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The Word as Scalpel:A History of

Medical Sociology

Samuel W. Bloom

OXFORD UNIVERSITY PRESS


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TheWordasScalpel


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THEWORDASSCALPELAHistoryof

MedicalSociology

SamuelW.Bloom

12002


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1Oxford NewYork

Auckland Bangkok BuenosAires CapeTown ChennaiDaresSalaam Delhi HongKong Istanbul Karachi Kolkata

KualaLumpur Madrid Melbourne MexicoCity Mumbai NairobiSaoPaulo Shanghai Singapore Taipei Tokyo Toronto

andanassociatedcompanyinBerlinCopyright2002byOxfordUniversityPress,Inc.

PublishedbyOxfordUniversityPress,Inc.198MadisonAvenue,NewYork,NewYork10016

www.oup.comOxfordisaregisteredtrademarkofOxfordUniversityPress

Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,ortransmitted,inanyformorbyanymeans,

electronic,mechanical,photocopying,recordingorotherwise,withoutthepriorpermissionofOxfordUniversityPress.

LibraryofCongressCataloging-in-PublicationDataBloom,SamuelWilliam,1921

Thewordasscalpel:ahistoryofmedicalsociology/SamuelW.Bloom.

p. cm.Includesbibliographicalreferencesandindex.

ISBN0195072324;ISBN0195149297(pbk.)1. SocialmedicineUnitedStatesHistory.

2. SociologyUnitedStatesHistory. I. Title.RA418.3.U6B562002

306.4'61'0973dc21 2001037042

1 3 5 7 9 8 6 4 2 PrintedintheUnitedStatesofAmerica

onacid-freepaper


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Acknowledgments

Among the many who helped me with thisbook, KurtDeuschlestandsout.HefirstsuggestedtheideaforaproposaltotheCommonwealthFundBookProgramon the Frontiers of Science. At the time, Kurt was the distinguishedandmuchlovedchairmanoftheMountSinaiSchoolofMedicineDepartmentofCommunityMedicine.Myfirstlargedebt,therefore,isowedtohimandtotheCommonwealthFund,especiallytoformerstaffmembersLesterEvans,JohnEberhart,andReginald H. Fitz. Special thanks are also due to Susan Garfield and the RockefellerInternationalConferenceCenteratBellagio,Italy,whereIdevelopedthefirstdetailedoutlineofwhatthisbookeventuallybecame.Soonafterward,myappointmentasaVisitingFellowattheRussellSageFoundationrelievedmeofacademicdutiesforsixmonthsoftotalimmersioninwriting.Fromthesesources,theshortbookfirstproposedevolvedintothepresentmuchmoreambitioushistory.

Mostoftheworkwasdoneintheold-fashionedoff-lineway,attypewriterandthenwordprocessor,heavilydependentondocuments,interviews,andlibraries.Reference librariansat theLevyLibraryofMountSinaiSchoolofMedicine,theNewYorkAcademyofMedicine,andtheNewYorkSocietyLibrarywereparticularlyhelpful.Thekindnessandefficiencyofarchivistsregularlysolvedcriticalproblems,especiallythoseattheMeiklejohnInstituteinCalifornia,theNewYorkPublicLibrary,theNationalArchivesoftheUnitedStates,andtheUniversityofWisconsinCenterforFilmandTheatreResearch.OrganizationsliketheNationalInstitutes of Health and the American Sociological Associationwere alwaysaccessibleandresponsive.Butmorethananyother,IowethankstothestaffoftheAmagansett Free Library. There seemed tobe no request too difficult for thisremarkablepubliclibraryofasmallNewYorkvillage.

When it comes to individualcontributions, it ismuchharder toassessinfluence and to adequately express my gratitude. For example, my students in thePh.D.PrograminSociologyattheCityUniversityofNewYorkweremyprimaryreadersandcriticsofchaptersindraft.Icouldnotpossiblylistthemindividually,butcollectively,theyareatthetopofmylistofthemosthelpful.TherearealsofriendsandcolleagueswhoservedthewritingprocessinwhatIcanonlydescribeas an intellectual context rather than in specific helping roles. Sol Levine, forexample,wassomeonewhoneverwaitedtobeasked.Heinitiatedcontact,askedaboutmywork,andthencriticallyrespondedtoanythingIsenthim.Mydebtto


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vi A C K N O W L E D G M E N T S him cannotbe estimated, and my sorrow for his recent death is deep. RobinBadgleyandBobStraushaveplayedsimilarroles.Bothwerepartnersinvariousprofessionalactivities.Badgleyalwaysbehavedwithquiethumorandunsparingdedication;

it

was

a

joyful

experience

to

work

with

him.

Straus

hasbeen

both

friendandco-worker foralmostfiftyyears,so itwasfitting thathewasselectedbythepublishertoreadthemanuscript.Hiscritiqueincludedmanyhelpfulsuggestions. Robert K. Merton, Patricia Kendall, Renee Fox, George G. Reader, andMaryE.W. Gosswere there atmyentry to the fieldwhen itwasnotyetknownas medical sociology. Mertons influence never ended, and all of them have remainedbothfriendsandprofessionalmodels.

Thoseindividualswhowereinterviewedarecreditedthroughoutthetext,andalloftheircontributionsareimportant.Some,however,deservespecialmention,including Eugene Brody, Donald Light, Albert Wessen, David Mechanic,JamesMcCorkle,andFredHafferty.Amonghistorians,IamindebtedspeciallytoMiltonRoemer, Milton Terris, Rosemary Stevens, and David Rosner. Robert H. Felix,Raymond V. Bowers, Herbert Klerman, Kenneth Lutterman, and Herbert Pardesgenerouslysharedtheirexperiencesat theNationalInstituteofMentalHealth.

ChloeE.Bird,PeterConrad,andAllenM.Fremont,editorsofthefiftheditionofTheHandbookofMedicalSociology, commissioned my article, The InstitutionalizationofMedicalSociology intheU.S.:19201980,a taskwhichservedinunexpectedwaystohelpcompletethefinaldraftof thisbook.

EdwardW.Barry,theformerpresidentofOxfordUniversityPress,encouragedandsupportedmethroughmanyyearsandtwoearlierbooks.Heisarareexampleofthetypeofpublishereverywriterwants.IamalsoindebtedtoValerieAubrey,my first editor at Oxford, and to Dedi Felman,Jennifer Rappaport, and RobinMiura,mycurrentOxfordeditors.

Caroline Helmuth was my secretary during the early drafts,but that hardlydescribesthepartsheplayed.Shewasalsoresearchassistant,friend,editor,andgenial ally. When Caroline went to California and I was forced to work mostlyon my own,Josephine Greene saved me from disaster regularly, serving as mywordprocessingconsultant.WhenIneededtoreturntoearlysources,MaryLouRussellattheCommonwealthFundwasgraciouswithhertimeandknowledge.Althoughmydebtisgreattoeveryonementionedsofar,thereisanotherlevelof gratitude that is reserved for my daughterJessica, my sonJonathan, and mygrandchildrenAlexanderandSoniawhoaretheanchorsandjoyofmyexistence;but it is Anne, my wife, who, more than any other, has given not only what Ineeded towrite thisbookbutalso thegreaterportionofwhatisvaluable inmylife.


