share their findings about the impact of short stature in children.115 Meanwhile, the new marketing campaign for Asellacrin appeared in The Journal of Clinical Endocrinology and Metabolism, rebranding the product as “the natural human growth hormone.” This renaming made Asellacrin appear safer and more reliable than its ostensible competitor as it reflected concerns over biotech-based pharmaceuticals. The advertisements also made use of the mother-son vignette to demonstrate the subcutaneous injections that were now being used to administer Asellacrin. To depict the ease of this new delivery system, the center of the advertisement featured a mother kneeling down and injecting her son with HGH. Natural, effective, and easy to use, Asellacrin seemed to meet all of the needs of the intended user. Through its efforts with psychologists and new ad campaign, Serono appeared poised to compete against Genentech’s unnatural hormone product. Serono’s efforts failed. Shortly after the new marketing for Asellacrin was launched, it came to a crashing halt. In the spring of 1985 cHGH was connected to cases of Creutzfeldt–Jakob disease in children. An incurable and fatal brain disease that was extremely rare in young adults, CJD was found in three patients who had undergone growth hormone therapy. In light of these cases, the FDA pulled commercial cHGH from the market, and the NPA halted its human growth hormone program. Journalists seized on the story and openly cast doubt on the advisability of treating short stature in the first place. The public had been wrongly assured of the safety of cadaver-based human growth hormone, with devastating results.116

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While the FDA halted the distribution of natural HGH indefinitely, it did reconsider its stance on Genentech’s HGH product. The agency had had some concerns about allergic reactions reported during Protropin’s human trials but, given the CJD crisis, it allowed Genentech to send shipments of the growth hormone to hospital pharmacies and gave Protropin formal approval in October 1985. The FDA also designated Protropin as an “orphan drug” specifically designed to treat rare medical conditions, which gave Genentech an apparent seven-year monopoly on the market and qualified the company for generous tax credits.117

The New Era in Human Growth Hormone, from Genentech, Inc. The new era in human growth hormone ushered in by Genentech was less revolutionary than the existing literature would suggest, especially when it came to accessibility and advertising. In fact, the marketing of growth hormone therapy stayed relatively the same. Genentech’s advertising for Protropin harkened back to previous marketing techniques used by Serono—which had relied upon decades-long scholarship in child psychology and sociology—and played on the fears and aspirations of a long-standing growth hormone industry. Protropin’s ad was innovative in its technical approach as a five-page spread printed on heavy grey stock with rich color graphics, but the content of the campaign resembled past human growth hormone advertisements as it included boys as its intended patients, emphasized the science behind its product, and addressed supply issues. The front page of the ad featured the portrait of a blue-eyed, blond-haired young white boy superimposed onto a landscape image of a large evergreen tree meant to symbolize growth. The caption read “Out of today’s technology, tomorrow’s growth.” To the left of the word “Protropin” was an outline of a person serving as an arrow pointing up—a clear allusion to the relationship between height and growth. While the boy served as an eye-catching, almost mascot-like image, inside the ad was a small picture of three white children—two boys and one girl—in an attempt to represent the diversity of potential patients. Genentech also used Protropin’s ad to discuss the supply of rHGH, but unlike past public relations campaigns and commercial advertisements, it touted “virtual endless quantities . . . for every child who needs it—or will ever need it.”118 At the same time, access to HGH remained elusive for

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many. Even though physicians no longer had to go through an application process in order to treat a patient with the hormone, treatment was still exclusive due to its price. Asellarcin and Crescormon had already set a precedent for the price of commercial HGH: a year’s supply of these medications cost between $9,000 and $20,000.119 Genentech’s pricing followed suit. One year of treatment cost from $15,000 to $20,000.120 Although most insurance companies would cover therapy for GHD, the high price tag made the treatment inaccessible to uninsured children from middle- and working-class families. In addition, short children not diagnosed with GHD would be denied coverage due to FDA regulations. Still, after a yearlong marketing campaign, sales for Protropin reached $43.6 million.121 During its first year, Protropin definitely benefited from its marketing campaign and orphan status. However, the situation unexpectedly changed in 1987, when Eli Lilly received FDA approval for its Human Growth Hormone product, Humatrope. The Lilly-backed scientists at UCSF had conducted successful clinical trials of their product in late 1985 and filed for a new drug application with the FDA in 1986. It was speculated that Humatrope would be a fierce rival to Protropin since it was an exact duplicate of human growth hormone and Protropin was not. Because of Protropin’s orphan drug status, Genentech understood it had a monopoly on the HGH market and tried to stop Lilly from competing with Protropin by suing the FDA over its approval of Humatrope, but the tactic failed. In 1987 Humatrope was approved on schedule and was also granted the prized orphan drug designation.122

Conclusion As the biotech era of human growth hormone therapy took off, journalists ceased the opportunity to comment on the changing ethical landscape of treating short stature and urge caution against the over use of recombinant Human Growth Hormone (rHGH). Some suggested rHGH might be ushering in a “Brave New World” where “cosmetic endocrinology” could enhance a child’s quality of life and reported on how parents had “already begun to besiege doctors to prescribe the hormone for kids who ultimately will be only slightly shorter than normal or even of average height.”123 Journalist Russell Baker cautioned his readers about rHGH’s potential in his article titled “Think Twice About Growth, Dads and Lads.” Baker warned, “with the powerful growth hormone coming onto the scene, it’s anybody’s guess what

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the social effects will be. We are not talking about a few gracefully muscled 7-footers . . . but about hordes of 400-pound giants, people who have had themselves artificially enlarged in hopes of cleaning up financially in athletic careers.”124 Reporters also related stories from pediatric endocrinologists about parents desiring HGH therapy for their sons so that the latter could be super fit and successful. Pediatric endocrinologist Rebecca Kirkland remarked to journalist Sandra Blakeslee that “one man said his son would be a better attorney if his was taller.”125 Journalists evoked these types of reports as examples of the ruthless nature of using the drug for the sole purpose of giving boys an advantage. For twenty years, media surrounding HGH therapy stressed the need to treat GHD boys in order to save them from short stature. Once the treatment became theoretically available to any short child, there was a backlash against its potential overuse. Speculation and criticism surrounding HGH’s potential to treat other somatic deviations followed quickly. Just one year after the FDA’s approval of Protropin, journalist Gina Kolata reported that HGH’s potential new markets included weight management and anti-aging.126 As her informant Barry Sherman of Genentech commented, “there aren’t that many short kids to treat.”127 By the mid-1980s HGH had become a symbol of the promise and danger of biotechnology, as it was identified as both a cure for short stature due to GHD and as the promulgator of cosmetic endocrinology. Either way, it continued to promote society’s heightened expectations for fantastically similar bodies collectively serving as the definition of a normal and healthy corporeality.

Epilogue A Billion Dollar Industry

Today, human growth hormone fuels a billion dollar industry. There are over a dozen different growth hormone products offered by a handful of pharmaceutical companies competing for a share of the global market, which reached almost $2 billion between 2006 and 2007.1 A wide range of people beyond short-statured children seek out human growth hormone, including those who want to stop the aging process, professional athletes looking for a performance advantage, and bodybuilders in search of increased muscle mass. There is a widely held belief that illicit distribution of HGH comprises the lion’s share of the market, as non-FDA approved (or what is called off-label) human growth hormone therapy has been linked by purveyors to increased energy, better skin, thicker hair, improved sleep patterns, and weight loss.2 Readily available on websites and from physicians willing to prescribe it for such uses, HGH is seen as a magical cure for an assortment of ailments, from bad skin to a weak golf swing. Many Americans became familiar with the illegal use of HGH by athletes in 2005 when Congress held hearings on steroid use in Major League Baseball. Beginning in March of that year, the House Government Reform Committee called a series of elite players—including Mark McGwire and Roger Clemens—to testify about doping in baseball. Some of Major League Baseball’s most revered players admitted to using steroids, others remained silent, while a few denied the allegations. The Committee and Major League Baseball’s Commissioner appointed former Senator George Mitchell to lead the investigation of steroid use in this professional sport. The Mitchell report was released in 2006; it named names and argued that everyone involved in baseball “shared to some extent responsibility for the steroids era.”3 Major League Baseball responded to the crisis by cracking down on players’ drug use even as the hearings were ongoing, implementing stricter

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mandatory drug testing and explicitly prohibiting specific performance enhancing drugs, including HGH, in 2005.4 While some observers considered the hearings to be a success, others questioned Congress’s motives and insinuated that government officials had simply created an opportunity to grandstand.5 Committee members vigorously refuted this accusation. Representative Henry A. Waxman, lead Democrat on the Committee, believed strongly in Congress’s responsibility to investigate drug use in baseball because of a possible link between athletes taking performance-enhancing drugs and the rise in the use of steroids among children. Republicans shared his concerns. Committee Chairman, Republican Tom Davis, elaborated that “kids aren’t just talking about their favorite teams’ chances in the pennant race. They are talking about which pro players are on the juice.”6 Members of the Congressional Committee also referenced data from the 2003 Centers for Disease Control’s “National Youth Risk Behavior Survey,” which estimated that 6.1 percent of children—or 500,000 American teens—were using steroids. Committee members criticized baseball heroes for contributing to this alarming trend.7 Members of Congress recognized teen steroid use as a serious matter, because experts were suggesting a connection between the cessation of taking steroids and suicide.8 Three young men—Efrain Marrero, Taylor Hooton, and Rob Garibaldi—were the subjects of particular media interest as they took their own lives shortly after they had stopped using steroids. The latter two boys’ stories caught the attention of committee members because the victims had been baseball players; their parents were asked to testify during the hearings.9 Hooton and Garibaldi’s parents saw a direct link between their children’s deaths and the out-of-control atmosphere in Major League Baseball. The mother of Rob Garibaldi, Dr. Denise Garibaldi, testified to Congress that professional baseball had killed her son. She argued, “there’s no doubt in our minds that steroids killed our son. In his mind he did what baseball heroes like [Jose] Canseco had done.”10 While human growth hormone was not directly incriminated in these suicide stories, it was often lumped into the catch phrases “steroids” and “performing-enhancing drugs,” all terms that were used throughout the hearings. Although the extent of doping in major league baseball was difficult for the Committee to determine, these personal stories evidenced a strong causal link between professional baseball players’ steroid use and the suicides of these American boys who strove to be as strong as their heroes.

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Gender Disparity in HGH Therapy Even after the Congressional hearings, small boys with dreams of being taller remained the bread and butter of the legitimate human growth hormone industry. In the 2000s the gender disparity in growth hormone treatment was examined in a study sponsored by the National Institutes of Health. A 2008 Journal of Clinical Endocrinology and Metabolism article reported on its findings, which documented gender-based patterns in pediatric recombinant human growth hormone therapy in the United States and other countries. The project was led by Dr. Adda Grimberg, a pediatrician at Children’s Hospital of Philadelphia. By using an already existing database acquired by Pfizer to document the long-term outcomes and safety of its HGH product, Genotropin, Grimberg and her team concluded that over the past twenty years the United States had experienced an almost two to one male to female ratio in pediatric patients receiving human growth hormone therapy and that boys outnumbered girls even more so in cases without “a clear organ etiology.”11 The global results revealed similar gender ratios in Japan, Europe, Australia, and New Zealand, which led Grimberg to conclude that “factors other than biology are at play” when children were treated for short stature.12 She alluded to patients’ parents as possible culprits and recommended that the gender divide in HGH care be corrected by increased diligence in diagnosing and treating girls with growth stunting conditions and by further considering the possible over-treatment of boys.13 Were parents really to blame? The history of growth hormone therapy demonstrates that they were not. Medical attempts to compensate for men’s shortcomings have deep roots in America. In the case of short stature, pharmaceutical companies have been able to capitalize on the condition’s longstanding stigmatization by society and its perceived pathologization by medicine. During the first half of the twentieth century, the scientific turn in medicine was characterized by a technological bent, which made pharmaceutical fixes seem not only appropriate but also preferred. Growth hormone became a viable weapon against bullying and a tactic to save young boys from unfulfilled adulthoods. As advances in medicine made it easier to alter an individual’s height to more culturally acceptable norms, little attention was given to changing society’s stature bias. Although pharmaceutical companies cannot be cast as the sole culprits in framing short stature as a disease, they have perpetuated and profited

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from the stereotypes of short men and have pumped millions of dollars into research solidifying short stature’s stigmatization and pathologization. In addition, pharmaceutical companies have plugged into longstanding medical traditions and protocols that endorse the correction of short stature in small boys by funding pediatric and psychological research at universities, making inroads into and funding existing volunteer organizations dedicated to promoting growth hormone therapy and growth disorders awareness, and fueling parental concerns over stature.

Finding Consumers for HGH As this book demonstrates, the burgeoning field of child psychology enabled pharmaceutical companies to legitimize the prescribing of human growth hormone in order to make short children taller. Indeed, forty years of research in the field suggested “that short statured children experienced more interpersonal anxiety, have greater sensitivity to their interpersonal environment, are often socially immature and have poor relations with peers.”14 Some research indicated that medically-induced height helped children overcome these psychosocial disorders. Even when reports in the 1990s questioned HGH’s ability to affect children’s final heights, several child psychologists argued that the growth spurt it often did facilitate was therapeutic in itself.15 These types of findings have created a synergy between child psychologists’ research and pharmaceutical companies’ financial endeavors. Prominent leader in research on the impact of stature in childhood child psychologist Dr. Brian Stabler of the University of North Carolina has worked closely with human growth hormone manufacturers throughout his career, and his research often supports the benefits of HGH therapy. Stabler’s findings have pointed not just to the benefits of being taller but also to the hormone replacement quality of HGH therapy, even in cases where a deficiency was undetermined. His hypothesis of the existence of a psychological disorder related to GH deficiency has led him to recommend HGH therapy beyond the growing stage period for children.16 In Stabler’s world, more—and not less—growth hormone needs to be prescribed. Not all experts agree with this approach. Beginning in the 1990s researchers began questioning previous conclusions about short stature’s negative impact on boys’ quality of life.17 What they found was that while some short boys were teased and unable to play certain sports this did not mean they developed psychological disorders. In addition, when it came to the realities

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of dating and finding employment, short men did not experience the level of discrimination that some of the previous studies had suggested.18 The new research also demonstrated that “no rigorously designed studies provide evidence demonstrating that GH treatment leads to improved psychosocial adaptation in individuals with . . . ISS.”19 Along with their findings, these researchers championed therapy for families struggling with accepting a member’s short stature and specifically cautioned against the use of rHGH in cases of ISS, as data were scant as to the long-term health risks that might be associated with this treatment.20 The above findings, however, face a less-than-receptive society, one in which the notion that short stature is a negative trait is deeply engrained. As this book has demonstrated, Americans have been told about the perils of short stature by reformers, scientists, short male journalists, educators, physicians, public service announcements, and pharmaceutical advertisements. In addition, less overt marketing campaigns have also affected public opinion about short stature. For example, beginning in the 1980s pharmaceutical companies became active in volunteer organizations dedicated to issues related to HGH therapy and short stature. Genentech, Eli Lilly, and Caremark (a distributor of human growth hormone) footed the bill for height screenings organized by the Human Growth Foundation.21 As a non-profit organization, HGF and its efforts are, on the surface, philanthropic rather than profit-driven, and companies engaged in the selling of human growth hormone have benefited from its volunteer health screenings and drives to educate the public about growth, growth disorders, and treatment. These companies have understood that their consumer base will grow as more people become aware of growth problems and their solutions. Even into the twenty-first century, HGF and other voluntary, non-profit organizations focusing on growth disorders continue to receive corporate funding from the pharmaceutical industry, as their volunteer efforts, websites, and support of medical research dovetail neatly with corporate interests. Pharmaceutical companies have also treated growth surveys in schools as prime opportunities to sell HGH directly to consumers. During the 1980s and 1990s Genentech played a role in school screening programs in North Carolina and Georgia. In North Carolina, it funded screening programs for the Charlotte Mecklenburg School System orchestrated by Susan Parker, a pediatric nurse, Genentech consultant, and wife of a pediatric endocrinologist. Like school nurses during the early twentieth century, Parker measured children and charted their growth. If they had two disappointing

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measurements, she would send the child’s parents a referral letter with an attached growth chart. The letter suggested that the parents seek additional medical counsel about their child’s short stature. The program in Georgia worked in a similar fashion. Genentech gained access to a school screening program in Atlanta by working with the local Human Growth Foundation chapter in training physical education teachers how to measure children. The company supplied free charts and equipment to those conducting the surveys. As was the case in North Carolina, children who didn’t measure up were sent home with a form letter recommending that their parents contact the HGF or a pediatrician about their child’s small stature. During the early 1990s Genentech’s work with schools caught the attention of the federal government. When Genentech’s spokesperson James Weiss was questioned about his company’s use of growth survey projects in schools, he argued that the screening effort was “a public health benefit to kids.”22 Although Weiss’s assessment seems artificially altruistic, school administrators had been championing health examinations in schools as a public good since the early twentieth century, and Genentech had simply extended the service to facilitate the treatment of short children with human growth hormone. Nevertheless, not everyone agreed with the appropriateness of Genentech’s tactics.

