How Real is Fetal Alcohol Syndrome?

Elizabeth M. Armstrong. Conceiving Risk, Bearing Responsibility: Fetal Alcohol Syndrome and the Diagnosis of Moral Disorder. Baltimore: Johns Hopkins Univ. Press, 2003. Pp. xvi+277. $42.95; Janet Golden. Message in a Bottle: The Making of Fetal Alcohol Syndrome. Cambridge: Harvard Univ. Press. 2005 (forthcoming). $25.95.

No idea in the history of medicine has had more impact in the last half century than the imperative of relating everything—discoveries, therapies, diseases themselves—to social context. Because social context is always changing, nothing in medicine is stable, or clear-cut, or obvious. Why, for example, did American practitioners discover inhalation anesthesia before their better-educated European colleagues? Because, Ernest Hook argues, the Americans were marginal professionals in a scientifically marginal country. They had fewer scruples about attending the "ether frolics" European physicians disdained. Sometimes the lightbulb of inspiration clicks on in embarrassing places (Hook 2001). And why, when inhalation anesthesia became available, didn't all patients receive it? Because 19th-century physicians believed in "a great chain of feeling": whites, rich people, women, and children were more sensitive to pain, while the darker-skinned, the lower classes, and adult men were supposed to be more insensitive (Pernick 1985, 157). Who received anesthesia depended, in part, on attitudes about race, class, gender, and age. The propriety of ether use itself depended on motive. Ether administered during surgery was unexceptionable. Ether inhaled or drunk to achieve intoxication brought condemnation.

If everything in the history of medicine needs a social context, it does not follow that social context is everything. Critics of the contextualizing trend complain that its practitioners neglect the internal logic of scientific discovery and the importance of biological factors. They resent the recasting of medical history as a "subfield of social or cultural history," to use Judith Walzer Leavitt's phrase (1990, 1472). They have retreated to bastions of internalist conservatism, such as the American Osler Society, leaving the American Association for the History of Medicine (AAHM) in the hands of the contextualists. If the AAHM's annual program is any guide, contextualists now dominate that venerable society.

Given the intellectual attractiveness and explanatory power of social context, the question becomes whether it is possible to have too much of a good thing. New books by Elizabeth Armstrong and Janet Golden, both dealing with the history of fetal alcohol syndrome (FAS), highlight this issue. For Armstrong has pushed the envelope of social construction as far as it will go, all but jettisoning the biological in her reinterpretation of FAS as a stigmatizing wastebasket diagnosis foisted on society's victims by ambitious moral entrepreneurs. Golden, by contrast, holds back, leavening her sociohistorical story with some old-fashioned medical internalism. Though Golden readily concedes that the meaning of FAS is contested, she hesitates to attribute ulterior motives to researchers or to dismiss their work as a moralizing fad.

FAS has four principal diagnostic criteria. These are (1) maternal drinking, of either the sustained or binge variety; (2) a pattern of facial anomalies, including epicanthal folds, a flat midface, and a thin upper lip; (3) growth retardation, such as low weight at birth or low body mass index in a growing child; and (4) neuro-developmental abnormalities, such as microcephaly or impaired motor skills. A child with classic FAS stigmata is funny-looking, scrawny, brain-damaged, and klutzy. The prognosis is bleak. Current thinking places full-blown FAS at one end of a spectrum of disorders caused by drinking alcohol during pregnancy. These include partial FAS, or maternal alcohol exposure plus some facial anomalies plus learning disorders and/or behavioral problems. Other diagnoses are alcohol-related birth defects, which include various malformations and dysplasias, and alcohol-related neurodevelopmental disorders. This last category, which Armstrong calls "particularly diffuse" (5), includes learning disorders and behavioral problems, such as poor impulse control...