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Contents

Introduction 3PARTI. MedicalSociologybefore1940

1. TheOrigins:MedicineasSocialScience,PublicHealth,andSocialMedicine 11

2. AmericanSociologybefore1920:FromSocialAdvocacytoAcademicLegitimacy 23

3. BetweentheWorldWars 394. TheUniversityofChicago 635. RegionalandIntellectualInfluences 83

PARTII. MedicalSociology,194019806.

FirstStepstowardSocialIdentity:EffectsoftheWarandItsAftermathonMedicalSociology 111

7. PostwarMedicalSociology:TheFoundersatMajorUniversities,19451960 131

8. TheRoleofNIMH,19461975 1559. BecomingaProfession:TheRoleofthePrivate

Foundations 18110.

From

Ad

Hoc

Committee

to

Professional

Association:

The

SectiononMedicalSociology,19551980 215

PARTIII. TheCurrentStatusofMedicalSociology11. AnEraofChange,19802000 247

Notes 285Index 335


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TheWordasScalpel


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Introduction

Medicine has many faces. Whatever your interests and talents are, there is aplaceforyoutoexpresstheminthisprofession.Thesewordshavealwaysstayedwith me, even though they were spoken almost fifty years ago on a Septemberday ina largeauditoriumattheUniversityofPennsylvaniaSchoolofMedicine.Thespeakerwasthedean,Dr.JohnMck.Mitchell,addressingthefreshmanclasson its first official day. I was there as an observer, part of a team of researchsociologistsfromColumbiaUniversity,justembarkingonastudyofmedicaleducation.Littledid Irealize thatDr.Mitchellswordswouldapplytomeaswellastotheneophytemedicalrecruits.Withinafewyears,Iwastobecomeafacultymemberofamedicalschool,embarkedonacareerthatwasjustbeingidentifiedwithaname,medicalsociology.

Atthetime,IthoughtDr.Mitchellwasremindinghisstudentsthattheboundariesofmedicalsubjectsincludedmuchdiversity,butstillwithinthelimitsofbiologicalscience.Evenpublichealthandpsychiatry,thoughdifferentfromthemainstream, were still traditional medical specialties. I was wrong, of course; Dr.Mitchell, a pediatrician himself, was saying what the famous medical historianHenrySigeristhadsaidinadifferentwayafewyearsearlier:Thereisonelessonthatcanbederivedfromhistory.Itisthis:thatthephysicianspositioninsocietyisneverdeterminedbythephysicianhimselfbutbythesocietyheisserving.1

We were, Dr. Mitchell and I, captives of the spirit of the years immediatelyfollowing the Second World War. Part of the fallout of that terrible event, withits ghastly statisticsofhumandestruction,was thatitbrought intoquestionourunderstanding of humanbehavior. Never had human reasoning, in the form ofscience,advancedsofar,but,atthesametime,neverhadthecapacityforhumandestructionreachedsuchdepths. Inmedicine, theprofessionassignedtobe thearbiter ofboth health and illness, the reaction was to seek redemption throughtheapplicationofthescientificmethodtohumanbehavior.Withoutanadequateunderstandingofthehumanhabitat,andofthecharacteristicsofhumanorganismandenvironment,NormanCameronwrotein1952,themedicalstudentcannotbe competently prepared for the role he has chosenthat of the physician inmodernAmericansociety.2

Because of farsighted medical educators like Cameron, courses inbehavioralscienceemerged,usuallyinthecurriculaofeitherpsychiatryorpreventivemed

3


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4 I N T R O D U C T I O N icine, and sociology was virtually always an important ingredient. Medicalschoolsbecame interested enough to add social scientists to their faculties, forthe first time, in more than token numbers and with more than tokenresponsi-bilities.

3Outoftheseorigins,medicalsociologyemergedasanewsubdisciplinetoplay

rolesinbothresearchandeducation.Asanearlyrecruittoteachbehavioralscience to medical students, Ibegan to chronicle its history.4 Soon, however, myattention was diverted to the past. I discovered that sociological inquiry abouthealthandmedicinecanbetracedbackatleasttothebeginningofthenineteenthcentury.Mostintriguingistheexcellentqualityoftheseearlystudies.Theirmethodologywasadvanced,comparablewithmodernwork.Why, then, thequestionarises,did they failtobecomepartofabodyofknowledge,growingwithcontinuityinthemannerofcontemporaryscience?Instead,theseearlyinvestigationswere typically episodic and were conductedby individual scholars. Each wasassociated with major, disruptivesocialevents likewaror politicalandtechnologicalrevolutionbutafterwarddisappeared frompublicconsciousness,onlytobe repeated lateras thoughnothing like themhadexistedbefore.Notonlycontinuitywaslackingbutclearscholarlyidentification.Whatwasnewtothemodernperiod, therefore,wasnotan innovative typeof intellectualworkbutrathertheestablishmentofaninstitutionalizedintellectualactivitycalledmedicalsociology.Butcouldsuchafieldbeunderstoodwithoutreviewingitspast?Ifoundmyselfdrawnbothtotheprehistoryofmodernmedicalsociologyandtoitssocialdevelopment.

As I explored further, it alsobecame evident that this was not a story of interdisciplinary discovery and cooperation. Both medicine and sociology soughtto deal with similar problems, and in the process medicine attempted tocreateitsownsocialscienceofmedicine.Whydidthiseffortfail?Thequestionpointedto the general histories ofboth professions. Each profession, for example, respondedinitsownwaytotheforcesinherenttothegrowthofhighereducationin the United States. In the process, they were drivenby the often competingpurposesofadvocacyandobjectivity.Drawntogetherbycommoninterests,theirpartnershipwasuneasy.In the end, I expanded the purpose of thebook. The focus wouldstillbeonthemodernperiod,butonlyafterareviewofmedicalsociologysearlierintellectualorigins.Andonthewhole,Idecidedtoemphasizetheinstitutionalhistory.Academicsubjectscharacteristicallyoffertwodimensionsforhistoricalstudy,thedevelopment of knowledge and professional or institutional formation. For example,Merton,inhisanalysisofthesociologyofscience,differentiatesthespe-cialtyscognitiveidentity,intheformofitsintellectualorientations,conceptualschemes, paradigms, problematics, and tools of inquiry, and itssocial identity,in the form of its major institutional arrangements.5 The former is the mostcommoninthe literatureofmedicalsociology,butthefocusherewillbeonthelatter,followingthestepsof institutionalization.6

Forsuchatask,myownoccupationalhistorywasanadvantage.Iwasanearlyparticipant in the rapid institutionalizationofmedicalsociology.Thepatternofmycareerfollowedamirror-courseofthemajordevelopmentsinthefield.Duringthe period when research offered virtually the only role open to sociologistsinmedical institutions, I apprenticed at perhaps thebest research organization insociology, the Columbia University Bureau of Applied Social Research (BASR),


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5I N T R O D U C T I O N working in itsfirst foray intoamedicallyrelatedproject.7 In1956,whensociologistswerejustbeginningtobeacceptedonmedicalschoolfaculties,IjoinedtheBaylor University School of Medicine and havebeen a medical educator eversince.