A New Red Line Surveys like the ones in North Carolina and Georgia depended on growth charts against which to measure normal and abnormal height; without these charts, there would be no averages to assess a child’s growth. The ability of charts to define a child’s height as abnormal and unhealthy has not gone unnoticed by pharmaceutical companies. During the past thirty years, they have used growth charts in marketing campaigns because of the diagnostic role they play in uncovering growth disorders, their assistance in legitimating the prescription of human growth hormone, and their cultural currency. Their value continued to grow during the 1990s, when pediatricians started prescribing HGH for children who had stature debilitating diseases but not growth hormone deficiency. And then grew again when the FDA’s Endocrinologic and Metabolic Drugs Advisory Committee decided to consider Eli Lilly’s rHGH product, Humatrope, for treating idiopathic short stature in 2003. At a meeting held by the FDA committee to consider the approval of

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Humatrope, representatives from Eli Lilly, pediatric endocrinologists, and other medical specialists championed the drug by providing a “rationale for treatment” and making claims about its efficacy and safety.23 GH expert Raymond Hintz from Stanford University argued that children who fell below the minus-two standard deviation score in height should not be denied treatment just because medicine had failed to link their short stature to a disease. He also noted that in cases of GHD or other FDA-approved conditions for rHGH therapy, short stature and/or growth hormone had been the focus of treatment and not the disease.24 The Committee also heard testimony advocating for Humatrope’s approval in cases of ISS during an Open Public Hearing. Anecdotal stories served as evidence documenting the perils of short stature and the curative promise of human growth hormone therapy. The hearing kicked off with a letter addressed to the committee from the “Short Child Family.” It highlighted the personal story of fifteen-year-old Bradley—who experienced a boost of self-esteem once he began rHGH therapy—and concluded with a parental plea for the FDA not to take this opportunity to grow away from him.25 Next, the committee considered a letter from the Human Growth Foundation. In it, HGF’s executive director, Patricia Costa, explained how in cases where physicians were unable to identify a cause for a child’s short stature, parents “have dual concerns: their child’s short stature, and their child’s self-esteem that is plummeting.”26 Costa argued for FDA approval of Humatrope for these children because it would be nothing short of a lifesaver.27 Individuals who had been successfully treated with HGH also testified. For example, Deno Andrews began his testimony on his knees in order to demonstrate how short he had been when he was prescribed cHGH (he would have been two inches shorter than on his knees). Andrews called himself lucky because his smallness was due to GHD, which made him eligible for treatment during the cadaver human growth hormone era. He reported on his tragic pre-cHGH days as a child and on the ways in which short stature negatively impacted his personality and school performance. Andrews also unequivocally championed FDA approval of Humatrope for use in cases of ISS.28 He concluded his testimony by quoting his mother, the founder of the Magic Foundation for Children’s Growth: “Please remember, before you make your decision, that children have only a short time to grow, and a lifetime to live with the results.”29 In the end, the FDA granted Eli Lilly approval for the use of Humatrope in cases of ISS.30 Since

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then, a child is officially a viable HGH consumer if his growth curve falls to or below the 1.2 percentile even if he produces adequate amounts of the hormone. As the prescribing of HGH has become less dependent on the diagnosing of a disease or biological dysfunction, a child’s measurements and the healthy norms portrayed on growth charts have become key components of initiating therapy.31 Human growth hormone advertising in the twenty-first century has reflected the added value of growth charts in determining potential consumers of HGH. The 2003 FDA approval of Humatrope, coupled with the 2000 revamping of the National Center for Health Sciences/Centers for Disease Control growth charts, created a prime opportunity for Eli Lilly to directly advertise its growth hormone product for idiopathic short stature to consumers, even though the FDA strongly urged Eli Lilly not to take this approach. The NCHS/CDC charts were a reconfiguration of the 1970s growth charts and included two new curves, the third and ninety-seventh, which were intended to “facilitate plotting data for children at extremes of the distribution,” an addition which must have pleased most human growth hormone manufacturers.32 In 2003 Eli Lilly published and distributed its own version of the charts, which were identical to the official version except for a bright red-lined curve at the 1.2 percentile to highlight the point at which the FDA permitted Humatrope to be prescribed for idiopathic short stature.33 This red line not only drew attention to the FDA’s approval but also to its proximity to the new third percentile. Lilly’s red line and the third percentile curve provided the borders of a danger zone of short stature, a zone that represented higher measurements in boys than in girls as the charts remained sex-specific.34 Parents would see that their child failed to make it to a normal percentile and would perhaps consider ways to help their son or daughter. Other pharmaceutical companies used a more synthetic approach. In 2011 Genentech’s website for Nutropin featured a growth chart tool. The website suggested that “the most widely used growth charts are created by measuring many boys and girls and breaking the range of their heights and weights into percentiles by age. To check your child’s growth percentile, enter his or her sex, age, and height on the growth chart below and press ‘Show Growth Chart.’”35 After inputting the data, a little black square representing the patient appeared on a height chart with a rainbow in the center. Each color of the rainbow pertained to certain percentile ranges, with light blue corresponding to the highest percentile spectrum and red serving as

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the color for the fifth to tenth percentile range. There was no reference to the origin of the chart; the medium of the chart itself gave the assessment meaning. The fact that most parents mistakenly believe they know how to read and interpret their child’s growth using growth charts contributes to these diagnostic tools’ usefulness in the marketing of HGH. In 2007 a study was conducted to assess parental knowledge and understanding of growth charts. Of those surveyed, 79 percent had seen a chart before, 98 percent of those had seen it in a doctor’s or nurse’s office, 64 percent thought it was important to be shown a growth chart to see how their child is growing, and 40 percent needed to see their child’s growth chart as confirmation of their health care provider’s interpretation of the state of their child’s health. Yet, when given a multiple-choice quiz, 77 percent of the surveyed parents incorrectly interpreted the charts.36 One source of misinterpretation had to do with the perception of percentiles. Since their invention by Francis Galton in the 1880s, percentiles have been used as the basis of most growth charts and standards. Although medical experts often refer to standard deviations when discussing height, physicians and growth studies experts have favored using percentiles over standard deviations to explain growth and development to parents because they assume percentiles are easier to understand. According to a well-known growth studies expert, “a parent who is told his child’s height is at the 10th percentile understands readily: 10 per cent of normal healthy children are shorter than his child. But the equivalent statement that the child’s height lies 1.28 standard deviations below the mean is incomprehensible, and has to be translated by a doctor equipped with both tables and understanding.”37 However, parental comprehension of percentiles is more tenuous than one would expect from such an assessment. Of those parents surveyed in 2007, 96 percent had heard the term percentile but only slightly more than half (56 percent) could define it.38

The Hardships of Heightism The pathologization of short stature, coupled with the perceived social stigmatization faced by short men, has perpetuated a manufactured desire for HGH therapy. Even as organizations such as Little People of America and the National Association of Short Adults have come out against HGH therapy and championed the end of discrimination based on height, personal

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testimonies from short male adults intended to document unfair treatment and inspire the halt of such behavior continue to serve as cautionary tales of being a short adult male. While personal commentaries by short men about heightism date back to the 1970s, this unexpected minority found a new voice in the mids-1990s. In 1995 the Economist ran an oft-cited article by Jonathan Rauch titled “Short Guys Finish Last: The World’s Most Enduring Form of Discrimination.”39 Reminiscent of Ralph Keyes’s popular discourse on heightism, Rauch argued “studies confirm that short men are judged, and even judge themselves, negatively. Several surveys have found that short men feel less comfortable in social settings and are less happy with their bodies. Short men are paid less than taller men, they have a tougher time winning in electoral politics and in finding a heterosexual partner.”40 Rauch presented the discrimination faced by short-statured adult men as a consequence of socially constructed barriers and not as a result of being too short. Documentaries, books, articles, and web pages have continued the ongoing dialogue about the discrimination that short-statured male adults face and the failures of society to accept them as men. It is their testimony that continues to give credence to heightism in America and serves as public service announcements for short boys worrying about their futures. The hardships of heightism do not seem exclusive to short men; short boys share similar war stories, at least according to popular media. In 2006 a USA Today article ran with the headline “The Debate is Growing: Is being short a disability?”41 In order to demonstrate the difficulties children of short stature face, journalist Rita Rubin began her article by sharing with readers a beginning-of-the-school-year to-do list from the Davies, parents of a son with short stature. Their list addressed the needs of their son Spencer as he entered kindergarten a few years before the article’s publication, and included items such as “check height of school toilets” in addition to the more stereotypical “get backpack.”42 According to Rubin, the boy’s parents feared that the facilities in the school restrooms would mirror those in other public places, and that Spencer’s height would prevent him from accessing the toilets without assistance. Their anxiety subsided after an inspection of the school bathroom revealed that the toilets were smaller than average. The article continued to document the trials and tribulations the Davies family, which included strangers commenting on his height without provocation. It got so bad, according to Rubin, that the parents placed their son on human growth hormone when he was six-and-a-half years old, even though clinical tests had not determined an organic cause for his short stature. At

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first, the family’s insurance would not cover the treatment because Spencer’s short stature could not be linked to a growth hormone deficiency and was not technically considered a disability requiring medical therapy, but this decision was reversed after an outside review board ruled in the family’s favor. Later in the article, the journalist reported on the success of Spencer’s therapy by using cultural indicators of success: he was four foot one at age eleven, a straight A student and a top-ranked wrestler.43 The continuous social and physical struggles Spencer faced, the family’s long fight in getting their insurance to cover his therapy, and the journalist’s selection of benchmarks used to document successful medical treatment spoke to how both short stature and disability were understood in the 2000s. Short stature was still seen as a shortcoming, even in children, and disability worked as an administrative category that opened the door to financial assistance, even after it had been slammed shut by an insurance agency. Spencer’s parents’ decision to claim a disability identity for their son no doubt came from the high cost of human growth hormone therapy. Treatment involves a series of daily shots of HGH given over several years. In the 2000s a month’s supply could cost anywhere between $2,000 to $5,000. On average, children like Spencer (diagnosed with idiopathic short stature) could expect to take human growth hormone for at least 5.3 years in order to gain 1.6 to 2.4 inches in adult height.44 Based on these calculations, denied coverage would have cost Spencer’s parents at lease $126,000.45 The fact that the Davies won their long fight against an insurance company is important. Even after the Food and Drug Administration approved the use of HGH for ISS in 2003, the top four health insurers in the United States—UnitedHealth Group, Kaiser Foundation Group, Wellpoint Inc. Group, Aetna Group—did not consider it either a disease or a functionally limiting impairment, and many plans excluded coverage for short stature not caused by “a diagnosed medical condition.”46 In fact, in 2015 the Human Growth Foundation featured on its website a “mini primer” on how to prepare an appeal of denial of insurance coverage, stating that if an appeal is unable to substantiate growth hormone deficiency as the cause for short stature, then it will likely be denied.47 While the USA Today article did not go into specifics of the Davies’s appeal, perhaps the lawyer for Spencer’s parents tried to meet the Social Security Administration’s (SSA) definition of disability for children. In 2015 the SSA asserted that in order for a child to be eligible for supplemental security

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income disability benefits, he or she must have “a physical or mental condition(s) that very seriously limits his or her activities; and the condition(s) must have lasted, or be expected to last, at least 1 year or result in death.”48 With Spencer’s diagnosis of ISS, the lawyer would have had a difficult time meeting the criteria set forth by this definition. While the SSA identified growth impairment in childhood as sometimes debilitating and/or a symptom of an undiagnosed disease, it did not consider short stature itself as “a medically determinable impairment.”49 Furthermore, when familial short stature could be established, as was possible in Spencer’s case since both of his parents were short, then short stature was understood neither as an impairment nor as a sign of an undiagnosed disease.50 Perhaps the Davies and their lawyer consulted a representative who dealt with denied claims or sought out assistance from a state-level bureau regulating health care plans and overseeing external appeals.51 As of 2015 Genentech and Eli Lilly offered free consultation and medicine for those who were struggling with their insurance companies. In addition, some states have created agencies to help patients in need. Since 2001 disgruntled consumers in California can file a complaint with the state’s Department of Managed Care’s Independent Medical Review if they have been denied a health care service or treatment. An Independent Medical Review (IMR) is conducted, after which a decision is made as to whether the department will uphold the health plan’s decision or overturn it. As of January 2015, out of the 226 cases of rHGH therapy for patients birth to eighteen filed with the California’s IMR, 107 have been overturned. Out of these overturned decisions, forty-nine patients were diagnosed with ISS as defined by the FDA.52 As California’s IMR seems open to approving the treatment of ISS with rHGH and has overturned cases based on a patient’s ability to meet the FDA’s criteria, correcting short stature remains the target of care and the debate about whether this medical fix is necessary persists. The symbiotic relationship between human growth hormone therapy and the pathologization of short stature has persisted into the 2010s. In 2012 Genentech’s website for its human growth hormone product Nutropin included an educational pamphlet for the potential consumer. The tagline from Nutropin’s advertising campaign “Growing Opportunity” appears throughout the booklet highlighting a boy’s successful HGH therapy. The pamphlet’s cover features a young man looking into the mirror at his former, younger, shorter self while being fitted by a tailor for a suit. The tailor is measuring the length of his suit coat to reinforce the notion that the

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young man has gained inches due to Nutropin. While his back faces the reader on the front cover, the pamphlet’s back cover features the boy looking straight ahead, smiling and straightening his tie. The label copy suggests that Nutropin could be “helping you strive toward your growth potential,” just like the well-dressed white young teenager. A mother’s wish for her son to grow tall is also depicted in this campaign. A variation of the pamphlet’s cover photo appeared on the Nutropin’s website. In this case, the image included the boy’s mother leaning on the mirror and smiling at the new, taller version of her son.53 This two-year advertising campaign for Nutropin was not unique. Throughout the twentieth and twenty-first centuries, educational pamphlets from pharmaceutical companies as well as federally produced growth charts, public health material, reports on psychosocial fears, and depictions of parental desires, simultaneously substantiated the perceived hardships brought on by short stature and touted the promise of growth-promoting hormone therapy. Since its inception, the human growth hormone industry has thrived on the manufactured heightened expectations of small boys who wish to be taller and on the widely held belief that medicine can help them.