Periodically

throughout

this

time,

I

served

on

special

commissions

that

studiedandmadepolicyrecommendationsconcerningtheroleofthebehavioralsciences in medical education. At the same time, I was drawn into activitiesofprofessional organizations, particularly in the early years of the Committee onMedical Sociology foundedby August Hollingshead and Robert Straus. As theCommittee evolved into the Section on Medical Sociology of the American SociologicalAssociation,Iservedastheprincipaladministrativeofficer.

In the meantime, a literature grew that showed medical sociology tobe concerned about its own development.8 However, just as my own publications onthese themes havebeen limited in scope, the review papers of the field tend tobespecialized,eachdealingwithasubtopicsuchasthecontributionofsociologytomentalhealth,publichealth,medicaleducation,orhealthservices.Eveninitstextbooksandcommissionedreports,thehistoryofthefielddoesnotyetemergeinfulldetail.9 Oncethewritingbegan,thebookexpandedfromthemorelimitedtask originally conceived, a direction that was encouragedby colleagues withwhomIcheckedandreviewedthematerialtobe included.

These informal conversations soon evolved into organized, lengthy interviews,andadimensionoforalhistorybeganto takeshapeaspartoftheworksmethodology. This, of course, changed a relatively straightforward library taskinto something more complex and expensive. The generosity of the CommonwealthFundhasmadethispossible,allowingmetoconductin-depthinterviewswithmanyofthose,bothfrommedicaleducationandfromsociology,whohavemadethishistory.

My natural tendency in thebeginning also was to screen my own personalinvolvementbehind the objective facts. But soon such a constraint came toseem artificial and somehow less honest than a frankly acknowledgedpersonalview.10 Thereisanobviousadvantagetobeingpartofthestoryoneistelling,andIdecidedtouseitfully.

ThePlanoftheBookTheoverallproblem-focusofthebook ison themodernperiodinthehistoryofmedicalsociology,beginningwithitsclearidentificationasasubfieldfiftyyearsago. However, the roots of medical sociology are much deeper historically,andtheysharecommonsoilwiththreeconceptions:medicineassocialscience;pub-lichealth;andsocialmedicine.Thesewereactivitiesdevelopedinternallywithinmedicine during the nineteenth century, whereas medical sociology grew as aseparatefield,drawingmainly fromcurrentswithinitsownparentfieldofsociologyand,toalesserextent,fromsocialpsychology.Together,Ihavetreatedtheseas the antecedents, or prehistory, of medical sociology. They are presented asPartI,TheOriginsofMedicalSociology,consistingoffivechapters.Inchapter1,thesearchforknowledgeabouthowsocialfactorsinfluenceillnessisreviewedina very condensed form,goingback two thousandyears,butwithmoredetailbeginning with the eighteenth century. This degree of historicalbackground isnecessarytoengagethequestion:Whydidasystematicsocialscienceofmedicine


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6 I N T R O D U C T I O N failtoemergefromthelongeffortbypublichealthandsocialmedicinetocreatea theoretical framework and continuous development of knowledge about therelationbetweensocialfactorsandillness?

Inthe

second

chapter,

the

organizing

premise

is

that

the

emergence

of

medical

sociologycanonlybeunderstoodwithinthecontextofthespecialcharacteristicsoftheAmericanuniversity.TheeffortismadetodescribehowamoreorganizedsocialsciencewasproducedinAmericanuniversitiesthananywhereelseintheworld.Aspecialcomparison ismadewiththeEnglishandGermanuniversities,which, though in many ways the models for American institutions,producedavery different sociology. Particular attention is paid to the role of the privatefoundationsinthegrowthofboththeuniversityandsocialscience.

The third chapter discusses medical sociology as an intrinsic and importantpartofthehistoryofsociologyitself,when,duringtheperiod192040,theparentdisciplinebecomesfullylegitimateasanautonomousintellectualactivity.Twomajor events, the Committee on the Costs of Medical Care and the PresidentsResearch Committee on Social Trends, are described in detail to show that thesociologyofmedicine,asanapproach,wasalreadydevelopedtoahighlevelatthat time and was much more than an academic activity, playing an importantroleinissuesofpublichealthpolicy.

Chapter4,stilldealingwiththeperiodbetweenthetwoWorldWars,turnstotheoriginsofwhatwouldbetwomajormethodologiesofthespecialty.Thefirstis the sociology that grew at the University of Chicago from 1893 to1935, withspecialattentiontothesocialecologyofmentaldisorderandurbanlifedevelopedbyR.E.L.FarisandWarrenH.Dunham.ThesecondisconcentratedintheworkofHarryStackSullivan.Sullivan,apsychiatristwhowasanearlyAmericanfollower ofFreud, introduceda shift from theFreudianemphasison instinctsandearly childhood experience to the etiological significance of interpersonal relations.TwopapersbySullivan,published in1931,aregenerallycitedas thebeginning of a movement toward a therapeutic orientation as opposed to thecustodialcarepracticesthatthendominatedhospitalcareforthementallyill.11 Theconceptionofthehospitalasatherapeuticcommunitygrewfromtheseoriginstobecomeoneof themostactivesubstantiveareasforsociologicalstudyimmediatelyfollowingWorldWarII.Thischapterdescribesthestudyofinterpersonalrelations in therapeuticsituationsandanalyzesthe importanceofitsadaptationofethnographicfieldmethodsofresearch.

Chapter 5shifts the focus from thesubstructureofmedicalsociologyinbothsocial medicine and general sociology to the intellectual origins most specificto the field. Two contrasting scholarsand their influencesonmedicalsociologyaredescribedinbiographicalandintellectualdetail:LawrenceJ.HendersonandBernhard Stern. Each laid foundations for subsequent major paradigms that fora time were to dominate sociology as a general science and the special studyof medical sociology. Henderson, who was abiochemist as well asa physician,adapted in midcareer the functional theory he had pioneered in physiology toearly structural-functional interpretationsofsocialrelations,andthistheory,forthe next three decades, was the guiding theory of much ofAmericansociology.In medical sociology, his analysis of the doctor-patient relationship as a socialsystem had a seminal effect. Stern, on the other hand, was a Marxist whosesocialhistoryofmedicineemphasizedasociopoliticalperspectivethatwasonlyto come into its own in the 1960s as an important approach in medical sociology.


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7I N T R O D U C T I O N Asummaryofpart Idealswith themajorquestionsthisextensiveprehistory

raisesfor themodernphasesofmedicalsociology.Itisarguedthatthecognitiveidentity of the specialty was established prior to the modern periods emphasison

its

social

identity.

Henderson,

Stern,

the

Chicago

sociologists,

and

Harry

Stack

Sullivan served primarily the development and consolidation of the cognitiveidentity of medical sociology. Their heirs continued tobuild the knowledge ofthefield,but the framework inwhichtheyworkedwasoneofrapidinstitutionalization.

Part II turns to the firststeps in theemergenceofmodernmedicalsociology,from 1940. A series of questionsareaddressedabout theprocessofbecomingavisiblespecialfieldofgeneralsociology.Howwasthisinitiated?Whatwerethemajor determining factors, the underlying patternsofdevelopment in itsparentdiscipline, thebarriers, the major accomplishments? World War II is shown tobe an event that established the role of sociology in national affairs in a waycomparabletotheemergenceofpsychologyundertheimpetusoftheFirstWorldWar. Through thebiographies of early medical sociologists and some of theirmedical sponsors the influences of contacts and experiences of this war aretraced.AlthoughtheDefenseDepartmentwasthemostsignificantsourceofsocialscience support during the war, medical sociology is shown to have receivedfinancial sponsorship in the postwar years mainly fromprivate foundations,especiallytheRussellSageFoundation,theCommonwealthFund,andtheMilbankFund.

Chapters8 through10describe theroleofexternalsupport,bothfederalandprivate, and of professional associations in the institutionalization of the field.Thestoryisoneoftheriseoffederalsupport,forbothresearchandtraining,andthen itsdecline.ThisisalsotheperiodwheninstitutionallegitimacyissecuredwiththeestablishmentoftheSectiononMedicalSociologyoftheAmericanSociologicalAssociation(ASA)andwiththecreationofseveraljournals,includingtheofficialASAsponsorshipoftheJournalofHealthandSocialBehavior.Withinmedicine, this legitimacy is represented most dramaticallyby the creation of anewsubjectmattercommittee forPartIoftheNationalBoardofMedicalExaminers(NBME),theCommitteeonBehavioralScience,signalingthefullacceptanceof sociology in the education of future physicians concerning the psychosocialaspectsofhealthandillness.

Part III assesses the current statusofmedicalsociology.Since1980, thefieldhasbeen attacked inboth its intellectual and institutional identity.Acceptancehas not meant security. Institutionally, there hasbeen a precipitouscontractionof federal support for the social sciences, all the more devastatingbecause itcomes as an added thrust to what was already a downward curve of federalresourcesforacademicworkingeneral.Compoundingtheproblemisevidencethatmedical sociology is losing its favoredposition in thebehavioralsciencemovement.Inthemarketofscarceacademicresources,thecompetitionofbehavioralmedicineandhealtheconomicshasintensified.Inaddition,psychiatryisacting towithdrawfromcollaborationwithmedicalsociology,preferringinsteadtokeep to itself the responsibility for teaching medical students about the socialaspects ofbehavior as well as the psychological. In spite of these challenges,medical sociology in the United States enjoys a status unequaledby its peersanywhereintheworld.

Mymainmotiveinapproachingmedicalsociologyshistoryfromthesevantagepointsistofindmeaninginwhat,forme,giventheeverydaypressuretoinquire


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8 I N T R O D U C T I O N and to teach,endsupsooftenasinterestingbutdisconnectedarraysofideas.Medicine is, after all, abasic social institution that,because of its importance,must reflect the societyschangingvaluesaboutpatternsofhumanrelationship.For

sociology,

therefore,

the

study

of

medicine

is

an

opportunity

to

find

and

test

generalnot specializedconceptions of humanbehavior. Always, in this historyofsociologyseffortstounderstandhealthandillnessassocialproblemsandto describe and interpret medicine, I have tried tobe alert to the more generalsocialmeaningsandhavenothesitatedtocommentonwhatIfind.

Finally,thetitletestifiestotheinfluenceofLawrenceJ.Hendersonswarning:A doctor can damage a patient as much with a misplaced word as with a slipof thescalpel.12 There is formeacompellingsimplicityandprecisiontothesewords, just as strong now as when I first read them almost forty-five years ago.Their initial attraction is not difficult to explain. Sociologists were stilla rarityin the halls and classrooms of medical schools, and I was groping in thisunfamiliarterrain.Herewasafamousphysicianfromthepast,whosenamewaspartof the lore of thebasic science of medicine13 and whobecame in midcareer asociological scholar and teacher of sociologists. His statement about the misplacedwordstruckmeonfirstreadingwiththeforceofOldTestamentprophecy.If words, the main substance of human relations, are so potent for harm, howequally powerful can theybe to help if used with disciplined knowledge andunderstanding? And where more certainly does this simple truth apply than inthemakingofaphysician?Withinthisframe,itisessentialtostudyandunderstandthesociologyofmedicine.


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PART I MEDICAL SOCIOLOGY

BEFORE 1940


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1TheOrigins

MedicineasSocialScience,PublicHealth,andSocialMedicine

Medical sociology is an old conceptionbut relatively young as a field of en-deavor.1 From early in the nineteenth century, one can trace research activitiesthatareremarkablyclose,atleastinstyle,to theirmoderncounterpartsinmedical sociology. Until about seventy-five years ago, however, such studies wereepisodic,linkedtomajoreventslikethestruggleforpoliticalandsocialrightsoftheEuropeanmiddleclassinthe1840s,thesimilarstruggleoftheEnglishworkingclasslaterinthenineteenthcentury,andtheradicaltechnologicalandsocialchanges causedby the Civil War in the United States. These events typicallyheightenedpublicfeelingsofsocialresponsibilityand,intheprocess,stimulatedearly variants of social science. Edwin ChadwicksReporton theSanitaryCon-ditionsof theLaboringPopulationofGreatBritain in 1842 is a good example.2Justastypically,however,atleastwithinquiryabouthealth,themotiveforceofsuchmovementswasnotsustained.Itwasnotuntilalmost1930thatanunbrokendevelopmentbegan in the sociology of medicine, and only after World War IIwereindividualsidentifiedasmedicalsociologists.

Medicalsociology, in itsnineteenth-centuryorigins,derivedfromthreeoverlappingconcepts:medicineassocialscience;socialmedicine;andthesociologyofmedicine.All threeareconcernedwithexplainingthelinkagebetweensocialconditionsandmedicalproblems,theideathathumandiseaseisalwaysmediatedand modifiedby social activities and the cultural environment.3 Medicine isasocial science, wrote Rudolph Virchow in 1848.4 Even earlier, French andGerman investigatorsusedsimilar termsas theybecameconcernedwiththesocialproblemsof industrialization.TheFrenchsocialhygienistsofthe1830sareone example, and, in Germany, another well-known physician, Salomon Neumann, studying the influence of poverty and occupation on the state of health,sharedVirchowsview.5

However, social science as Neumann and Virchow perceived it was quitedifferent from what it is today. For them it was a partisan, utilitarian activity,identified with advocacy and reform. Although Virchow isnow remembered as

11


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12 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 the fatherofmodernpathology,hismedicalreformwas farremoved from theacademic natural science model that social science later adopted in its strugglefor professional legitimacy.6 Instead, the right to health and the obligation ofthe

state

to

provide

for

it

were

inherent

parts

of

these

early

conceptions.

It

was,

afterall,themidnineteenthcentury,atimeofrevolutionandtheconsolidationofthevaluesoftheEnlightenment.Liketherightstoeducationandreligiousandpoliticalfreedom,therighttohealthwasinsertedintothebasicdiscourseoftheWesternEuropeannations.Itwasabeliefthatthesepioneersofmodernmedicinefought for ardently, utilizing as they went early variants of epidemiology,biostatistics,andsurveyresearch.