Coda

Shortly after Heightened Expectations went to press, findings from a study suggesting that people who had received cadaver-based Human Growth Hormone (cHGH) and died of Creutzfeldt-Jakob Disease (CJD) also developed amyloid-ß (Aß) deposits in the brain were published in Nature and received wide attention. Aß deposits are considered pathological traits of Alzheimer’s disease and in these cases were probably caused by Aß seeds present in the cHGH extracts. These findings have led some researchers to suggest that Alzheimer’s—a neurodegenerative disease like CJD—could be transmissible. While future experiments to test this theory of transmission are required and their findings are not yet known, surviving cHGH recipients must now face the real possibility of being at high-risk for developing Alzheimer’s.1

Notes

Introduction 1. “The Nutropinville Kids,” Genentech, Inc., accessed December 17, 2008, http:// www.nutropin.com/pdf/13898_gene_ntrpnvlle_fa4.pdf. 2. Ibid. 3. David G. Orloff (director of the Division of Metabolic and Endocrine Drug Products, Office of Drug Evaluation II, Center for Drug Evaluation and Research) to Pat Harada of Genentech, Inc. regarding a labeling revision approval of Nutropin for long-term treatment of Idiopathic Short Stature, Application number NDA 19- 676/S020, S-021, June 28, 2005, Food and Drug Administration, accessed May 20, 2012, http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2005/019676s020,021_ rel2_ltr.pdf. 4. Leona Cuttler et al., “Short Stature and Growth Hormone Therapy: A National Study of Physician Recommendation Patterns,” Journal of the American Medical Association 276, no. 7 (August 21, 1996): 532–534. 5. Leona Cuttler and J.B. Silvers, “Growth Hormone and Health Policy,” Journal of Clinical Endocrinology and Metabolism 95, no. 7 (July 1, 2010): 3150. 6. “Human Growth Hormone Therapy for Children and Adults—Nutropin’s website: Where are YOU in your Growth Hormone JOURNEY?” Genentech, Inc., accessed August 20, 2012, http://www.nutropin.com/index.jsp. This campaign has been replaced as of January 1, 2015. 7. Saul D. Feldman, “The Presentation of Shortness in Everyday Life—Height and Heightism in American Society: Toward a Sociology of Stature,” (paper, 1971 meeting of the American Sociological Association), box 17, folder 5, Records of the Sociology Department, Case Western Reserve University Archives, 3LZ, Cleveland, Ohio. 8. Gilles Deleuze and Félix Guattari, Anti-Oedipus: Capitalism and Schizophrenia (Minneapolis: University of Minnesota Press, 1983). 9. Georges Canguilhem, The Normal and the Pathological (New York: Zone Books, 1989). 10. Charles Rosenberg, “Framing Disease: Illness, Society, and History,” in

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Framing Disease: Studies in Cultural History, ed. Charles Rosenberg and Janet Golden (New Brunswick: Rutgers University Press, 1997), xxi–xxvi. 11. Beth Linker, “On the Borderland of Medical and Disability History: A Survey of the Fields,” Bulletin of the History of Medicine 87, no. 4 (2013): 505. 12. Elizabeth Siegel Watkins, The Estrogen Elixir: A History of Hormone Replacement Therapy in America (Baltimore: Johns Hopkins Press, 2007), 7. 13. Alison Li, “J. B. Collip, A. M. Hanson and the Isolation of the Parathyroid Hormone, or Endocrines and Enterprise,” Journal of the History of Medicine and Allied Sciences 47, no. 4 (1992): 406. 14. Nicolas Rasmussen, “Steroids in Arms: Science, Government, Industry, and the Hormones of the Adrenal Cortex in the United States, 1930–1950,” Medical History 46, no. 3 (2002): 299. 15. Vivian Quirke, “Making British Cortisone: Glaxo and the Development of Corticosteroids in Britain in the 1950s–1960s,” Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 36, no. 4 (2005): 645–74. 16. Harry Marks, “Cortisone, 1949: A Year in the Political Life of a Drug,” Bulletin of the History of Medicine 66, no. 3 (1992): 419–39. 17. Dominique A. Tobbell, Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequence (Berkeley: University of California, 2011). 18. Diana Long Hall and Thomas F. Glick, “Endocrinology: A Brief Introduction,” Journal of the History of Biology 9, no. 2 (1976): 233. 19. Watkins, Estrogen Elixir, 1. 20. Ann Douglas Wood, “’The Fashionable Diseases’”: Women’s Complaints and Their Treatment in Nineteenth-Century America,” Journal of Interdisciplinary History 4, no. 1 (1973): 25–52; Carroll Smith-Rosenberg and Charles Rosenberg, “The Female Animal: Medical and Biological Views of Woman and Her Role in Nineteenth-Century America,” The Journal of American History 60, no. 2 (1973): 332–356. 21. Alice Domurat Dreger, Hermaphrodites and the Medical Invention of Sex (Cambridge, MA: Harvard University Press, 1998). 22. R. W. Connell, Masculinities (Berkeley: University of California Press, 1995). 23. Ben Barker-Benfield, “The Spermatic Economy: A Nineteenth Century View of Sexuality,” Feminist Studies 1, no. 1 (1972): 45–74. 24. Jesse Berrett, “Feeding the Organization Man: Diet and Masculinity in Postwar America,” Journal of Social History 30, no. 4 (1997): 805–825. 25. Laura Davidow Hirschbein, “The Glandular Solution: Sex, Masculinity, and Aging in the 1920s,” Journal of the History of Sexuality 9 (2000): 277–304; Elizabeth Siegel Watkins, “The Medicalization of Male Menopause in America,” Social History of Medicine 20, no. 2 (2007): 369–388. 26. Gail Bederman, Manliness & Civilization: A Cultural History of Gender and Race

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in The United States, 1880–1917 (Chicago: University of Chicago Press, 1995); Tom Pendergast, Creating the Modern Man: American Magazines and Consumer Culture, 1900–1950 (Columbia: University of Missouri Press, 2000). 27. Catherine J. Kudlick, “Disability History: Why We Need Another ‘Other,’” The American Historical Review 108, no. 3 (June 2003): 763–93. 28. Linker, “Borderland,” 499–535. 29. Lloyd Shearer, “We Can End Dwarfism!” San Diego Union, Parade Magazine, August 22, 1965, cover, MSS 72, Box 13, Folder 1, Mandeville Special Collections Library, University of California San Diego. 30. Genentech, Inc. advertisement for Protropin, “Out of Today’s Technology Tomorrow’s Growth,” Journal of Pediatrics 108, no. 1 (1986): 27A–31A.

Chapter 1 1. Lewis Hine, “‘The mill has kep’ us from growin.’ Charley Brazell says 13 years old but couldn’t write his name. Doffing 2 1/2 years, spinning room. Highland Park, No. 2, Rock Hill, Floyd Brown said 14 years old (?)‘been sweepin and doffin’ unto four years sure as I kin remember.’ Location: Rock Hill, [South Carolina],” May 1912, National Child Labor Committee Collection, Library of Congress Prints and Photographs Division, Washington, DC. 2. See William G. Whittaker, Child Labor in America: History, Policy, and Legislative Issues (New York: Novinka Books, 2004), cover; Hugh D. Hindman, Child Labor: An American History (Armonk, NY: M. E. Sharpe, 2002), cover; George Brown Tindall and David Emory Shi, America: A Narrative History (New York: Norton, 2013), 2:949; Robert E. Bain, “Children and the Industrial Revolution: Changes in Policy,” OAH Magazine in History 15, no. 1, 2000, 48–56, image of Lewis Hine photo on 50; J. Hansan, “The American Era of Child Labor,” The Social Welfare History Project: Child Labor, accessed August 10, 2014, http://www.socialwelfarehistory.com/programs/child-labor/. 3. Robert Hamlett Bremner, Children and Youth in America: A Documentary History, vol. 1, 1600–1865 (Cambridge, MA: Harvard University Press, 1975), 145–146. 4. Thomas E. Cone, History of American Pediatrics (Boston: Little, Brown and Company, 1979), 95. 5. Carolyn M. Moehling, “State Child Labor Laws and the Decline of Child Labor,” Explorations in Economic History 36, no. 1 (1999): 74. 6. Cone, 95–96. 7. Lee A. Craig, To Sow One Acre More: Childbearing and Farm Productivity in the Antebellum North (Baltimore: Johns Hopkins University Press, 1993), 9. 8. Hindman, Child Labor, 98–118, 122, and 228–229. 9. Jacob Riis, How the Other Half Lives; Studies among the Tenements of New York (New York: Sagamore Press, 1890).

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10. Susan B. Carter and Richard Sutch, “Fixing the Facts,” Historical Methods 96, no. 1 (1996): 5–20. 11. J. M. Tanner, A History of the Study of Human Growth (New York: Cambridge, 1981), 147. 12. A. Aspinall, E. Anthony Smith, and David C. Douglas, English Historical Documents 1783–1832 (1959; repr., New York: Routledge, 2000), 782. 13. Tanner, 147. 14. G. M. Young and W. D. Hancock, English Historical Documents, 1833–1874 (New York: Routledge, 1956), 934–949. 15. Tanner, 164. 16. Ibid. 17. Lee Shai Weissbach, “Child Labor Legislation in Nineteenth-Century France,” The Journal of Economic History 37, no. 1 (1977): 268–271. 18. Walter I. Trattner, Crusade for the Children: A History of the National Child Labor Committee and Child Labor Reform in America (Chicago: Quadrangle, 1970), 47. 19. Ibid., 56–58. 20. Ibid., 59–60. 21. Ibid. 22. Edward T. Devine, “The New View of the Child,” in Child Labor and Social Progress: Proceedings of the Fourth Annual Meeting of the National Child Labor Committee (Philadelphia: The American Academy of Political and Social Science, 1908), 4–10. 23. Trattner, 70. 24. Kate Sampsell-Willmann, Lewis Hine as Social Critic (Jackson: University Press of Mississippi, 2009), 59–62. 25. Ibid. 26. Naomi Rosenblum, “Biographical Notes,” in America and Lewis Hine by Lewis Wickes Hine and Alan Trachtenberg (New York: Aperture, 1977), 18–19. 27. Sampsell-Willmann, 55. 28. Ibid., 77. 29. Peter Seixas, “Lewis Hine: From ‘Social’ to ‘Interpretive’ Photographer,” American Quarterly 39, no. 3 (1987): 393. 30. Ibid. 31. Lewis Hine, “[Boy with Coat in Hand Is 11 Years Old] Gastonia, North Carolina,” November 1908, National Child Labor Committee Collection, Library of Congress Prints and Photograph Division, Washington, DC. 32. Russell Freedman, Kids at Work: Lewis Hine and the Crusade against Child Labor (New York: Clarion Books, 1994), 22. 33. Lewis Hine, “[Leo, 48 Inches High, 8 Years Old.] Fayetteville, Tennessee,” November 1910, National Child Labor Committee Collection, Library of Congress Prints and Photographs Division, Washington, DC.

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34. Freedman, 29. 35. Sampsell-Willmann, 81. 36. Lewis Hine, “Photograph of Exhibit at the Panama-Pacific International Exposition. Location: San Francisco, California, San Francisco, California,” 1915, National Child Labor Committee Collection, Library of Congress Prints and Photograph Division, Washington, DC. 37. Sampsell-Willmann, 82. 38. Daile Kaplan, ed. Photo Story: Selected Letters and Photographs of Lewis W. Hine (Washington, DC: Smithsonian Institution Press, 1992), 57. 39. Angelo Albrizio, “Biometry and Anthropometry: From Galton to Constitutional Medicine,” Journal of Anthropological Sciences 85 (2007): 101–23. 40. Henry Pickering Bowditch, The Growth of Children (Boston: Albert J. Wright, State Printer, 1877), 4. 41. Douglas Cole, Franz Boas: The Early Years, 1858–1906 (Seattle: University of Washington, 1999), 142; Tanner, A History of the Study of Human Growth, 195. 42. Ibid., 216–217. 43. Douglas Cole, Franz Boas: The Early Years, 1858–1906 (Seattle: University of Washington, 1999), 142–143. 44. Ibid. 45. Lee D. Baker, Anthropology and the Racial Politics of Culture (Durham: Duke University, 2010), 144. 46. Cole, 143. 47. Ibid., 241. 48. Frederick Starr, “Anthropology at the World’s Fair,” Popular Science, September 1893, 613. 49. Tanner, 242. 50. James B. Gilbert, “Anthropometrics in the U.S. Bureau of Education: The Case of Arthur MacDonald’s ‘Laboratory,’” History of Education Quarterly, 17, no. 2 (Summer 1977): 169. 51. Ibid., 169–195. 52. Arthur MacDonald, Experimental Study of Children Including Anthropometrical and Psycho-physical Measurements of Washington School Children (Washington, DC: Government Printing Office, 1899), 997. 53. Arthur MacDonald, “Experimental Study of Children,” The School World, July 1899, 263. 54. For a full description see MacDonald, Experimental Study of Children, entire. 55. Ibid., 998. 56. Ibid. 57. Arthur MacDonald, Man and Abnormal Man (Washington, DC: Government Printing Office, 1905), 7. 58. Gilbert, 184.

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59. Charles Michel Billard, A Treatise on the Disease of Infants: Founded on Recent Clinical Observations and Investigations in Pathological Anatomy, trans. James Stewart, second American edition translated from the third French edition (New York: J. & H. G. Langley, 1839), 35–38, 548–550. 60. M. Adolphe Quetelet, A Treatise on Man and the Development of His Faculties, trans. into English (Edinburgh: William and Robert Chambers, 1842), 58. 61. Ibid., 57–58. 62. Ibid., 58. 63. Ibid., 57. 64. Henry Pickering Bowditch, “The Relation between Growth and Disease,” Transactions of the American Medical Association 32 (1881): 371–377. 65. Bowditch, The Growth of Children, 37. 66. Bowditch, “The Relation between Growth and Disease,” 373. Italics in the original. 67. Alexandra Minna Stern and Howard Markel, Formative Years: Children’s Health in the United States, 1880–2000 (Ann Arbor: University of Michigan Press, 2002), 7. 68. Ibid., 9. 69. L. Emmett Holt, The Diseases of Infancy and Childhood: For the Use of Students and Practitioners of Medicine (New York: Appleton, 1897), vi. Spelling in the original. 70. Ibid., v. 71. Ibid., vii. 72. Ibid., 15. 73. Ibid. 74. Ibid. 75. Ibid., 19–21. 76. Ibid. 77. Ibid. 78. L. Emmett Holt, The Diseases of Infancy and Childhood: For the Use of Students and Practitioners of Medicine, 7th ed. (New York: Appleton, 1920). 79. Holt, 1920, 18. 80. L. Emmett Holt, The Diseases of Infancy and Childhood: For the Use of Students and Practitioners of Medicine, 8th ed. (New York: Appleton, 1922), 15. 81. Ibid. Even though nutrition was discussed, alcohol consumption’s impact on children’s growth was not. Some physicians did write about a possible relationship between alcohol and health problems. See Mary Scharlieb, “Alcoholism in Relation to Women and Children,” in The Drink Problem in its Medico-Sociological Aspects, ed. T. N. Kelynack (New York: E. P. Dutton, 1907), 161–188. Scharlieb argued that “children of alcoholic parents are usually found to be stunted in growth, deficient in with, suffering markedly from anemia, and in many instances infested by vermin,” 169. 82. Holt, 1922, 19. 83. Cone, History of American Pediatrics, 71.

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84. Maud Humphrey, Baby’s Record: With Frontispiece in Colour and Thirty Illustrations in Black & White (New York: Frederick A. Stokes Company, 1898) n.p. 85. Albertine Randall Wheelan, Mother Stork’s Baby Book (New York: Dodge Publishing Company, 1904); Biography of Our Baby: From Birth to Seven Years (C. Junceau, 1941); Our Baby’s Journal (Kansas City: Emery, Bird, Thayer Co., not after 1914), Baby Books Collection, History & Special Collections for the Sciences, University of California Los Angeles Library Special Collections (hereafter cited as UCLA’s Baby Books Collection). 86. Anonymous mother writing in J. B. Fonssagrives, The Mother’s Register Current Notes of the Health of Children (boys). The Mother Records for the Physician to Interpret, trans. from French (New York: John Ross and Company, 1872), n.p. UCLA’s Baby Books Collection. 87. Ibid., 7. 88. “To Save 100,000 Children,” New York Times, January 25, 1918, 12. 89. US Children’s Bureau, Children’s Year: A Brief Summary of Work Done and Suggestions for Follow-up Work, Children’s Year Follow Up Series no. 4, Bureau Publication no. 67, (Washington, DC: Labor Bureau,1920), 7–9, Maternal and Child Health Library, Georgetown University, Washington, DC. 90. Ibid. 91. “Children’s Day in Church,” New York Times, August 4, 1918, 23. 92. “To Save 4,700 Babies Here,” New York Times, July 29, 1918, 5. 93. Robert Morse Woodbury, Statures and Weights of Children Under Six Years of Age (Washington, DC: Government Printing Office, 1921), 9. 94. Sydney A. Halpern, American Pediatrics: The Social Dynamics of Professionalism, 1880–1980 (Berkeley: University of California, 1988), 90. 95. US Children’s Bureau, Weighing and Measuring Test (Washington, DC: US Department of Labor, not before 1916 ), UCLA’s Baby Books Collection. 96. Ibid. 97. Ibid. 98. Ibid. 99. According to Tanner, Crum had gathered the measurements of 5,602 boys and 8,821 girls aged six months to four years. Baby Health Conferences sponsored by the American Medical Association in twenty-three states facilitated the measuring of more than one hundred infants of each sex, from zero to three months. Tanner, 491; Walter F. Willcox, “Frederick S. Crum,” Quarterly Publications of the American Statistical Association 17, no. 136 (1921): 1020–1021. 100. US Children’s Bureau, April and May Weighing and Measuring Test, Children’s Year Leaflet no. 2 part 2, Bureau Publication no. 38 (Washington, DC: Labor Bureau, 1918), 3, Maternal and Child Health Library, Georgetown University, Washington, DC. 101. Robert Morse Woodbury, “Stature and Weight of Children,” American Statistical Association 17, no. 134 (1921): 780.