Virchow, for example, studied and reported on the epidemic of typhusfeverin1847inUpperSilesia.Heidentifiedthecausesofthisoutbreaktobeacomplexof socialand economic factors, andhe concluded that littleshouldbeexpectedfrommedicinaltherapywhenpoliticalactionisrequiredtodealwithepidemics.7Neumann, similarly, conducted in 1851 a study of the medical statistics of thePrussianstate.Whatissostriking,however,isthatalthoughsuchresearchidentified the social and economic conditions of particular groups of people as riskfactors for disease, it rarely included the type of theoretical analysis that is thebasisofcontinuous,cumulativeresearch,nordiditattractdiscussionbyacommunityofscholarswithsimilarinterests.Asaconsequence,itwasnotuntiltheearlytwentiethcenturythatadistinguishablefieldofacademicstudyemergedtoseriouslyexplorethesocialaspectsofmedicine.8

Fromwithinmedicine,itwasthefieldofpublichealththatwasmostreceptivetosocialscience.Publichealth,orsocialmedicineasitwascalledinEurope,ispopulationbasedmedicine, thespecialfieldconcernedwithpreventionandthepolitics of health anddevoted to using scientific medicineasanantidote to thesocial illsbroughtaboutby the IndustrialRevolution. In theUnitedStates,socialhasbeenachargedword,associatedwithsocialismandradicalism,sothatpublic health and, more recently, community medicinearepreferred.Especially in Europe, this field saw the poor as medicines natural jurisdiction andwasorientedtohealthrelatedsocialreform.

Untilthemidnineteenthcentury,medicineequatedsocialsciencewithactivism, as often political as it was professional. Sigerist, for example, was thephysician-historian who,between the 1920s and1940s, identifiedhimselfmorecloselywithsociologythananyothermedicalscholar.Yet,althoughheconceivedanambitiousprojectinthesociologyofmedicine,forhimthesociologicalenterprise wasbelieved to stand at the intersection of social analysis and socialreform:

Not yet entirely differentiated from economics, political science, anthropology, and social work, sociology . . . was broadly understoodby intellectualsandpolicymakers,evenbymanysociologists,asacountervailingpointofviewandamoraldispositionratherthanasaspecializedacademicdiscipline.9

The differentiation of roles within medicine also gave social science relevance.ForVirchow,especially,medicineassocialscienceisadirectexpressionofthataspectofthehistoryofmedicineinwhichthephysician,asphysician,takestheroleofpublicbenefactor.


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T H E O R I G I N S 13In modernWesternmedicine today,all thevariouspossiblerolesofthephy

sicianareassigned toseparateplaceswithin theprofession.Recruitstotheprofession have a choice to focus their activities in a particular role, whether ashealer,

physician-scientist,

or

public

benefactor.

At

the

same

time,

the

society

chooses one or more aspects of a profession to press for emphasisbyaddingorsubtracting the allocation of public resources,but all receive some substantialmeasureofsupport.Itwasnotalwaysso.

ThePhysicianasPublicBenefactor:EarlyOriginsAncientGreece triedoneachprofessionalmantleknowntodaybutnever inthefull combination we now take for granted. Individualized medicine, our 2,400-year-old

link

to

Hippocrates,

seems

to

have

arisen

only

in

the

fifth

century

B.C.,

just prior to theappearance ofHippocrateshimself.Before that time, thephysicianappearedasadispenserofpredeterminedmodesofpractice10 andnotasindividualhealer. Independenceofthought,speculationaboutapatientscondition,rationalexplanations to thepatientabout the factsandpossibilitiesofhis/her condition, and the freedom to make thebest possible choice of therapeuticactionthesebasicsofprofessionalbehaviorsotakenforgrantedtodaywerehardto comeby. Nevertheless, they are included in Hippocratic writings, and soonafter,thephysician-scientistappeared.

Atfirst thesedifferentaspectsofphysicianhoodwere thespecialtiesofsects,but each in itself always evoked ambivalent response in society. In effect, onefindsinhistoryrehearsalsforeachofthevariousstylesanddilemmasofmodernmedicine.Theroleofphysician-scientist, forexample,variedwiththestructureofsocietyandwasbothpromotedandfeared.Suspicionofthescientist,Temkintellsus,

dependedpartlyontheprevailingmodeofresearchandpartlyonpopularimagination moldedby the sensibilitiesandmorals of the times. Inantiquity, when medical research was sporadic, the fear that the unscrupulousphysicianmisusedhisknowledgeofpoisonswasprobablygreaterthanthefear thatthescientistmightusemansbodyforresearch.11Aspublicbenefactor,anearlymodelwasHippocrateshimself,whowashon

oredby hisown societyfor havingsenthispeople tovariousplaces inGreeceto teach the inhabitants how to save themselves from the plague whichhad invaded the country from the lands of thebarbarians.12 Not until the nineteenthcentury,however,did theroleof the physicianaspublicbenefactorfind itsfullexpression.Onlythendidagenuinepublichealthmovementoccur.ForWesternEuropeansocieties,theinterveningmillennia,fromantiquity,weredominatedbya search forboth knowledge and healing skills that focused on humanbiology.In the prevailing dualism of thebody and thesoul,ofmatterand thespirit,thebody was the domain of the physician and the remainder of humanexperiencetheprovinceof thephilosopheror thepriest.

TheRenaissanceandAfterThe pattern of social change described here isnot so much conceptualas institutional. Since antiquity there was awareness and, during the Renaissance and


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14 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 immediately after, a heightened consciousness about theeffectsofsocialconditions on the health of populations. What was lacking was the systematic investigationof theserelationshipsandtheinstitutionalizedexpressionofsuchideasin

public

policy.

Althoughsome of the early-nineteenth-centuryrhetoricspokeofmedicineas

socialscience,thefirststeptowardtheinstitutionalizationofpublicresponsibility in the role of the physician was in the medical specialty of public health.Althoughconceptsofsocialmedicinewereinherentinstudiesofthelasthalfofthenineteenthcentury,theinstitutionalizationofsocialmedicineinEuropeandpublichealthintheUnitedStatesonlycrystalizedattheturnofthecentury.Thefield was emerging as it is currently defined: the effortorganizedby society toprotect, promote, and restore the peoples health. The programs, services, andinstitutions involved emphasize the prevention of disease and the healthneedsof the population as a whole.13 From such a perspective, health problems, instead ofbeing considered as they occur in a seriesof individuals,areseen inthecontextof thecommunityasawhole.Emphasisisontheorganizednatureof the efforts involved and on prevention.14 The more specific elements of thepublichealthconceptinclude:

The need tostudy the relationbetween thehealthofagivenpopulationandthelivingconditionsdeterminedby itssocialposition

Thenoxiousfactorsthatactinaparticularwayorwithspecialintensityon thoseinagivensocialposition

Theelementsthatdeleteriouslyaffecthealthandimpedeimprovementofgeneralwell-being15

Suchideasdidnotemergeintoclearandsubstantialoperationalformbytheforceoftheirinnerlogicorbytheirpersuasivenessasideas.Theyonlyemergedaspartof policy with the aim of placing social and economic life in the service of thepowerpoliticsof thestate.

Ofcourse,someformofcommunitylifehasexistedasfarbackintimeasweare able to describe, and always with the need to deal with healthproblems insome organized way. The supply of acceptable food and water, the preventionand control of epidemic and endemic diseases, and the provision of some typeofhealthcareareasoldascivilizationinitsmostprimitiveforms.Publichealthas a concept emerged from the need to deal with the health problems of groupliving.

Similarly,although thebiologicalcharacterofdiseaseandphysicaldisabilityhavealwaysbeenrecognized,communityactionconcerninghealthhasbeenfilteredthroughculturalbeliefsystems;andattributionsofcausehaveinturnbeeninfluencedbysocialandeconomiccircumstances,includingtheavailableknowledge and technology. Thus, for thousands of years, epidemics were seen as theactsofspiritsorgods,retributionsforwickednessorothertransgressions,notasnatural events; avoiding them therefore required some form of appeasement oftheseforces.EventhoughtheGreeksdevelopedtheideathatdiseaseresultsfromnaturalcauses,theuseofeffectivecommunityactiontopreventandcontroldiseasefollowedaveryunevencourseuntilmoderntimes.Todealwiththemenaceof illness and disability, agencies havebeen created and laws established andprocedures to implement such laws havebeen instituted. In these ways,publichealthhasbeencloselylinkedwithgovernmentactivitysinceearly times.


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T H E O R I G I N S 15AslongastheinfluenceofthePericleanGreekssurvived,publichealthprac

tice was rational. The Romans, for example, were engineers and administratorswhobuiltsewersystemsandbathsandcreatedsystemsofwatersupplyandotherhealth

facilities.

They

also

organized

medical

care,

so

that

by

the

second

century

A.D., there was a public medical service, and hospitals hadbeen created.16 Although these institutions were the models for later Christian practices, the disintegrationoftheGreco-Romanworldledtoadeclineofurbancultureandwithittoadecayofpublichealthorganizationandpractice.ThisdoesnotmeanthatmedievalEuropejettisonedentirelytheearlierorganizationofpublichealth.Theprotectionagainstepidemics, forexample,eventhoughfilteredthroughthereligiousandsuperstitiousideasthatprevailedatthetime,ledtoamodeofpublichealthactionthat isstillwithus,namely,the isolationofpersonswithcommunicablediseases.17 Thisistheinstitutionwenowknowasquarantine.

Duringthethousandyearspriortothemodernera,theadministrationofpublichealth was decentralized to the local community. The first major step towardlinkinghealthtothestatewasintheeighteenthcentury,when,withinthepoliticalparadigmofmercantilism,Europeangovernmentsassumedresponsibilityforthe protectionof individualandgrouphealth.Absolutemonarchywas thecontinuing political foundationbut was no longerbased on a system of personalloyaltiestothemonarch.EspeciallyasexemplifiedbyGermanCameralism,Rosenargues,thiswasacrucialstageinthedevelopmentof themodernstate.18

As the state took over public administration, managing material and humanresources,healthbecameamatterofpublicpolicy.Thestatehadavestedinterestin the health of the populace. Tobest serve the stateat thispointrepresentedby monarchythe physician was enjoined to act in thebest interestsofhispatientsineffectasmedicalpolice;thestate,inturn,actedtoassurethewelfareofthe landandthepeople.19

Rosen describes an almost fanatical emphasis at this time (the eighteenthandnineteenthcenturies)ontheincreaseofpopulationandconsequentlyonthereduction of disease mortality.20 Thebenefit to the individual patient was real,but it was secondary to the centralmotif to serve the state. If one asks, Whatdoes it matter?the answer is found in the different histories of France andEngland compared with Germany, where the medical police concept survivedlongestanddevelopedmostdeeply.

England and France, in the first half of the nineteenth century, moved awayfrom absolutism andmercantilism.TheFrenchRevolutionandtherapidindustrialization of England produced the first phase of a genuine social medicine,including the use of the survey as a tool for documenting the class differencesand their consequences in disease that resulted from the new social order. InGermany,meanwhile,theheritageofthemedicalpolicewasthetraditionalizationof the ideal of orderly efficiency. As a result, by the middle of the nineteenthcentury in Germany, the concept [medical police] had largelybecome a sterileformula.OnceGermanyencounteredthehealthproblemsconnectedwiththenewindustrialorder,anewapproachwasnecessary.21

The ideology of the medical reform movement, meanwhile, fared nobetterthan the organizational vitality of the medical police. Voices like Virchow andNeumannweretunedoutofthepublicconsciousnesswiththedefeatoftheRevolution of 1848. Theirbroad conception of health reform as social science wastransformedintoamorelimitedprogramofsanitaryreform,andtheimportanceofsocialfactorsinhealthwasdowngradedwhilethebiomedicalemphasisgained


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16 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 overwhelming dominance from the scientific revolution causedby thebacteriological discoveries of Robert Koch. Social medicine, in Germany, was aborteduntilitemergedagainintheearly twentiethcentury.

InEngland,

meanwhile,

the

economic

liberalism

of

classical

economists

like

AdamSmithforestalledforatimepublicconsciousnessoftheconsequencesforhealthofthe IndustrialRevolution.Withinthisphilosophy,thenaturalnessofan economic system was said to flow from the objective necessity of labor, industry, value, and profit; just as the naturalness of Newtonian physics flowedfrom the perfectharmonyofmatterand its universal lawsofattractionandre-pulsion.22 Not until the second half of the nineteenth century did this theoryabout the absolute necessity of submission to the laws of society yield to thefactsofindustrialization.Inexorably,

the industrial revolution . . . changed the living conditions of millions ofpeople:illhealth,poorhousing,dangerousandinjuriousoccupations,andexcessive morbidity and mortality could notbe overlooked and investigations of the causes and possible remedies of these social problems wereundertaken,oftenbymedicalmen.23

OneofthemostfrequentlycitedoftheseearlyEnglishstudiesistheChadwickreport. Prepared in 1842by Edwin Chadwick, a lawyer and administrator, thisreport to the Poor Law Commission was not the first of Englands pioneeringsocialsurveys.In1832,JamesPhilipKay,M.D.,publishedTheMoralandPhys-icalConditionsof theWorkingClassesEmployed in theCottonManufacture inManchester, in which he documented how poverty and illness were infinitelyinterlocked.24 PeterGaskellin1833presentedasurvey,TheManufacturingPopulation of England, with similar conclusions. Both Gaskell and Kay, however,interpreted the meaning of their data inways thatreinforced theexistingsocialorder.Povertywasseenaspartof thenaturalorder.Thepoorweremorevulnerabletodisease,itwasreasoned,becauseoftheirmoralcondition.Therefore,itwasnecessary tochange themorals (notthesocioeconomicconditions)ofthepoor inorder to improvetheirhealth.Today,wewouldseethisasblamingthevictim.Earlyeconomicliberalismdidnotrecognizetheparadoxofsurveydocumentationthatrevealedhighmorbidityandmortalityamongthepoorandthenusing these data to justify the practice of child labor.25 The Chadwick report,however,broke with the traditionsofeconomic liberalism,recognizing therelationsbetweensocialproblemsandmedicalconditions.Proposalstochangesocialorganizationandtoinitiategovernmentactionconcerningpublichealthandmedical care were soon to follow. Such proposals, however, did not result in a rationally argued policy, drawn from the evidence-based theoretical formulationsthat were inherent in the Chadwick Report. Instead, onlypartialsolutionswereinstituted,especiallyfocusedonthespecificsofthemostevidentproblems,suchassanitationintherapidlygrowingcities.