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102. Woodbury, Statutes and Weights of Children Under Six Years of Age, 15. 103. “Pupils Prepare for May 1,” New York Times, April 22, 1928, 33. 104. Ibid. 105. “City to Observe Child Health Day May 1; Pupils to Take Part in Park Exercises,” New York Times, April 29, 1928, N2. 106. “Babies in Physical, Mental Tests at Hollywood,” Los Angeles Times, April 17, 1925, A1. 107. Frederic J. Haskin, “Celebration to Set New Mark,” Los Angeles Times, April 13, 1928, 18. 108. Alexandra Minna Stern, “Better Babies Contests at the Indiana State Fair: Child Health, Scientific Motherhood, and Eugenics in the Midwest, 1920–35,” American Journal of Public Health 92, no. 5 (2002): 748, 742–752. 109. “Register for Baby Week,” Los Angeles Times, March 28, 1926, B1. 110. “City to Observe Child Health Day May 1.” 111. Glenn D. Rohleder, “Accomplishments of the Child-Health Demonstration of Mansfield and Richland County, Ohio,” Educational Research Bulletin 6, no. 16 (November 9, 1927), 344. 112. Ibid. 113. Frederick J. Haskin, “Mothers and Babies Saved: Statistics Show. . .” Los Angeles Times, April 23, 1928, 18. 114. Halpern, 88. 115. US Children’s Bureau, The Seven Years of the Maternity and Infancy Act (Washington, DC: Labor Bureau, 1931), 1. 116. Halpern, 88. 117. Stern and Markel, 1–22. 118. Thomas Denison Wood, The Ninth Yearbook of the National Society for the Study of Education: Health and Education (Chicago: University of Chicago Press, 1910), 20. 119. Wood, Ninth Yearbook, 14. 120. Ibid., 15–16. 121. Ann E. Nolte, “An Historical Study of the Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association” (PhD thesis, Ohio State University, 1963), 47. 122. Nolte, 1 and 14–15. 123. Thomas Denison Wood, The Child in School: Care of Its Health (New York: Funk and Wagnalis Company, 1924), 50–51. 124. Richard Meckel, Classrooms and Clinics: Urban Schools and the Protection and Promotion of Child Health (New Brunswick: Rutgers, 2013), 177. 125. Grace T. Hallock, A School Health Program for Parent-Teacher Associations and Women’s Clubs (New York City: The Child Health Organization of America, 1922), 4. 126. Joint Committee on Health Problems in Education and Thomas Denison

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Wood, Health Service in the City Schools of the United States. Report of the Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association (n.p., 1922), 13. 127. Ibid., 13, 15. 128. White House Conference on Child Health and Protection, White House Conference, 1930, Addresses and Abstracts of Committee Reports (Washington, DC: Century, 1931). 129. Franz Boas, “Observations on the Growth of Children,” Science, New Series 72, no. 1854 (1930): 44–48. 130. Jeffrey Brosco, “Weight Charts and Well-Child Care: How the Pediatricians Became the Expert in Child Health,” Archives of Pediatric & Adolescent Medicine 155, no.12 (2001): 1385–1389. 131. H. S. Mustard and J. I. Waring, “Heights and Weights of Colored School Children,” American Journal of Public Health 16, no. 10 (1926): 1017. 132. Ibid., 1021. 133. US Children’s Bureau, “President’s Proclamation,” The Child 1, no. 11 (1937): 13. 134. Ibid. 135. Ibid. 136. Ibid., 12 137. Ibid. 138. For an innovative analysis of interpretations and concerns over stature and degeneracy of the American male that explores the shifting relationship between patriotism, eugenics, and whiteness, see Mary K. Coffey, “The American Adonis: A Natural History of the ‘Average American’ (Man), 1921–32” in Popular Eugenics: National Efficiency and American Mass Culture in the 1930s, eds. Susan Currell and Christina Cogdell (Athens: Ohio University Press, 2006), 185–216.

Chapter 2 1. Today, the term “midget” is deemed offensive. I am placing the term in quotes to deference to its current interpretation. For more on the topic of “midget” being understood as the “m-word” see Lynn Harris, “Who Are You Calling a ‘midget’?” Salon, July 16, 2009, accessed March 2, 2015, http://www.salon.com/2009/07/16/m_ word/; “LPA and the ‘M’ Word,” Little People of America, accessed March 2, 2015, http://www.lpaonline.org/the-m-word. 2. Walter Bodin and Burnet Hershey, It’s a Small World: All About Midgets (New York: Coward-McCann, Inc., 1934), 12. 3. Ibid., 17. 4. Ibid., 12–23. 5. Ibid., 24.

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6. “Books Published Today,” New York Times, April 25, 1934, 19. 7. “All About Midgets Is Interesting Book on ‘A Small World’,” Chicago Daily Tribune, May 26, 1934, 12. 8. “Lives of Midgets: It’s a Small World. All About Midgets,” New York Times, May 6, 1934, BR12. 9. Robert Bogdan, Freak Show: Presenting Human Oddities for Amusement and Profit (Chicago: University of Chicago Press, 1988), 66. 10. Today, the term “freaks” is deemed offensive. I am placing the term in quotes to deference to its current interpretation. Rosemarie Garland-Thomson, Freakery: Cultural Spectacles of the Extraordinary Body (New York: New York University Press, 1996), 34. 11. Michael M. Chemers, Staging Stigma: A Critical Examination of the American Freak Show (New York, NY: Palgrave Macmillan, 2008), 22. 12. Li, “Isolation of the Parathyroid Hormone,” 406. 13. E. Leslie Gilliams, “Side-Show Freaks as Seen by Science,” Illustrated World, October 1922, 215. 14. Willis Goldbeck et al., “Special Message Prologue,” Freaks, directed by Tod Browning (1932; Burbank, CA: Turner Entertainment Co., distributed by Warner Home Video, 2004), DVD. 15. Charles-Edouard Brown-Séquard, “The Effects Produced on Man by Subcutaneous Injections of a Liquid Obtained from the Testicles of Animal,” Lancet (July 20, 1889): 105. 16. Merriley Borell, “Brown-Séquard’s Organotherapy and Its Appearance in America at the End of the Nineteenth Century,” Bulletin of the History of Medicine 50, no. 3 (1976): 310. 17. Ibid., 319. 18. Ibid., 309 and 318. 19. C. J. Marinus to Dr. King, memorandum, February 6, 1917, Series 1: Joint Research Notebooks, Box #8, Lab Book #33, 756–757, Parke, Davis Research Laboratory Records, Archives Center, National Museum of American History, Washington, DC (hereafter cited as Parke, Davis Laboratory Records). 20. Ibid. 21. Ibid. 22. Hans Lisser, “The Endocrine Society: The First Forty Years (1917–1957),” Endocrinology 80, no. 1 (1967): 5–28. 23. Harvey Cushing, “Disorders of the Pituitary Gland: Retrospective and Prophetic,” The Journal of the American Medical Association 76, no. 25 (June 18, 1921): 1726. 24. Ibid. 25. Ibid.

NOTES TO PAGES 52–55

157

26. Ibid. 27. Ibid. 28. E. P. Bugbee to Dr. Houghton, “Re: Dr. Harvey Cushing—Antuitrin,” August 5, 1927, Series 2: Individual Laboratories Notebooks, Box #71, Lab Book of E. P. Bugbee, 1927, 546, Parke, Davis Laboratory Records. 29. Herbert Evans, “Pituitary Function,” Transactions of the Congress American Physicians and Surgeons, Fifteenth Session (Menasha: Published by the Congress, 1933): 26–27. 30. Elizabeth Siegel Watkins, “The Medicalisation of Male Menopause in America,” Social History of Medicine 20, no.2 (2007): 369–388. For a discussion of the early years of endocrinology, see 372–374. 31. Bederman, Manliness & Civilization, 11–12. 32. Michael S. Kimmel, “Consuming Manhood: The Feminization of American Culture and the Recreation of the American Male Body, 1832–1920,” Michigan Quarterly Review 33, no. 1 (1994): 8. All spelling and grammar inaccuracies are as detailed in the original. 33. John Kasson, Houdini, Tarzan, and the Perfect Man: The White Male Body and the Challenge of Modernity in America (New York City: Hill and Wang, 2002), 10. 34. Ibid. 35. Bederman, 4–7. 36. Ibid., 16. 37. Kasson, 8. 38. Ibid., 19. 39. Ibid., 8. 40. Ibid. 41. Bogdan, 149. 42. Eric Lehman, Becoming Tom Thumb: Charles Stratton, P. T. Barnum, and the Dawn of American Celebrities (Middletown: Wesleyan, 2013), 3–4. 43. Ibid., xi. 44. Tom Thumb, Sketch of the Life, Personal Appearance, Character and Manners of Charles S. Stratton, the Man in Miniature, known as General Tom Thumb, and His Wife, Lavinia Warren Stratton Including the History of Their Courtship and Marriage: With Some Account of Remarkable Dwarfs, Giants, & Other Human Phenomena of Ancient and Modern Times: Also, Songs Given at Their Public Levees (New York: Printed by S. Booth, 1874), 13. 45. Ibid., 24–29. 46. Lehman, 185–194. 47. Bogdan, 4–5. 48. “Decline of the Freak: The Curio Business Has Passed Its Old Halcyon Days,” Washington Post, March 4, 1894, 17. 49. Bogdan, 159.

158

NOTES TO PAGES 56 – 60

50. H. C. Miner Litho. Co., The Rossow Midgets, Star Speciality Co., 1897, the Theatrical Poster collection, Library of Congress. 51. “The Smedleys, Rossow Midgets, and Lockhart’s Elephants at New Grand,” Washington Post, October 2, 1900, 4. 52. George Gould and Walter Pyle, Anomalies and Curiosities of Medicine (Philadelphia: W. B. Saunders, 1896), 1. 53. Ibid., 7–17. 54. “The Pathology of Circus and Museum Freaks,” New York Medical Journal: Incorporating the Philadelphia Medical Journal and The Medical News, eds. Frank P. Foster and Smith Ely Jelliffe, 87 (February 15, 1908): 313–314. 55. Ibid., 314. 56. Ibid. 57. Ibid. 58. “Museum Freaks,” New York Times, February 23, 1908, 6; “Passing of Museum Freaks: A Medical Authority Gives Scientific Information Regarding Them,” Washington Post, March 15, 1908. 59. “Circus and Museum Freaks. Curiosities of Pathology,” Scientific American Supplement, April 4, 1908, 222. 60. “Museum Freaks”; “Passing of Museum Freaks”; “Circus and Museum Freaks.” 61. “ Pathology of Circus and Museum Freaks”; “Circus and Museum Freaks.” 62. “No More Circus Freaks,” Washington Post, March 8, 1908, SM7. 63. “New Feats Startle at Circus Opening,” New York Times, March 20, 1908, 7. 64. “Circus in Hospitals, Elephant and All,” New York Times, April 5, 1908, 8; “Circus Sued on Contract: Ringlings Accused of Bad Faith in Engagement of Princess Weenie Wee,” Washington Post, May 6, 1908, 10. 65. “The Circus Comes to Town: Led by the Elephants as of Old, Barnum & Bailey’s Big Show is Here,” New York Times, March 16, 1913, C7; “Elephants, Peanuts and Freaks Again,” New York Times, March 23, 1913, C7; “The Circus Freak Seen Off Guard as a Human Being,” New York Times, April 6, 1913, SM11. 66. “Amusement at the Abnormal,” The Nation 89, no. 2229 (1908): 254–255. 67. “Slump in the Freak Market,” Washington Post, April 3, 1910, MS1. 68. M. C. D, “Lilliputians in Varied Acts Astound Orpheumites,” San Francisco Chronicle, August 16, 1920, 7. 69. “Marvelous Midget Beloved of Children,” Los Angeles Times, September 12, 1920, III15. 70. “New Coney Dazzles Its Record Multitude: Luna Park and Dreamland the Centres of Great Crush. 250,000 Persons at Island Novel and Costly Shows, with the Frankfurter and Peanut as Reminders of By-Gone Days,” New York Times, May 15, 1904, 3. 71. Ibid.

NOTES TO PAGES 60 – 63

159

72. Isaac Marcosson, “Sawdust and Gold Rush: The Earnings of the Circus People,” The Bookman: A Review of Books and Life 31, no. 4 (June, 1910): 409. 73. Gilliams, “Side-Show Freaks,” 213. 74. Ibid., 214–215. 75. Ibid., 213. 76. Ibid., 215. 77. “Notes and News,” Bulletin of the Johns Hopkins Hospital 33, no. 371 (1922), 34. 78. E. Kost Shelton, “Pituitary Growth Factor: Some Clinical Considerations,” California and Western Medicine 45, no. 1 (1936): 23. 79. Michael Bliss, Harvey Cushing: A Life in Surgery (Oxford: Oxford University Press, 2005) 205. 80. Ibid., 212. 81. Neil A. Campbell and Jane B. Reece, Biology, Seventh edition, (San Francisco: Pearson, 2006), 950–52. 82. E. Kost Shelton, “Pituitary Growth Factor: Some Clinical Considerations” California and Western Medicine, 45, no. 1 (July 1936): 20. 83. George W. Corner, “Herbert McLean Evans, 1882–1971,” National Academy of Sciences (Washington, DC: National Academy of Sciences, 1974): 152–192. 84. Ibid., 14. 85. Lisser, “The First Forty Years,” 7. 86. Hans Lisser, “Hypopituitarism and Its Treatment,” Journal of Clinical Endocrinology and Metabolism, 6 (1921): 15–39. 87. Sol Hyman ed., “Tethelin Presented to the University of California by Doctor Robertson,” California State Journal of Medicine 15, no. 6 (1917): 181. 88. C. J. Marinus to Dr. King, report, “The Presence of Tethelin in Commercial Desiccated Anterior Lobe Substance,” July 18, 1918, Series 2: Individual Laboratories Notebooks, Box #117, Lab Book of C.J. Marinus, 1919–1920, 19–21, Parke, Davis Research Laboratory Records; C. J. Marinus, final report, “Presence of Tethelin in Commercial Desiccated Anterior Lobe Substance,” October 8, 1918, Series 2: Individual Laboratories Notebooks, Box #117, Lab Book of C. J. Marinus, 1919–1920, 22–23, Parke, Davis Research Laboratory Records. 89. Jack Cecil Drummond and Robert Keith Cannan, “Tethelin—The Alleged Growth-Controlling Substance of the Anterior Lobe of the Pituitary Gland,” The Biochemical Journal 16, no. 1 (1922): 53–59. 90. “Historical Review,” 1939, Box #34, Folder #36, Addenda 2006, 5, Parke, Davis Research Laboratory Records; C. J. Marinus to Dr. Houghton, memorandum, October 15, 1919, Series 2: Individual Laboratories Notebooks, Box #117, Lab Book of C. J. Marinus, 1919–1920, 40, Parke, Davis Research Laboratory Records. 91. C. J. Marinus to Dr. Houghton, memorandum, October 15, 1919. 92. Ibid., 41. 93. C. J. Marinus to Dr. Houghton, memorandum, “Activity of Anterior Lobe

160

NOTES TO PAGES 64 – 66

Extracts,” July 19, 1920, Series 2: Individual Laboratories Notebooks, Box #117, Lab Book of C. J. Marinus, 1919–1920, 44, Parke, Davis Research Laboratory Records. 94. Choh Li and H. M. Evans, “The Isolation of Pituitary Growth Hormone,” Science 99, no. 2566 (1944): 183–84. 95. Hypophysectomy is the surgical removal of the pituitary gland. 96. Dr. Bugbee to Dr. Houghton, memorandum, “Subject: Anterior Lobe of Pituitary,” March 24, 1924, Series 1: Joint Research Notebooks, Box #16, Lab Book #71, January 1924-March 1924, 309, Parke, Davis Research Laboratory Records. 97. Dr. Bugbee to Dr. Houghton, “Re: Dr. Harvey Cushing—Antuitrin.” August 5, 1927, Series 2: Individual Laboratories Notebooks, Box #71, Lab Book of E.P. Bugbee, 1927, 546, Parke, Davis Laboratory Records. 98. E. P. Bugbee, A. E. Simond, and H. M. Grimes, “Anterior Pituitary Hormones,” Endocrinology 15, no. 1 (1931): 41. 99. E. A. Sharp to Dr. Lescohier, memorandum, “Department of Experimental Medicine,” April 18, 1932. Grace Hospital was located in Detroit, Michigan. 100. Ibid. 101. Dr. Kamm to E. P. Bugbee, “Re: Antuitrin-G,” July 23, 1932, Series 2: Individual Laboratories Notebooks, Box #72, Lab Book of E. P. Bugbee, 873, Parke, Davis Laboratory Records. The list of those receiving Antuitrin-G is based on an internal memorandum: W. F. Kamm to Dr. Sharp, “Research Department,” October 1, 1932, Series 2: Individual Laboratories Notebooks, Box #72, Lab Book of E. P. Bugbee, 1150–51, Parke, Davis Laboratory Records, Archives Center, National Museum of American History. Names listed are “Dr. Cushing; Dr. H. Lisser; Engelbach & Schaefer; Dr. Calder of Duke University; Dr. David Marine, Monte Fiore Hospital; Dr. Lerman, Massachusetts General Hospital; Dr. Bowie, University of Pennsylvania; Johns Hopkins Group; Dr. Chas T. Brown of San Antonio, Texas, Dr. A. C. Silverman of Syracuse, NY; and perhaps Dr. H. H. Turner of Oklahoma City in the future.” 102. William Engelbach and Robert L. Schaefer, “Endocrine Dwarfism,” The Journal of the American Medical Association 103, no. 7 (1934): 464–468. 103. W. F. Kamm to E. P. Bugbee, “Re: Antuitrin-G.” 104. W. F. Kamm to Dr. Sharp, Research Department, March 29, 1933, Series 2: Individual Laboratories Notebooks, Box #73, Lab Book of E. P. Bugbee and D. A. McGinty, 298, Parke, Davis Laboratory Records. 105. Dr. Kamm to Dr. Sharp, Research Department, December 23, 1933, Lab Book of Dr. E. P. Bugbee and Dr. D. A. McGinty, 937, Parke, Davis Research Laboratory Records. 106. Report, “Antuitrin G,” February 1, 1935, Series 1: Joint Research Notebooks, 1910–1945, Box #35, Lab Book #134, Laboratory Notes from Research Dept. Parke, Davis and Company, January–February 1935, 1460, Parke, Davis Research Laboratory Records. 107. To Mr. A. M. Holmes, memorandum, December 22–23, 1936, Series 1: Joint

NOTES TO PAGES 66 –70

161

Research Notebooks, 1910–1945, Box #39, Lab Book #155, Laboratory Notes from Research Dept. Parke, Davis & Company, November–December, 630, Parke, Davis Research Laboratory Records. 108. A. Wilmot Jacobsen and Arthur J. Cramer, “Clinical Results of Anterior Pituitary Therapy in Children.” Journal of the American Medical Association 109, no. 2 (1937): 101. 109. Ibid., 102, 108. 110. To Mr. F. C. Taylor, January 5, 1939, Series 1: Joint Research Notebooks, 1910– 1945, Box #44, Lab Book # 182, Laboratory Notes from Research Dept. Parke, Davis & Company, January–February 1939, 1385, Parke, Davis Research Laboratory Records. 111. To Mr. F. C. Taylor, January 23, 1939, Series 1: Joint Research Notebooks, 1910–1945, Box #44, Lab Book # 182, 1386, Laboratory Notes from Research Dept. Parke, Davis & Company, January–February 1939, Parke, Davis Research Laboratory Records. 112. Delbert Fisher, “A Short History of Pediatric Endocrinology in North America,” Pediatric Research 55, no. 4 (2004): 716–726. 113. Ibid., 719. 114. A. Wilmot Jacobsen and Arthur J. Cramer, “Clinical Results of Anterior Pituitary Therapy in Children,” Journal of the American Medical Association 109, no. 2 (1937): 101–108. 115. Hans Lisser, “Organotherapy, Present Achievements and Future Prospects,” Endocrinology 9 (1925): 2. 116. Ibid., 8, 9. 117. William Engelbach, “The Growth Hormone: Report of a Case of Juvenile Hypopituitarism Treated with Evans’ Growth Hormone,” Endocrinology 16, no. 1 (1932): 19. 118. “Dr. Engelbach Dies; Expert on Glands,” New York Times, November 23, 1932, 22. 119. Engelbach and Schaefer, “Endocrine Dwarfism,” 465. 120. Leona M Bayer and H. Gray, “Pituitary Dwarfs: Their Growth and Treatment,” California and Western Medicine 47, no.4 (1937): 228–233. 121. Engelbach and Schaefer, “Endocrine Dwarfism,” 468; Emil Novak, “Glandular Physiology and Therapy: Anterior Pituitary and Anterior Pituitary-Like Substances,” Journal of the American Medical Association 104, no. 12 (1935): 998–1002. 122. Shelton, “Pituitary Growth Factor,” 25. 123. “Doctors Hear Gland Talk,” Los Angeles Times, November 3, 1923, II1. 124. “Medicine Gets New Place in Gland Control,” Chicago Daily Tribune, April 22, 1932, 24. 125. Staff Correspondent, “Chemist Discovers ‘Growth Hormone’,” New York Times, September 4, 1931, 1. 126. “Says Hormones Add Inches to Children,” New York Times, February 22, 1933, 24. 127. “Medicine: Cornstalk,” Time, August 1, 1938, 36.

162

NOTES TO PAGES 70 –73

128. Hannah Lees, “Side-Show Diagnosis,” Collier’s, June 5, 1937, 22. 129. Ibid. 130. Ibid. 131. Ibid., 35. 132. Artwork produced for the Golden Gate International Exposition serves as a prime example of this treatment of science. See Diego Rivera, “Pan American Unity,” mural, 1941 (City College of San Francisco); Herman Voltz, “Organic and Inorganic Science,” mosaic, 1942 (City College of San Francisco). 133. A Century of Progress: Chicago World’s Fair Souvenir Booklet, 1833–1933 (Chicago: The Arena Company, 1933), title page. 134. G. A. Barclay, “A Century of Progress International Exposition,” Bankers’ Magazine, 127, no. 1, 1933, 49. 135. A Century of Progress. 136. Century of Progress International Exposition, Official Guidebook of the Fair (Chicago: A Century of Progress, 1933), 172. Duke Mill Amusements Corporation of Chicago organized both the “freak” show and the plantation show. In an advertisement on page 158 featuring both of these attractions, they were called “Living Wonders” and “Old Plantation Show.” 137. Benjamin Klein, Modern Lilliputia: The Story of Midgets, (n.p., 1933), 3, Eugenics Record Office Records, 1670–1964, Box Series XII. Midget Schedules, Mss.Ms.Coll.77, American Philosophical Society, Philadelphia, Pennsylvania. 138. Ibid. 139. Ibid., 9. 140. Ibid., 4. 141. Ibid., 3. 142. Ibid., 3, 9. 143. Ibid., 10. 144. Official Guide Book of the World’s Fair of 1934 (Chicago: A Century of Progress International Exposition, 1934), 119; photograph, “A Crowd Gathered to See a Group of Midgets at the Midget Village during the 1935 Exposition,” San Diego Historical Society Negative Collection (C004) California Border Region Digitization Project: 1870–1939, San Diego History Center; Jim Parsons and David Bush, “A ‘Texanic’ World’s Fair: The 1936 Texas Centennial Exposition,” Chicago Art Deco Society Magazine, Fall 2011, 21–25; Great Lakes Exposition Souvenir Map, “Exhibit #42,” Ohio Memory Collection, Cleveland Public Library Photograph Collection; photograph, “The Singer Midgets, the Smallest Family in the World, Golden Gate International Exposition on Treasure Island,” San Francisco Call Bulletin, October 14, 1940, San Francisco History Center, San Francisco Public Library, AAK-0271; “The Amusements: Right This Way!” New York Times, April 30, 1939, 135. 145. “List Anthropological Statistics, Made From Exposition at Chicago: Males Averaged 29 years and 68 inches in height,” The Harvard Crimson, March 28, 1934,

NOTES TO PAGES 73–78

163

http://www.thecrimson.com/article/1934/3/28/list-anthropological-statistics-madefrom-exposition/. 146. L. Emmett Holt, John Howland, and Rustin McIntosh, Holt’s Diseases of infancy and Childhood: A Textbook for the Use of Students and Practitioners, 11th ed. (New York, London: D. Appleton-Century Company, Incorporated, 1940), 761. 147. Harry Laughlin to Nate Eagle, July 11, 1934, Eugenics Record Office Records, 1670–1964, Box Series XII, Midget Schedules, Mss.Ms.Coll.77, American Philosophical Society, Philadelphia, Pennsylvania. 148. Mordaunt Hall, “The Screen: Charley’s Niece,” New York Times, August 11, 1926, 25. 149. “Movie Detail, The Sideshow,” American Film Institute Catalog, accessed June 13, 2014, http://www.afi.com/members/catalog/DetailView.aspx?s=&Movie=12087. 150. Mordaunt Hall, “The Screen: The Holy Terror,” New York Times, April 12, 1926, 18. 151. “Summary View of Movie: The Unholy Three,” American Film Institute Catalog, accessed June 13, 2014, http://www.afi.com/members/catalog/AbbrView. aspx?s=&Movie=12952. 152. Mordaunt Hall, “The Screen: An Excellent Drama,” New York Times, August 4, 1925, 14. 153. Ibid. 154. Freaks, DVD. 155. Muriel Babcock, “‘Freaks’ Rouse Ire and Wonder: Horrified Spectators Write Scathing Letters,” Los Angeles Times, February 14, 1932, B9 and B20. 156. Movie Poster, “Can a Grown Woman Truly Love a Midget?” n.d. 157. “Screen News Here and In Hollywood: ‘The Wizard of Oz’ in Demand following the Box-office Success of ‘Snow White,’” New York Times, February 19, 1938, 19; Stephen Cox, The Munchkins of Oz (Nashville: Cumberland House Publishing, 2002), 180. 158. Baum depicts the Munchkins as small people who were “not as big as the grown folk . . . but neither were they very small,” in L. Frank Baum, The Big Book of Oz—volume 1: The Oz Series, ed. Emma Ashe (Glastonbury: Glastonbury Books, 2007), 19. 159. Martin F. Norden, The Cinema of Isolation: A History of Physical Disability in the Movies (Rutgers University Press, 1994), 1. 160. L. Frank Baum, The Wonderful Wizard of Oz (New York: Knopf, 1900), 5; Victor Fleming et al., The Wizard of Oz (1939; Turner Entertainment Co., 1999), DVD. 161. Cox, 11, 37. 162. Bodin, Hershey, It’s a Small World, 311–312. 163. Cox, 32–35. 164. “Scientists Predicts Pituitary Treatment Will Overcome the ‘Inferiority

164

NOTES TO PAGES 78–83

Complex,” New York Times, August 2, 1937, 34. 165. Ibid.

Chapter 3 1. Allen Greenacre, “We’re Getting Bigger Again,” American Weekly, April 7, 1947, 14. 2. C. H. Li and H. M. Evans, “The Isolation of Pituitary Growth Hormone,” Science 99 no. 2566 (1944): 183–184. 3. Susan Cohen and Christine Cosgrove, Normal at Any Cost: Tall Girls, Short Boys, and the Medical Industry’s Quest to Manipulate Height (New York: Tarcher, 2009); Melody Peterson, Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs (New York: Farrar, Straus and Giroux, 2008); Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (Baltimore: Johns Hopkins Press, 2007); David J. and Sheila Rothman, The Pursuit of Perfection: The Promise and Perils of Medical Enhancement (New York: Pantheon, 2003). 4. Wilton Marion Krogman, “Principles of Human Growth,” Human Growth, Ciba Symposia 5 no. 1 (1943): 1458. 5. John E. Anderson and Florence L. Goodenough, How Normal Children Grow: Their Physical, Mental and Character Development (New York: The Parents’ Publishing Association, 1930), 2. 6. Richard M. Smith and Douglas A. Thom, Health: Physical, Mental, and Emotional (Boston: Houghton Mifflin, 1936), 22; Anderson and Goodenough, 24. 7. Conrad, 148–149. 8. Werner Kornfeld, “The Anthropometric Approach to the Practice of the Pediatrician,” Child Development 18, no. 3 (1947): 113. 9. See chapter 1. 10. See J.P. Crozer Griffith, The Diseases of Infants and Children, 1st ed., 2nd ed., and 3rd ed. (Philadelphia: W.B. Saunders, 1919, 1938, and 1935 respectively); Holt, The Diseases of Infancy and Childhood, 1st ed., 4th ed., 6th ed., and 7th ed. 11. L. Emmett Holt et al., Holt’s Diseases of Infancy and Childhood: A Textbook for the Use of Students and Practitioners (New York: D. Appleton-Century Company, Incorporated, 1940), 8–43. 12. Ibid., 10. 13. Ibid., 11. 14. Murray B. Gordon, “Diseases and Disorders of the Endocrine System,” in Therapeutics of Infancy and Childhood (Philadelphia: F. A. Davis Company, 1942), 2641–2642. 15. Ibid., 2641. 16. Ibid., 2645. 17. Ibid.

NOTES TO PAGES 83–89

165

18. Holt et al., 739–40. 19. Gordon, 2644. 20. L. Emmett Holt and Rustin McIntosh, Pediatrics (New York: Appleton-CenturyCrofts, 1953), 1442 and 1443. 21. Holt et al., 739. 22. Armour Laboratories, The Pituitary Gland: Clinical Application of Its Hormone Factors, revised edition (Chicago: Armour and Company, 1944), 3. 23. Ibid., 64. 24. Ibid. 25. Ibid. 26. Ibid., 65. 27. Ibid. 28. Monthly Report, “Antuitrin, Growth, Project No. 9769” January 1940, Series 1: Joint Research Notebooks, 1910–1945, Lab Book #183, 775 Laboratory Notes from Research Dept. Parke, Davis and Company, Parke, Davis Research Laboratory Records. 29. Ibid., Memo, from D. A. McGinty to Executive Research Committee, Dr. Kitchen, Secretary “Recommendations of Proposed Research for the Immediate Future in the Endocrine Field,” April 24, 1944, 1432. 30. Li and Evans, 183–84. 31. A. E. Wilhelmi, Jacob B. Fishman, and Jane A. Russell, “A New Preparation of Crystalline Anterior Pituitary Growth Hormone,” Journal of Biological Chemistry 176, no. 2 (1948): 735–45. 32. Letter from Helen Chin to Choh Hao Li, Folder “C-misc., 1944—49,” Choh Hao Li Papers, MSS 88–9, Archives & Special Collections, UCSF Library & CKM (hereafter cited to as Choh Hao Li Papers). 33. William A. Reilly, Lawson H. Wilkins, and William C. Deamer, “American Academy of Pediatrics, Inc. Proceedings and Reports, Round Table Discussion, Endocrine Therapy in Childhood,” Pediatrics 6, no. 6 (December 1950): 917. 34. Roger A. Lewis, Robert Klein, and Lawson Wilkins, “The Effect of Pituitary Growth Hormone in Dwarfism with Osseous Retardation and Hypoglycemia and in a Cretin Treated with Thyroid,” Journal of Clinical Investigation 29, no. 4 (1950): 460. 35. Reilly, Wilkins, and Deamer, 917. 36. William C. Deamer, “Stimulation of Growth in Boys by Sublingual Testosterone Therapy,” American Journal of Diseases of Children 75, no. 6 (1948): 859. 37. Ibid. 38. Reilly, Wilkins, and Deamer, 917. 39. Ibid. 40. Delbert A. Fisher, “A Short History of Pediatric Endocrinology in North America,” Pediatric Research 55, no. 4 (2004): 719; Lawson Wilkins, The Diagnosis and Treatment of Endocrine Disorders in Childhood and Adolescence, 1st ed. (Springfield: C.C. Thomas, 1950).