OneexamplewasChadwicksrecommendationthatadistrictmedicalofficershouldbeappointedineachlocality.ThePublicHealthActof1848providedforsuchappointments,andby1855thelawwasextendedtoincludeLondonaswellastheotherregionsofEngland.Themedicalofficerbecameamodelpublichealthroleforphysiciansofthefuture.


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T H E O R I G I N S 17Another consequence was the establishment of public health as a course of

study.InSt.ThomassHospital,acourseoflecturesonpublichealthwasstartedasthefirstofitskindinEngland.

Therewere

advances,

therefore,

but

mainly

in

public

health

practices,

not

in

the systematic organization of knowledge about the relationsbetween medicalproblems and social and economic conditions.Thereadinesswas for the inclusion of new medical measures for the prevention of disease and the promotionofhealth.Muchslowerwastherecognitionthatsocialmeasureswerenecessaryas well.26 Pressures arising from the emerging political strength of the Englishworking classes produced some partial reformsbut were not strong enough yettobreakthedominanceofeconomicliberalismastheguidingphilosophyofBritain.

TheUnitedStatesIn the United States, during the eighteenth and nineteenth centuries, attitudesandpracticesconcerninghealthandillnessweresimilartothoseinEngland.Theprestige of the medical profession was quite low generally.27 Except for an elitefew who traveled to the medical centers in Edinburgh or Germany, physicianslearnedasapprentices,evenaftertheproliferationofprivateproprietaryschoolsofthenineteenthcentury.Withlittlefaithintheefficacyofmedicineitself,Americawasdominatedevenmorethanitsmothercountrybythemoralconceptofillness. Although the individualism that was promotedby the frontier rejectedolder ideas of immutable fate, it saw individual intelligence asboundedby therulesofnature:thatis,manismotivatedtolearntherulesofnatureandtherebytobe able to order hisbehavior toward a perfect society. It was reasoned thatsickness, disease, and poverty resulted from immorality; conversely, health,wealth, and happiness were proof of ones adherence to the moral laws.28 Theconcreteresultsof thisphilosophy,inhindsight,werestriking:

Itwas

this

assumption

which

enabled

a

prominent

New

Yorker

during

the

1832choleraoutbreak to thankGod that thediseaseremainedalmostexclusively confined to the lower classes of intemperate, dissolute, or filthypeople huddled together like swine in their polluted habitation. At thesame time, a minister proclaimed that the epidemic was promoting thecause of righteousnessby sweeping away the obdurate and the incorrigible . . . A SpecialMedicalCouncilappointedbytheBoardofHealthduringtheoutbreaklentitsauthoritytothisbeliefbyassertingthatthediseasewasconfinedtotheimprudent,theintemperate,andtothosewhoinjurethemselvesby takingimpropermedicines.29

Not until the shattering impact of the Civil War was there serious challenge totheconceptthatdiseasewasapunishmentfromGod,tobealleviatedonlywhenthelowerclasseslearnedtoobservethemorallawspersonalcleanliness,temperance,hardwork,thrift,andanorderlylife.

ThedeadlinessoftheAmericanCivilWariswellknown.Althoughtherecordsarenotadequatetoallowanexactaccounting,itiscertainthatmoreUnitedStatessoldiersdied than in any otherwar, probablyoversixhundred thousand.What


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18 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 islesswellknownistheimpactofsicknessanddiseaseonthemilitarycasualties.Dr.JosephJones,

anindefatigable

Confederate

medical

inspector

who

kept

voluminous

records,estimatedthat . . . the ratioofbattledeathstothosefromdiseasewas

roughlyonetothree:i.e.,50,000deathsfrombattleinjuriesto150,000fromsicknessanddisease.TheratiofortheUnionforces,whichwerebetterfed,clothed, and housed, was approximately one to two: 110,000 deaths frombattleand225,000fromdisease.Inotherwords,grimasthebattlestatisticsare, thetroopsfacedanevengreaterthreatfromsickness.30TheUnitedStateswaspoorlypreparedforthehealthproblemscausedbythe

massive movements of populations and the destruction of the war. In spite ofwarningsigns,virtuallynoorganizedpublichealthsystemexisted.Onlytwoorthreecitieshadanykindofdecentwatersystem . . . [and]nocityhadaseweragesystemworthyofthename.AsDuffyreports:

The reek of overflowing privies in the impoverished sections must havebeenbeyondimagination.Addingtothefoulatmosphereweredairies,stables, manure piles, and heaps of garbage scattered through the towns.Butchersandslaughterersfrequentlyletbloodflowintheguttersandsimplypiledoffalandhidesonvacantgroundnexttotheirplacesofbusiness.Tannersandfat-and-boneboilersgatheredoffalandhidesinopenwagons,thus adding further to the already pungent city aromas. Rivers, creeks,streamsandbrooksflowingthroughthecitieshadallbecomeopensewersby midcentury. Shallow wells, which still supplied most city-dwellerswithwater,werepollutedbeyondredemption.Thewonderisnotthatmortalityratesweresoaringbutthatsomanyofthepoorsurvived.31In spite of these conditions, and the additional warning providedby major

outbreaksofyellowfeverandAsiaticcholeraduringthe1850s,nonationalpublichealth organization had yetbeen formed. Moreover, the prosperity of Americaduring thisperioddidnothelp.On thecontrary,commercialinterestsgenerallyopposedtheestablishmentofcodesandregulationsforsanitationandimprovedsocialconditions.Onsimilargrounds, theArmyMedicalDepartmentwassmalland poorly financed. In March 1861 the Congress voted only $115,000 for theArmy Medical Department. It remained for a civilian organization of reformers,theUnitedStatesSanitaryCommission,topressureCongressintoareorganizationof military medical, and eventually, of public health practices in the UnitedStates.