166

NOTES TO PAGES 89–94

41. Nathan B. Talbot et al., Functional Endocrinology: From Birth Through Adolescence (Cambridge: Harvard University Press, 1952), 466. 42. Ibid., 472. 43. Dr. Roberto Escamilla to Dr. Cyril M. MacBryde, March 28, 1929, Choh Hao Li Papers. 44. Howard V. Meredith, “A Physical Growth Record for Use in Elementary and High Schools,” American Journal of Public Health 39, no. 7 (1949): 878. 45. Ibid. 881. 46. Ibid. 47. Orren Lloyd-Jones, “Race and Stature: A Study of Los Angeles School Children,” Research Quarterly, American Association for Health, Physical Education and Recreation 12, no. 1 (1941): 83. 48. Walter D. Matheny and Howard V. Meredith, “Mean Body Size of Minnesota Schoolboys of Finnish and Italian Ancestry,” American Journal of Physical Anthropology 5, no. 3 (1947): 344. 49. Meredith, 884. 50. Tanner, A History of the Study of Human Growth, 491–492. 51. Heather Munro Prescott, “‘I Was a Teenage Dwarf’: The Social Construction Of ‘Normal’ Adolescent Growth and Development in the United States,” in Stern and Markel, Formative Years, 160. 52. Waldo Nelson, Textbook of Pediatrics, with the Collaboration of Eighty-One Contributors (Philadelphia: Saunders, 1959), 44. 53. Harold C. Stuart and Howard V. Meredith, “Use of Body Measurements in the School Health Program,” American Journal of Public Health and the Nation’s Health 36, no. 12 (December 1946): 1370–1371. 54. “How Children Should Grow: Grid Discards ‘Average Size,’ Charts Progress of Seven Body Types,” Life, April 10, 1950, 80–81. 55. Ibid. 56. Ibid., 82. 57. Jeffrey Jensen Arnett, “G. Stanley Hall’s Adolescence: Brilliance and Nonsense,” History of Psychology 9, no. 3 (2006): 186–197. 58. “How Children Should Grow,” 79. 59. Stanley Marion Garn, “Physical Growth and Development,” American Journal of Physical Anthropology 10, no. 2 (1952): 186–187. 60. H. M. Kallen, “Psychology Without Compromise,” The Dial, March 1925, 236. 61. “Review of Problem Children, by Alfred Adler,” The British Medical Journal 2, no. 3684 (August 15, 1931): 300. 62. Lewis Way, Alfred Adler: An Introduction to His Psychology (New York: Pelican Books, 1956), 6. 63. Alfred Adler, The Science of Living (Garden City: Garden City Publishing Company, 1929), 173.

NOTES TO PAGES 94 –99

167

64. Genevieve Forbes Herrick, “Holds Plane of Life is Fixed in First 5 Years,” Chicago Daily Tribune, February 16, 1927, 33. 65. Adler, 181. 66. Herrick. 67. Adler, 64–65 68. Ibid., 93. 69. Ibid., 94–95. 70. Ibid. See also “Dr. Adler on Complexes,” Los Angeles Times, February 17, 1929, B4. For references illustrating use of the term Napoleon Complex at this time, see Christine Sadler, “Officials Warn Raid Wardens Against ‘Napoleon’ Complexes,” Washington Post, January 27, 1942, 26; Walter Trohan, “Recall Dewey’s Napoleonic Rudeness of ‘48,” Chicago Daily Tribune, June 30, 1952, 5. 71. Comic 24, Los Angeles Times, November 4, 1951, J31. 72. Robert Coughlin, “How to Survive Parenthood: Theories on How to Raise Children Have Come Full Circle as Parents Get ‘Neuroses-Neurosis’ Wondering What to do with and to the Kids,” Life, June 26, 1950, 112. 73. Ibid., 116. 74. Ibid. 75. Ibid. 76. Celia B. Stendler, “Sixty Years of Child Training Practices,” Journal of Pediatrics, 36, no. 1 (1950): 125. 77. Smith and Thom, Health, 13. 78. Ibid., 223. 79. Ibid., 226. 80. Stendler, 132. 81. Benjamin Spock, The Common Sense Book of Baby and Child Care, 2nd ed. (New York: Duell, Sloan and Pearce, 1957), 1. 82. Ibid., 3. 83. Rima D. Apple, Perfect Motherhood: Science and Childrearing in America (New Brunswick, Rutgers University Press, 2006), 117. 84. Elaine Tyler May, Homeward Bound: American Families in The Cold War Era (Basic Books, 1999), x. 85. Apple, 108. 86. Benjamin Spock, The Common Sense Book of Baby and Child Care, 1st ed. (New York: Duell, Sloan and Pearce, 1946), 492; Spock, Common Sense Book, 1957, 578. 87. Spock, 1946, 497–496; Spock, 1957, 580–581. 88. Ibid. 89. Spock, 1946, 362; Spock, 1957, 437. 90. M. S. Raben, “Preparation of Growth Hormone from Pituitaries of Man and Monkey Science,” Science 124, no. 3253 (May 3, 1957): 883–84, 884 footnote 7. 91. Dwight J. Ingle to Professor Choh H. Li, February 14, 1951, Carton 2, Folder

168

NOTES TO PAGES 99–101

“Ingle, Dwight Upjohn Co.”; Contract, March 24, 1950, Carton 2, Folder “Major Randolph T. Merck & Co,” Choh Hao Li Papers. 92. For a further investigation into Li’s relationship with pharmaceutical companies and the topic more generally, see Dominique Tobbell, Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences (Berkeley, UC Press, 2011). 93. While Li also published a paper indicating his lab’s ability to crystallize growth hormone, supposedly his process did not yield large enough quantities for research. See Wilhelmi, Fishman, and Russell and J. C. Beck et al., “Metabolic Effects of Human and Monkey Growth Hormone in Man,” Science 124, no. 3253 (1957): 884. 94. Beck et al., 884. 95. Lewis, Klein, and Wilkins, “Effect of Pituitary Growth Hormone on Dwarfism,” 463. 96. Raben, “Preparation of Growth Hormone,” 883, footnote 7; Letter from E. C. Kleiderer to Choh H. Li, September 4, 1951, Carton 2, Folder “Eli Lilly and Co.”; Letter to Dr. Otto K. Behrens from Choh Hao Li, May 10, 1955, Choh Hao Li Papers. 97. Choh Li and H. Papkoff, “Preparation and Properties of Growth Hormone from Human and Monkey Pituitary Glands,” Science 124, no. 3235 (December 1956): 1293; Otto K. Behrens to Dr. Choh Hao Li, May 24, 1956, Choh Hao Li Papers. 98. Ernest Knobil, Richard C. Wolf, and Roy O. Greep, “Abstracts of Papers Presented at the Thirty-Eighth Meeting: Some Physiologic Effects of Primate Pituitary Growth-Hormone Preparations in the Hypophysectomized Rhesus Monkey,” Journal of Clinical Endocrinology and Metabolism 16, no.7 (1956): 912–992. Abstract #10 is on page 916. 99. “The 1958 Annual Meeting,” Journal of Clinical Endocrinology and Metabolism, 18, no.5 (1958): 545–553, 548–549; “Human Growth Hormone: Prolonged Administration of Moderate Doses in Three Patients with Panhypopituitarism,” abstract #40, “Human Growth Hormone: Prolongued Administration of Moderate Doses in Three Patients with Panhypopituitarism,” by Philip H. Henneman was presented in the section titled “Pituitary and Hypothalamus.” The abstract from this paper was cited by subsequent researchers as a successful case of HGH therapy and became the basis for an article published in 1960. 100. John J. Hutchings et al., “Metabolic Changes Produced by Human Growth Hormone (Li) in a Pituitary Dwarf,” Journal of Clinical Endocrinology and Metabolism 19, no.7 (1959): 761. 101. Ibid., 759. Letter from Robert Escamilla to Choh Li, September 25, 1958. Carton 4, Folder “Escamilla, Robert, “ Choh Hao Li Papers. 102. “Find Pituitary Hormone Aids Girl’s Growth,” Chicago Daily Tribune, August 24, 1958, 26. 103. Maurice S. Raben, “Treatment of a Pituitary Dwarf with Human Growth Hormone,” Journal of Clinical Endocrinology and Metabolism 18, no. 8 (August 1958): 901–903.

NOTES TO PAGES 101–108

169

104. Ibid. 105. Ibid., 901.

Chapter 4 1. Shearer, “We Can End Dwarfism!” 2. Ibid., 5. 3. Ibid. 4. Ibid., 5–6. 5. Ibid., 6. 6. Ibid. 7. Cohen and Cosgrove, Normal and Any Cost; Peterson, Our Daily Meds; and Conrad, The Medicalization of Society; Rothman and Rothman, The Pursuit of Perfection. 8. Raymond Mellenger to Elizabeth Force, director of Medical Sciences National Academy of Sciences, July 30, 1973, Committee for Evaluation of National Pituitary Agency Files, National Research Council Division of Medical Sciences Records Group, 1946–1973, National Academies Archives, Washington, DC (hereafter cited as Committee for Evaluation of National Pituitary Agency Files). 9. From Ann Johnson, MD, University of Virginia School of Medicine Department of Pediatrics to Dr. Elizabeth Force and Robert T. Chatterson, June 26, 1973, Committee for Evaluation of National Pituitary Agency Files. 10. Leonard Sussman to Elizabeth Force, July 11, 1973, Committee for Evaluation of National Pituitary Agency Files. 11. Ibid. 12. Ibid. 13. Dr. H. David Mosier to Elizabeth Force, July 27, 1973, Committee for Evaluation of National Pituitary Agency Files. 14. A. Wilhelmi, responses to questions for Panel I, Folder “Wilhelmi, Dr. A,” Committee for Evaluation of National Pituitary Agency Files. The Hormone Laboratory moved to University of California, San Francisco in 1967; Li remained its director. 15. “News Notes,” Science, New Series 132, no. 3422 (July 29, 1960): 284. 16. “Pituitary Bank Foundation Fifth Annual Meeting—Minutes,” September 13, 1967, 3, Folder “Pituitary Bank,” Choh Hao Li Papers. 17. Dr. H. David Mosier to Elizabeth Force, July 27, 1973, Committee for Evaluation of National Pituitary Agency Files. 18. Carton 8, Folder “National Pituitary Agency,” Choh Hao Li Papers. 19. S. Douglas Frasier, “The Not-So-Good Old Days: Working with Pituitary Growth Hormone in North America, 1956 to 1985,” Journal of Pediatrics 131, no. 1 part 2 (July 1997): S52. 20. They entertained a protocol for the collection, storage and shipment of human growth hormone proposed by Dr. Sanford Steelman of Merck and Co. Supposedly

170

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Merck was making “clinical grade” human growth hormone in high yield. Carton 8, Folder “National Pituitary Agency,” Choh Hao Li Papers. 21. Salvatore Raiti to Elizabeth Force pertaining to specific questions pertaining to the evaluation, September 11, 1973, File: NPA Background, Committee for Evaluation of National Pituitary Agency Files. 22. Ibid. 23. Salvatore Raiti, “To All Pathologists,” March 15, 1973, Committee for Evaluation of National Pituitary Agency Files. 24. Betty Latty, “Rare Treatment Helps Dwarfed Children Grow,” Los Angeles Times, June 5, 1970, 11. 25. Cohen and Cosgrove, 76; Human Growth, Inc., Dwarfism: The Butt of Jokes— The Challenge of Science (1964), Human Growth Foundation Folder, Little People of America Archives. 26. Latty. 27. Mariah Heath Mundy, “Undersized Boy Helps Others Like Him,” New York Times, August 20 1972, 77. 28. Report, “Operational Procedures in Brief,” Committee for Evaluation of National Pituitary Agency Files. For a brief period there was an initiative at the Veteran’s Administration program in the Bronx organized by Dr. Harold Elrick. The program deteriorated after Elrick left until Dr. Teh Lee took over. The NPA assumed responsibility of the collections of glands at that point. Dr. Wilhelmi, “Answers to questions for Panel I,” May 22, 1973, 1, Committee for Evaluation of National Pituitary Agency Files. 29. G. Donald Whedon, “Opening Address,” in Advances in Human Growth Hormone Research: A Symposium held at Baltimore, Maryland, October 9–12, 1973, ed. Salvatore Raiti (Washington, DC: DHEW publication (NIH), 1974), 15. 30. Report, Part 3, “B. Quality of Products, A. Human Growth Hormone— Preparation, Structure, Standardization, Distribution,” Committee for Evaluation of National Pituitary Agency Files. 31. Ibid. 32. S. Douglas Frasier, “Clinical use of NPA Human Growth Hormone,” Committee for Evaluation of National Pituitary Agency Files. 33. Report, Part 3, “B. Quality of Products.” 34. Cohen and Cosgrove, 94–97. 35. Centers for Disease Control and Prevention, “CJD, (Creutzfeldt-Jakob Disease, Classic),” accessed August 16, 2012, http://www.cdc.gov/ncidod/dvrd/cjd/. 36. Cohen and Cosgrove, 80–82; National Endocrine and Metabolic Diseases Information Service, National Hormone and Pituitary Program (NHPP): Information for People Treated with Pituitary Human Growth Hormone (Comprehensive Report) (Washington, DC, NIDDK, March 2014): 1, accessed August 8, 2014, http://endocrine. niddk.nih.gov/pubs/creutz/hGH_Comprehensive_Report_508.pdf.

NOTES TO PAGES 110 –115

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37. G. Donald Whedon, “Opening Address,” in Advances in Human Growth Hormone, 15. 38. Ibid. 39. International Symposium on Growth Hormone, Growth and Growth Hormone; Proceedings of the Second International Symposium on Growth Hormone, Milan, May 5–7, 1971 (Amsterdam: Excerpta Medica, 1972), 19. 40. Solomon Kaplan, MD, “Chapter 1: Growth and Growth Hormone: Disorders of the Anterior Pituitary, in Clinical Pediatric and Adolescent Endocrinology, ed. Solomon Kaplan, (Philadelphia: W.B. Saunders Company, 1982), 35–37. 41. National Pituitary Agency, Report, Section A: HGH, December 31, 1972, Committee for Evaluation of National Pituitary Agency Files. 42. Frasier, “The Not-So-Good Old Days,” S3. 43. Ibid. 44. Ibid. 45. Richard E. Behrman, Victor C. Vaughan, and Waldo E. Nelson, Nelson Textbook of Pediatrics (1979; Philadelphia: W. B. Saunders company, 1983), 43. 46. Kaplan. 47. Shearer; Robert Steinbrook, “Hormone Means Life Is Looking up for Short People,” Chicago Tribune, Tempo, May 23, 1978, A1. 48. Walter Alvarez, “Little Help for Short Child,” Los Angeles Times, December 26, 1966, D12; “Children with Growth Ills ‘Starve’ for Hormone Shots,” Chicago Tribune, September 5, 1971, A5; “Helping the Little People,” Time, May 7, 1973, 106; Steinbrook. 49. Alvarez. 50. “Helping the Little People,” 106. 51. Steinbrook. 52. Ibid. 53. Carolyn Lewis, “Their Hope Grows by the Yardstick,” Washington Post, July 1, 1965, F5. 54. Leo Bowler, “Virgil is Proud of 5 feet 3: Scripps Doctors Make Dwarf 11 Inches Taller,” Evening Tribune San Diego, June 29, 1965, A23. 55. Ibid. 56. Lewis. 57. Ernesto Pollitt and John Money, “Studies in The Psychology of Dwarfism I. Intelligence Quotient and School Achievement,” Journal of Pediatrics 64, no. 3 (1964): 421. 58. Pollitt and Money, 415; John Money and Ernesto Pollitt, “Studies in the Psychology of Dwarfism II. Personality Maturation and Response to Growth Hormone Treatment in Hypopituitary Dwarfs,” Journal of Pediatrics 68, no. 3 (1966): 389. 59. Money and Pollitt, 388. 60. Ibid., 386. 61. Michael Gordon et al., “Psychosocial Aspects of Constitutional Short Stature:

172

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Social Competence, Behavior Problems, Self-Esteem, and Family Functioning,” Journal of Pediatrics 101, no.3 (1982): 477; Brian Stabler and Louis E. Underwood, Slow Grows the Child: Psychological Aspects of Growth Delay (Hillsdale: Lawrence Erlbaum Associates, 1986); Ruth F. Gold, “Constitutional Growth Delay and Learning Problems,” Journal of Learning Disabilities 11, no. 7 (1978): 36–38. 62. Hans-Christoph Steinhausen and Nikolaus Stahnke, “Psychoendocrinological Studies in Dwarfed Children and Adolescents,” Archives of Disease in Childhood 5, no.10 (1976): 780. 63. Ibid., 782. 64. Gordon et al., 479–480. 65. Stabler and Underwood, 27. 66. C. M. Law, “The Disability of Short Stature,” Archives of Disease in Childhood 62, no. 12 (1987): 855. 67. Virginia Mansfield, “Growing Up in a Tall World,” Washington Post, February 18, 1982, MD1. 68. Stabler and Underwood, xi. 69. “Symposium Focuses on Short Stature,” Galveston Daily News, March 20, 1979, 2-A. 70. Richard R. Clopper et al., “Chapter 7: Post-Treatment Follow-up of Growth Hormone Deficient Patients: Psychosocial Status,” in Slow Grows the Child, 95. 71. C. M. Mitchell et al., “Chapter 8: Psychosocial Impact of Long-Term Growth Hormone Therapy, in Slow Grows the Child, 108. 72. Henry G. Friesen, “Raben Lecture 1980: A Tale of Stature,” Endocrine Reviews 1, no. 4 (1980): 309. 73. Feldman, “Presentation of Shortness in Everyday Life.” 74. Feldman;. “Toward a Sociology of Stature,” in Lifestyles, eds. Saul D. Feldman and Gerald W. Thielbar (Boston: Little, Brown, 1972), 437. 75. Ibid. 76. Ibid., 442. 77. Jeffrey F. Popkin and Fred Sassoon, “Heightism and the Short Man: An Exploratory Study,” (MSW thesis, School of Social Welfare, University of California Los Angeles, 1977). 78. John S. Gillis, Too Tall, Too Small (Champaign: Institute for Personality and Ability Testing, inc., 1982), 10. 79. Feldman and Thieblar, 438. 80. Popkin and Sassoon, 17. 81. Ibid., 23–24. 82. Feldman. 83. Garrison Nelson and W. Ross Brewer, “Watch Out, Jimmy—Ford and Reagan are Taller,” Los Angeles Times, July 11, 1976, B4. 84. Popkin and Sassoon, 5.

NOTES TO PAGES 119–126

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85. Feldman and Thieblar, 439. 86. Ibid., 440. 87. Carol Kramer, “Minilib: Short Men Just Want Us to Look up to Them,” Chicago Tribune, April 29, 1975, B1. 88. Popkin and Sassoon, 5. 89. Feldman and Thieblar, 437. 90. Popkin and Sassoon,13. 91. Randy Newman, “Short People,” Little Criminals, 1977. 92. Robert Hilburn, “Pop Music,” Los Angeles Times, March 5, 1978, N72. 93. Carol Oppenheimer, “‘Short People’ Song Sets Off a Tall Furor,” Chicago Tribune, January 8, 1978, 3. 94. Peter V. V. Hamill, “NCHS Growth Curves for Children Birth-18 Years: United States,” ed. National Center for Health Statistics, Vital Health Statistics, 165, no. 11 (1977): 1. 95. Ibid. 96. Ibid. 97. Ibid., 2. 98. Tanner, A History of the Study of Human Growth, 394. 99. Ibid. 100. Ibid., 395. 101. Drugs@FDA, “Drug Details, Asellacrin 10,” accessed August 10, 2014, http:// www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search. DrugDetails. 102. Drugs@FDA, “Drug Details, Crescormon,” accessed August 10, 2014, http:// www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search. DrugDetails. 103. Sally Smith Hughes, Genentech: The Beginnings of Biotech (Chicago: University of Chicago Press, 2011), 49–55. 104. Ibid., 111. 105. Nicolas Rasmussen, Gene Jockeys: Life Science and the Rise of Biotech Enterprise (Baltimore, Johns Hopkins University Press, 2014): 83. 106. Ibid., 89–91. 107. Smith Hughes, 119. 108. Ibid., 121. 109. Kabi Group Inc.’s advertisement for Crescormon, “Now You Can Prescribe Somatropin: Crescormon,” Journal of Pediatrics 199, no. 5 (1981): 14A. 110. “National Institute of Arthritis, Metabolism, and Digestive Diseases Research Materials Available to Qualified Investigators,” Journal of Clinical Endocrinology and Metabolism 50, no. 1 (1980): 209–10. 111. Serono Pharmaceuticals’ advertisement for Asellacrin, “The Miracle of Growth,” The Journal of Pediatrics 98, no. 3 (1981): A46–48.

174

NOTES TO PAGES 126 –131

112. Serono Pharmaceuticals advertisement for TGE, Journal of Pediatrics 99, no. 6 (1981): A44–45. 113. Ibid. 114. Genentech Inc., Advertisement for Protropin, Journal of Pediatrics (1984): 6A–9A. 115. Serono Pharmaceuticals subsidized the conference documented in Slow Grows the Child; Serono Pharmaceuticals’ advertisement for Asellacrin, “Series 2: Subcutaneous Injection,” Journal of Clinical Endocrinology and Metabolism 60, no. 6 (1985): 17–20A. 116. Salvatore Raiti, “Human Growth Hormone and Creutzfeldt-Jakob Disease,” Annals of Internal Medicine 103, no. 2 (1985): 288–9. 117. Smith Hughes, 127. 118. Genentech, Inc. Protropin, “Out of Today’s Technology Tomorrow’s Growth”, Journal of Pediatrics 108, no. 1 (January 1986): 27A–31A. 119. Deborah Franklin, “Growing up Short,” Science News 125, no. 6 (February 11, 1984): 93. 120. Sandra Blakeslee, “Supply of Growth Hormone Brings Hope for New Uses: Growth Hormone’s Promise Brings Fear of Abuse,” New York Times, February 10, 1987, C11. 121. Wendy L. Wall, “Eli Lilly Gets Approval to Sell Growth Hormone,” Wall Street Journal, March 10, 1987, 18. 122. Ibid. 123. Gina Kolata and Alan L. Otten, “Synthetic Growth Hormone Raises Hopes of Man—and Ethical Concerns Over Use,” Wall Street Journal, April 8, 1987: 33. 124. Russell Baker, “Think Twice about Growth, Dads and Lads.” Chicago Tribune, January 9, 1987, 19. 125. Blakeslee. 126. Gina Kolata, “New Growth Industry in Human Growth Hormone?” Science 234, no. 4772 (1986): 22–24. 127. Ibid., 22.

Epilogue 1. Cuttler and Silvers, “Growth Hormone and Health Policy,” 3152. 2. “Growth Hormone Illegal for Off-label Anti-Aging Use, Study Warns,” ScienceDaily, November 8, 2005, http://www.sciencedaily.com/releases/2005/11/051108084527.htm. 3. George Mitchell, “Report to the Commissioner of Baseball of an Independent Investigation into the Illegal use of Steroids and Other Performance Enhancing Substances by Players in Major League Baseball. Summary and Recommendations,” Office of the Commissioner of Baseball (New York: NY, 2007): SR-36. 4. Ibid.

NOTES TO PAGES 132–134

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5. Gail Gibson, “Congress Set to Probe Use of Steroids in Baseball: Hearing Opens Tomorrow Top Names Called to Testify,” Baltimore Sun, March 16, 2005, http:// articles.baltimoresun.com/2005–03–16/news/0503160203_1_contempt-of-congresssubpoenas-steroids. 6. Maria Newman, “Congress Opens Hearing on Steroid Use in Baseball,” New York Times Learning Network, March 18, 2005, http://www.nytimes.com/learning/ teachers/featured_articles/20050318friday.html. 7. Centers for Disease Control and Prevention, “Testimony on Steroid Use Among Females: Results of the Youth Risk Behavioral Surveillance System before Committee of Government Reform,” June 15, 2005, http://www.hhs.gov/asl/testify/t050615a.html. 8. Dan Jung, “Congressional Hearing on Steroids in Baseball,” washingtonpost. com, March 16, 2005, http://www.washingtonpost.com/wp-dyn/articles/A41366– 2005Mar16.html. 9. Duff Wilson, “After a Young Athlete’s Suicide, Steroids are Called the Culprit,” New York Times, March 10, 2005, A1. 10. Ibid. 11. Adda Grimberg, E. Stewart, and M. P. Wajnrajch, “Gender of Pediatric Recombinant Human Growth Hormone Recipients in the United States and Globally,” Journal of Clinical Endocrinology and Metabolism 93, no. 6 (2008): 2050–56. 12. Ibid. 13. Grimberg , Stewart and Wainraich, 2055. The lead author of the article, Adda Grimberg, received an honorarium and travel expenses from Pfizer to present preliminary data from this study at the 2006 Pfizer International Growth Study. United States investigators Elizabeth Stewart and Michael P. Wajnrajch were also employees of Pfizer. 14. Robert Delcampo, Teresa Chase, and Diana s. Delcampo, “Growth Disorders in Children: The Impact on the Family System,” Family Relations 33, no. 1 (1984): 79. 15. Barry Werth, “How Short is Too Short,” New York Times Magazine, June 16, 1991, 29. 16. Deborah Franklin, “Growing up Short,” Science News 125, no. 6 (February 11, 1984): 92, B. Stabler et al., “Behavior Change after Growth Hormone Treatment of Children with Short Stature,” Journal of Pediatrics 133, no. 3 (1998): 366–73. 17. D. E. Sandberg, A. E. Brook, and S. P. Campos, “Short Stature: A Psychosocial Burden Requiring Growth Hormone Therapy?” Pediatrics 94, no. 5 (1994): 832–840; D .E. Sandberg et al., “Height and Social Adjustment: Are Extremes A Cause for Concern and Action?” Pediatrics 114, no.3 (2004): 744–750; Melissa D. Colsman et al., “Treating Short Stature with Growth Hormone,” American Medical Association Journal of Ethics, Virtual Mentor 7, no. 11 (2005), n.p., accessed January 23, 2015, http:// virtualmentor.ama-assn.org/2005/11/toc-0511.html. 18. Colsman et al., 17–25. 19. Ibid.

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20. Ibid. 21. Werth, 28. 22. Ralph T. King Jr., “Charity Tactic by Genentech Stirs Questions,” Wall Street Journal, August 10, 1994, B1. 23. Department of Health and Human Services, Food and Drug Administration, Endocrinologic and Metabolic Drugs Advisory Committee Meeting, June 10, 2003, transcripts, accessed January 15, 2015, http://www.fda.gov/ohrms/dockets/ac/cder03. html, 1–19. 24. Ibid., 20–30. 25. Ibid., 183. 26. Ibid., 188. 27. Ibid., 189. 28. Ibid., 193–203. 29. Ibid., 203. 30. Leona Cuttler and J. B. Silvers, “Growth Hormone Treatment for Idiopathic Short Stature: Implications for Practice and Policy,” Archives of Pediatrics and Adolescent Medicine 158, no.2 (2004): 108. 31. Cuttler and Silvers, “Growth Hormone and Health Policy,” 3150. 32. R. J. Kuczmarski, C. L. Ogden, S. S. Guo, et al. “2000 CDC Growth Charts for the United States: Methods and Development,” ed. National Center for Health Statistics, Vital Health Statistics, 262, no. 11 (2000): 12. 33. Stephen Hall, “The Short of It,” New York Times, October 16, 2005, ES4. 34. Ibid. 35. Genentech Inc.’s website for Nutropin, accessed October 20, 2011, http://www. nutropin.com/tools-resources/faqs/pghd.jsp. 36. Elana Pearl Ben-Joseph, Steven A. Dowshen, and Neil Izenberg, “Do Parents Understand Growth Charts? A National, Internet-Based Survey,” Pediatrics 124, no. 9 (2009): 1100. 37. Tanner, A History of the Study of Human Growth, 394. 38. Ben-Joseph, Dowshen, and Izenberg., 1100. 39. Jonathan Rauch, “Short Guys Finish Last,” Economist (December 1995), http:// www.jonathanrauch.com/jrauch_articles/height_discrimination_short_guys_finish_ last/. 40. Ibid. 41. Rubin, Rita. “The Debate Is Growing: Is Being Short a Disability,” USA Today, November 13, 2006, 6D. 42. Ibid. 43. Ibid. 44. Cuttler and Silvers, “Growth Hormone Treatment,” 108. 45. Cuttler and Silvers, “Growth Hormone and Health Policy,” 3154. 46. Evi Heilbrunn, “Top Health Insurance Companies,” US News and World

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Report, November 5, 2014, http://health.usnews.com/health-news/health-insurance/ articles/2013/12/16/top-health-insurance-companies; Aetna, “Growth Hormone (GH) and Growth Hormone Antagonists,” Clinical Policy Bulletin (2014): number 0170; UnitedHealth Care Community Plan, Growth Hormone: Prior Authorization Request Form, December 2013; Kaiser Permanente, Flexible Choice Coverage 2010, Summary of Benefits, 2010, 6; Anthem, “Position Statement: Growth Hormone Therapy in Children and Adolescents,” Medical Policy, 2014. All work cited in this footnote was accessed January 10, 2015. 47. Earl A. Gershenhow, “Mini Primer on How to Handle an Appeal of Denial of Insurance Coverage of Growth Hormone Replacement Therapy,” Human Growth Foundation, July 1, 2007, 1, accessed January 8, 2015, http://www.hgfound.org/res_ medicalinsurance_claims_appeals.asp. 48. US Social Security Administration, “Child Starter Kit. Disability Starter Kits,” n.p., n.d. 49. US Social Security Administration, “DI 24598.001, Growth Impairment— General Information,” Program Operations Manual System June 9, 2011, accessed January 10, 2015. 50. Rubin; Ibid. 51. “Humatrope DirectConnect Is Here for You,” Humatrope: Patient Support, Lilly USA, December 1, 2014, accessed January 21, 2015. 52. Independent Medical Review Search, Department of Managed Health Care, State of California, accessed January 16, 2015. 53. “Human Growth Hormone Therapy for Children and Adults.”

Coda 1. Mathias Jucker and Lary C. Walker, “Neurodegeneration: Amyloid-ß Pathology Induced in Humans,” Nature 525 (September 2015): 193–94.

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Archives and Special Collections Baby Books Collection, Louise M. Darling Biomedical Library at University of California, Los Angeles. Case Western Reserve University Archives, Records of the Sociology Department, Cleveland Ohio. Choh Hao Li Papers, 1937–1987, Archives and Special Collections, University of California, San Francisco Library & Center for Knowledge Management. Committee for the Evaluation of the National Pituitary Agency, Central Files, National Academies of Sciences Archives, Washington, DC. Eugenics Record Office Records, American Philosophical Society, Philadelphia, Pennsylvania. Herbert McLean Evans Papers, Archives and Special Collections, University of California, San Francisco Library & Center for Knowledge Management. National Child Labor Committee Collection, Library of Congress Prints and Photographs Division, Washington, DC. Parke, Davis Research Laboratory Records, National Museum of American History’s Archives Center, Washington, DC. Records of the Sociology Department, Case Western Reserve University Archives, Cleveland, Ohio. Scripps Research Institute Archive, Mandeville Special Collections Library, University of California San Diego.

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Index

Adler, Alfred, 93–95, 114 adrenocorticotropic hormone (ACTH), 7, 89, 99 Alzheimer’s disease, 145 American Academy of Pediatrics (AAP), 41, 89, 122 American Chemical Society, 64 American Medical Association (AMA), 32, 39, 41–42, 90 American Pediatric Association, 88 American Pediatric Society (APS), 32, 41 Anomalies and Curiosities of Medicine (Gould and Pyle), 56 anterior pituitary hormone deficiency, 80, 83–84 Anthropometry, 3, 25–30, 32, 82; at Chicago’s Century of Progress World’s Fair, 73 Antuitrin, 63, Antuitrin-A, 63; Antuitrin-B, 63 Antuitrin-G, 63–66, 68–69, 85. See also Parke, Davis and Company Armour Laboratories, 62, 84–85, 88, 99, Growth Complex, 84–86 Anterior Pituitary Powder, 84–85, 87 Asellacrin (Serono Pharmaceuticals), 124, 126–7 baby book, 34–36, 40

baby health conference, 3 Bartz, Quentin, 66, 85 better baby contests, 39 Barnum and Bailey Circus, 58 Barnum, P. T. 54 Blizzard, Robert, 107–8 Boas, Franz, 27–28, 33 Bowditch, Henry, 26–27, 31–33, 38 Burroughs Wellcome, 62 cadaver Human Growth Hormone (cHGH), 4, 80, 101–17, 121; commercial, 124–8; FDA hearing, 137; Creutzfeldt-Jakob Disease (CJD), 127–8, 145 California: California Pacific International Exposition in San Diego, 72; Child Health Day, 38, consumers in, 142; growth survey, Oakland, 28; Hyland Laboratory, 109; Independent Medical Review (IMR), 142; medical inspection of pupils, 42; Golden Gate International Exposition, 73, 162n132; Panama-California Exposition (San Diego), 42; Panama-Pacific International Exhibition (PPIE, San Francisco), 24; San Diego Union, 102–6; Scripps Clinic in La Jolla, 113. See also University of California Canseco, Jose, 132

190

INDEX

Caremark Rx, 135 Centers for Disease Control (CDC), 121–3, 132, 138 Chadwick, Edwin, 17–18 Century of Progress World’s Fair (Chicago), 71–74 Child Health Day, 36, 38–40, 45–46 childhood: endocrine therapy, 89; industrialization 15, 16; Progressives, 19, 24; The Diagnosis of Treatment of Endocrine Disorders in Childhood and Adolescence (Wilkins), 67, 89; disability, 142; disease 32, Diseases of Infancy and Childhood (Holt), 38, 73, 82; growth hormone therapy, 116; normalization of, 81; psychological study of, 94–95, 121; stature, 92–93, 104, 134–5 child labor: anti-child labor campaign (US), 18–25; Europe, 16–18; Fair Labor Standards Act, 25; regulation of child labor in Europe, 16–18, and in United States, 15–16, 18–19, 25. See also Hine, Lewis Child’s Health Organization (CHO), 43–44 circus: Barnum and Bailey, 58–59; freaks, 56–58, 71. See also midget performers Clark University, 27–28, 29 Clemens, Roger, 131 Columbian Exposition, 28 Coney Island: Dreamland, 59–60 Congress of American Physicians and Surgeons, 52 Constitutional Short Stature (CSS), 115 Crescormon, 124–126 Creutzfeldt-Jakob Disease (CJD), 11, 104, 110, 127–8, 145 Cushing, Harvey, 52, 61, 64–65

Department of Health, Education, and Welfare (DHEW), 122 disability, 6; disability studies, 9–10; medical model 48; Benjamin Spock, 98–99; short stature, 112–5, 140–2; Social Security Administration, 141–2 dwarfism, 66, 73, 83, 105; Hattie Williams (Princess Weenie Wee), 53; hypopituitary dwarfs, 108; in the media, 11, 70, 102–4, 112–3; pituitary dwarfism, 65, 84–85, 100–1; Snow White and the Seven Dwarfs, 76-77; Stratton, Charles Sherwood, 54

Deamer, William C., 88–89

Factory Acts, 16–17

Eli Lilly, 2, 99–100, 125, 129, 135–8, 142 Emory University, 99, 107, 109–10 endocrinology, 48, 50, 52, 63; Association for the Study of Internal Secretions, 67; historiography of, 7–8, 10; in the media, 69–70, 115, 117, 126, 129; pediatric, 2, 4, 11, 67, 80, 88–89, 90, 109–12, 116–7, 123–4, 137 Endocrine Society: annual meetings, 100–1, 117 Engelbach, William, 64–65, 67–69, in the media, 70 estrogen therapy, 112 Eugenics, 25–26, 39, 81. See also Laughlin, Harry Evans, Herbert, 52, 61–62, 64, 68, 84–85 extract: anterior pituitary, 67–69, 85; glandular, 51; growth-promoting hormone extracts, 48, 60–61; human growth hormone, 108–9, 117, 145 (Coda); pituitary (gland), 60-66, 70, 79, 87–88; testicular, 51; thyroid, 66. See also Antuitrin-G and growth hormone, medications

INDEX

fair, 56, 60; Century of Progress World’s Fair, 71–74, 162n136; Columbian Exposition, 28; Golden Gate International Exposition, 74, 162n132; Great Lakes Exposition, 74; Iowa State Fair, 39; Louisiana Purchase Exposition, 60; New York’s World’s Fair, 74; Pacific International Exposition, 73; Panama-California Exposition, 24; Panama Pacific International Exposition, 24; Texas Centennial Exposition, 73–74 father: as activist, 108; depicted in the media, 113–4; idealized notions of, 45, 118; parenting advice, 97–98; psychoanalysis, 96 Feldman, Saul, 5, 117–20 Fels Research Institute: growth study, 122–3 femininity, 53, 112, feminized, 83 Food and Drug Administration (FDA), 1–2, 104, 124–5, 127–31, 136–8, 142, Endocrinologic and Metabolic Drugs Advisory Committee, 136–37 “freaks”: circus, 58–59; Freaks (1932), 75; freak show, 72; lusus naturae, 56; medicalization of, 48, 56–60; museum, 58; negative portrayal of, 59– 60, 70–71; popularity of, 55; science’s interest in, 56, 60; vaudeville, 57–58. See also “midget” performers Fröhlich’s syndrome, 83 Galton, Francis: percentile, 139 Genentech, Inc., 124, 135–6, Nutropin, 1–2, 138, 142–3; Protropin, 104, 125, 128–30 gonads: gonatropic, 65; hormone, 83, 85; hypogonadism, 66, 82–83 growth charts and tables: in baby books, 34, 40, Baldwin-Wood tables, 43; Centers for Disease

191

Control (CDC) charts, 138; and class, 82, 92; and gender, 33, 37, 80, 84, 101; critique of, 44, 123; in marketing, 126–7, 138–9; in the media, 120; National Center for Health Statistics/ Centers for Disease Control (NCHS/CDC) charts, 103–4, 121–3, 138; in pediatrics, 26, 81–82, 31–33, 41, 123–4; in Public Health, 37–38, 41; Quelelet, Adolphe, 31; and race, 33–34, 80, 84, 101; use in schools, 43, 90–92, 135–6; World Health Organization (WHO), 121–2. See also Physical Growth Record, Sheldon William, Stuart-Meredith charts, and Wetzel Grid growth hormone: discovery of, 60–62; isolation of, 79, 85, 87–88; species-specificity, 62, 66, 85, 99–101. See also Human Growth Hormone growth hormone deficiency (GHD) 1–2, 4, 11, 65, 67, 89, 102–104, 111, 113, 115, 117, 124, 129–30, 134, 136–7, 141 growth hormone, medication: Anterior Pituitary Powder, 84–85, 87; anterior preparations featuring growth hormone, 52, 62, 63; Antuitrin-G, 63–66, 68–69, 85; Asellacrin, 124, 126–7; Crescormon, 124–6; Genotropin, 133; Growth Complex, 84–86; Humatrope, 2, 129, 136–8; Nutropin, 1–2, 138, 142–3; Protropin, 104, 125, 128–30. See also National Pituitary Agency growth survey (study), 14; Boston (Massachusetts), 26–27, 33, 38; Britain, 16–17; Fels Research Institute, 122– 3; France, 18; Health Examination Surveys (NCHS), 122; Johns Hopkins Pediatric Growth Study, 114; Los Angeles, 91; Milwaukee (Wisconsin), 27; Minnesota, 91; Oakland

192

INDEX

(California), 28; Pfizer International Growth Study, 175n13; and race, 91 St Louis (Missouri), 27; Toronto (Canada), 28; used in marketing, 135–6, Washington DC, 29–30; Worcester, 27–28; Year of the Child (US Children’s Bureau), 36–38. See also Anthropometry, Bowditch, Henry, and Quelelet, Adolphe Hall, G. Stanley, 93 Harvard, Medical School, 26, 101; School of Public Health, 90–92; University, 73, 99 heightism, 4–5, 11, 104, 117–21, 126, 139–40. See also Feldman, Saul Hine, Lewis, 13, 19–25 Hintz, Raymond, 137 Holt, L. Emmett, 43, Diseases of Infancy and Childhood (book), 32–34, 37–38, 73, 82 Human Growth Foundation (HGF), 4, 108–9, 116, 127, 135–7; Mahler, Fred and Gwen, 108–9 human growth hormone (HGH): immunoassay (testing levels) 67, 111, See also cadaver human growth hormone (cHGH), growth hormone deficiency (GHD), growth hormone medication, and recombinant human growth hormone (rHGH) Humatrope, 2, 129, 136–8 Hyland Laboratory, 109 hypopituitarism, 63, 68–69, 100 Idiopathic Short Stature (ISS), 1–2, 135–9, 141–2 Independent Medical Review (IMR), 142 industrialization: impact on children 15–18, 24–25, 46; masculinity, 53, Pittsburgh Survey, 20 infantilism, 66, 68, 83

inferiority complex, 10–11, 78, 80, 93, 114. See also Napoleon Complex It’s a Small World: All About Midgets (Bodin and Hershey), 47–49, 77 Johns Hopkins University, 61, 96, 99 107, 114–6 Joint Committee on the Health Problems in Education (Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association), 42–44, 90; Physical Growth Record (pamphlet), 90–91. See also Wood, Thomas D. Kabi Pharmaceuticals, 121–6 Kaplan, Solomon, 107 Kelley, Florence, 18, 21 Kirkland, Rebecca, 130 Laughlin, Harry 73–74 Levi-Lorian dwarfism, 83 Li, Choh Hao, 79, 85–87, 99–101, 107–8 Lisser, Hans, 60–62, 67–69 Little People of America, 139, 155n1 MacDonald, Arthur, 29–30 Mann, Horace, 15 Magic Foundation for Children’s Growth, 137 Masculinity, 8–10; and boys, 1–5, 12, 80, 83, 88–89, 93–95, 98, 111–3, 118–9, 126, 130, 133, 142–3; growth hormone therapy, 111–2; growth-promoting hormone therapy, 80, 88–89; and heightism, 117–20; manhood, 9, 53, 55, 74–75; manliness, 9-10, 50, 54, 78; and “midget” performers, 49–50, 54, 56, 74–78; and modernity, 53–54; and short stature, 120, 130, 139–40 Massachusetts: Boston Growth Survey,

INDEX

26, 33, 38; child labor, 15; Board of Health of the State 26–27; General Hospital, 100; medical inspection of students, 42; Worcester, 27–28 Medicalization: of children’s height 14, 30–33, 46; of freaks, 48, 56–60; of midgets, 5, 55, 56–57, 59–60 Merck, Sharp and Dohme, 99–100, 169–70n20 Meredith, Howard V., 90–93 “midget” performers, 47–50; amusement parks and fairs, 56, 60, 71–74; circus, 58–59; It’s a Small World: All About Midgets (Bodin and Hershey), 47–49, 77; medicalization of, 48–49, 56–57, 60, 70–71; portrayal of Munchkins, 76–77; Rhodes, William, 74, 76–77; Rossow midgets, 56, 57 Schneider, Kurt (Harry Doll/Harry Earles), 74–77; Singer Midget Troupe, 59, 77; Stratton, Charles Sherwood (Tom Thumb), 54–55, 57; treatment of, 60– 61; terminology, 155n1; vaudeville, 55–57, 59; Warren, Lavinia, 54–55, 60; Williams, Hattie (Princess Weenie Wee), 58; Wizard of Oz, 76–77 The Mitchell Report, 131–2 Money, John, 114–5 mother, 45, 80; as activist, 108, 137; measuring children, 36–37; Mother’s Register, 34–36; “native mothers,” 38; and parenting advice, 95–98; portrayed in advertisements, 127, 143; role in growth hormone therapy, 102–3; testifying in front of Congress, 133 museums, 57–58; dime museums, 56; P.T. Barnum, 54 Napoleon Complex, 94–95, 131, 167n70 National Academy of Sciences, 122 National Association of Short Adults, 139–40

193

National Center for Health Statistics (NCHS), 104, 122–3, 138 National Child Labor Committee (NCLC), 13–14, 19–25; race/racism, 20–21. See also Hine Lewis, Kelley, Florence, and Wald, Lillian D. National Education Association, 43. See also Joint Committee on the Health Problems in Education National Institutes of Health (NIH), 2, 7, 102, 107, 133 National Institute of Arthritis and Metabolic Diseases (National Institute of Arthritis and Metabolic Diseases, NIAMDD), 99, 107–8 National Pituitary Agency (NPA), 4, 102–4, 105–12, 116, 124, 126–7; Canada, 108; Veterans Administration, 170n28 Noonan Syndrome, 2 Nutropin, 1–2, 138, 142–3 organotherapy, 51, 63 Origin of Species (Darwin), 25 Parke, Davis: Antuitrin-G, 63–66, 68, 85; Company, 52, 63–66, 68, 85; 99; Research Laboratory (scientists), 51, 63–66, 85; Tethelin, 63 pediatric endocrinology, 4, 11, 67, 80, 88–89, 90, 106–7, 110, 112, 116–7, 123–4, 130, 135, 137 pediatric growth study, 114–5. See also growth survey (study) pediatric growth tables, 26. See also growth charts and tables pediatricians, 14, 32–34, 41, 80–82, 84, 89, 91, 97, 102, 121, 126, 133, 136 pediatrics: American Academy of Pediatrics, 122; field of, 30–32, 80, 82, 89, 112, 115, 122; investigative, 67; Journal of Pediatrics,

194

INDEX

96, 115, 125–6. See also, American Pediatric Society, and American Pediatric Association pediatric textbooks, 32, 81–84, 91–92 Pfizer Pharmaceuticals, 175n13, Genotropin, 133 pharmaceutical companies: Armour Laboratories, 62, 84–85, 87–88, 99; Caremark Rx (distributor), 135; Eli Lilly, 2, 99–100, 125, 129, 135–8, 142; Genentech, Inc., 1–2, 104, 124–5 128–30, 135–6, 138, 142–3; Kabi Pharmaceuticals 121–6; Parke, Davis, and Company: 52, 63–66, 68, 85, 99; Pfizer, 133, 175 n13; Pitman-Moore and Company, 99–100; Serono Pharmaceuticals, 124, 126–7; Squibb and Company, 62; Wilson Laboratories, 62; Wyeth Laboratories, 99 Physical Growth Record (Stuart, Meredith), 90–91 Pitman-Moore and Company, 99–100 pituitary gland, 48, 52, description of, 61; Armour Laboratories, 84–85, 86; in the media, 60, 69–70, 78–79, 102– 3; Parke, Davis and Company, 62–64; National Pituitary Agency, 108, 112 Pollitt, Ernst, 114–5 Prader-Willi syndrome, 2 prions, 110 Progressives, 16, 18, 21; National Child Labor Committee (NCLC), 13, 14, 19–25. See also Hine, Lewis, Kelley, Florence, and Wald, Lillian D. Protropin (Genentech), 104, 125, 128–30 Psychology: educational, 29, 93; short stature, 4, 5, 10–11, 73, 80, 114–7, 134–5; psychoanalysis, 93–97, 101; and marketing growth hormone, 127–8

Quelelet, Adolphe, 31 Raben, Maurice, 99, 101, 107, 109, 117 recombinant human growth hormone (rHGH), 2, 4, 11, 129–30 133–7, 142; development of, 124–5, 127–8 Reilly, William A., 89 Riddle, Oscar, 78 Roosevelt, Franklin D., 45 Schaefer, Robert L., 64–65 school: accommodations, 140–1; and anti-child labor campaign, 20, 24; Ethical Cultural School, 19; growth surveys (study), 26–30, 135–6; medical inspection of schoolchildren, 41–44, 80, 90–91; public health campaigns, 36, 38–41; student behavior, 113, 121; student performance, 103, 113–5, 137; screening programs 135–6 Sheldon, William: classification system, 92–93 Sheppard-Towner Maternity and Infancy Protection Act, 40–41 Short People (song, Newman), 120–1 Short Stature Homeobox-Containing gene SHOX, 2 Small for Gestational Age (SGA), 2 sociology: American Sociological Association, 5; short stature, 5, 103, 117– 120, 122, sociological study, 30–31. See also heightism Spock, Benjamin: Common Sense Book of Baby and Child Care, 97–99 Stabler, Brian, 134–5 Stratton, Charles Sherwood (Tom Thumb), 54–55, 57, 60 Stuart, Harold C., 90–93 Stuart-Meredith charts, 90–93 Squibb (Pharmaceuticals), 62

INDEX

Tanner, James M., 123 testosterone, 4, 50-51, 80, 88–89, 101, 103, testicular extract, 51 thyroid hormone, 33, 68, 82, 85, 100; extract, 51, 66, 70; hypothyroidism, 69, 83 Traité des Maladies des Enfants Nouveau-nés et à la Mamelle (Billard), 31 Trans World Airlines (TWA), 108 Turner Syndrome, 2 United States Children’s Bureau (US Children’s Bureau), 36–39, 45 United States Commissioner of Education (US Commissioner of Education), 28–30 University of California, 62–63, 66, 88, 99–100, 107–8, 110; UCSF, 124–5, 129; UCSF’s Ductless Gland Clinic, 60 Vanderlaan, Willard, 113–4

Vaudeville, 55–57, 59 Villermé, Louis-René, 17–18 Wald, Lillian D. 18–19 Watson, John B., 96 Waxman, Henry A., 132 Wetzel Grid, 92–93 Wilhelmi, Alfred E., 85, 99–100, 107, 109–10 Wilkins, Lawson H., 89 Wilson Laboratories, 62–63 Wilson, Woodrow, 37 Wizard of Oz, The, 76–77 Wood, Thomas Denison, 42–44 World Health Organization (WHO), 121–2 World War I, 36–37, 59 Wyeth Laboratories, 99–100 Year of The Child, 36–38

195