Another little-known aspect of this important chapter inAmericanmedicineis theroleofwomen.TheUnitedStatesSanitaryCommissioncame intoofficialexistence onJune 13, 1861. Three prominent New Yorkers are credited with itsfounding and its effectiveness: Dr. Elisha Harris, who was a significant publichealthfigure; theReverendHenryW.Bellows,awell-knownUnitarianminister;andFrederick LawOlmsted, famous lateras thedesignerofNewYorksCentralPark. But, Duffy tells us, the real impulse came from the thousandsofwomenwhowere anxious to emulate the workofFlorenceNightingaleandhercohortsin theCrimeanWar.32 Customwasagainstany formofparticipationbywomenin the war. Any combat role was, of course, out of the question, and that was


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T H E O R I G I N S 19where attention was focused. As thedevastationofbattlewounds, injuries,andsicknessbecameoverwhelming,however,womenforcedtheirwayintoimportantmedicalrolesasnurses.Itwasnoteasy:

Shortly after the outbreak of fighting, Dorothea Dix, whose activities onbehalf of the insane had made her a national figure, offered her servicesand was appointed Superintendent of Female Nurses. Subsequently Congress authorized the employment of female nurses in general hospitals.Apubliccontroversy immediatelybrokeoutwhetherornotdelicatefemalesshouldbe exposed to the horrors,brutality, andmoral dangers ofwar. . . . Armysurgeonswereopposedtotheintroductionofwomeninto[army] . . . hospitalwardsasamatterofprinciple.33

Nevertheless,thewomenpersisted.TheUnionArmyofficiallyenlistedoverthreethousand women as nurses, and many more served as volunteers. They wererecognizedtobe farmoreeffectivethanthemalenurses.Theirrecordofaccomplishmentnotwithstanding,therewaslittlecarryoverafterthewar.Althoughtheprejudiceagainstwomeninmedicinewasmodified,theprejudicesoftheprewarsocietywerereassertedanddidnotyieldappreciablyuntilmuchlaterinhistory.

Thesamecanbesaidforthepublichealthmovementgenerallyandevenmoreso for social science in medicine. The United States Sanitary Commission, justlike the Chadwick report, was part of a major historical episode. The publicawareness that these dramas forced intobeing did not survive the crisis eventitself.Therewasno institutionalizationoflastingreforms,andmostimportantfor thestorybeing toldheretherewasno theoreticalinsightabouttherelationbetweensocialfactorsandmedicalproblems.Notforanotherhalf-centurywouldsubstantialprogressbemadetowardthegoalsofsocialmedicine.

TheTwentiethCentury:TheBeginningofBothSocialMedicineandMedicalSociology

Atthemidpointofthenineteenthcentury,Westernsocietiesappearedtobereadyfor a different and more systematic conception of how social factors relate tomedical problems. The grip of economic liberalisms natural laws of societyhadbeenloosenedbygradualrecognitionthatindustrializationwasamanmadeforceagainstwhichmoralreformwaspuny.MajordisastersliketheCivilWarintheUnitedStatesandthetyphusepidemicthatVirchowinvestigatedinSilesialedpeopleintheWesternworldtoreconsiderthecausesandtoreassignresponsibilityforproblemsofhealthandillness.However,therewereotherinterferenceswiththeemergenceofthefieldthatisnowcalledsocialmedicine.

Thiswasaperiodwhenthetermspublichealth,socialhygiene,andsocialmedicinewereoftenusedinterchangeably.Theideaofmedicineassocialscience was dropped. In spite of the farsighted efforts of men like Virchow,however,theperspectiveoforganizedmedicinenarrowedratherthanbroadened,and there was not yet an independent social science to take over the task foritself.Inretrospect,itappearsthattherapidgrowthofmedicalbacteriologyduringthisperiodturnedattentionawayfromthepromisingbeginningsofsystematicconception and control of the social environment as major means of reducingdiseaseandpromotinghealth.


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20 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 The latter half of the nineteenth century saw public health as a specialfield

joinforceswiththosewhobelievedthenewbacteriologywouldsolveallofmed-icinesproblems.Thesocialperspective inmedicinewas frozen,setasidemorethan

rejected,

to

reappear

in

the

early

twentieth

century.

Emil

Behring,

one

of

Virchowschiefacademiccritics,epitomizedthishistoricaltrend.In1893,writingabout the etiology of infectiousdisease,Behringreferred toVirchowsstudyof the 1847 typhus fever epidemic as characteristic of the attribution of socialmiseryasthemajorcauseofdisease.Remarkingthatwhiletheseviews . . . had theirmerits,now,followingtheprocedureofRobertKoch,thestudyofinfectiousdiseasecouldbepursuedunswervinglywithoutbeingsidetracked[myemphasis]bysocialconsiderationsandreflectionsonsocialpolicy.34 Virchowhimself,afterthe defeatof hismedicalreform policies in theaftermathof theEuropeanrevolutions of 1848, achieved an outstanding career as abasic scientist, thepioneerof modern pathology. At the same time, he continued to see medicine in itsorganic relation to the restofsociety,and [he]recognizedhealthanddiseaseasenmeshed within the web of social activity.35 Virchows reputation survives,whileBehring,whocondescendinglydismissedVirchowssocialmedicineinfavor ofanarrowerbiologicalview, isvirtually forgotten today.There isadoubleirony to this story: at the time, it was Behrings view that prevailed, and today,Virchows identity is mainly for the kind ofbiological focus that Behringstoodfor,whileVirchowsadvocacyofsocialscienceisknowntoonlya few.

Soonaftertheturnofthecentury,thesocialmedicineperspectivewasrevived.Alfred Grotjahn, who was a young medical student when Behring proclaimedbacteriology tobe the ultimate medical truth, published in 1904 a statementoftheorythathecalledsocialhygiene.Medicalproblems,hebelieved,shouldbesystematicallyinvestigatedinthelightofsocialscience,soastoarrivefinallyata theoryofsocial pathologyandsocialhygiene,whichwithitsownmethods...wouldbe used to investigate and todetermine how life andhealth,particularly of the poorer classes, are dependent onsocial conditionsand theenviron-ment.36

Grotjahn, more than any other medical scholar up to that time, was able tocreateacompletesetofprinciplesforasystematicstudyofhumandiseasefromasocialviewpoint.Norwashisalonelyvision.Similarideasweregivenexpression during the first decade of the twentiethcentury,suggesting thattherewerenewconditionsinthesocialclimatethatfavoredsuchdevelopment.Itwasprobablynotcoincidentalthatsociology,independentofmedicine,wasgoingthroughamajorgrowthphaseatthistimeorthatthesocialworkprofessionemerged.Allthree, medicine, social science, and social work found a common ground foractionin the prevention of tuberculosis and the securing of decent workingconditionsinfactories,betterhousing,andthelike.37 HarvardUniversityisacaseexample of the interprofessional cooperation and competition among them. AtHarvard,medicalsocialworkwasintroducedasadistinctspecialtyin1905andwas combined with sociology within the Department of Social Ethics that wascreatedin1920.RichardClarkeCabot,thefirstHarvardprofessorofsocialethics,isgenerallyconsideredthefounderofmedicalsocialwork.Cabot,Kanetellsus,althoughhewasaphysician,emphasizedthediscrepancybetweenmedicalrecommendations and their feasibility, especiallybecause of what he saw as thedistancebetweentheworldofthemedicalpractitionersandtherealitiesoftheirimpoverishedpatients.Medicalsocialworkwasexpectedtobridgethatgap,Cabotbelieved,andhewasaneloquentspokesmanforteamworkbetweenphysician


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31/356

22 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 Medical sociology was in existencebutbarely, a foundling of social work in

theUnitedStatesandofsocialhygieneinEuropeandEngland.Itwastohavearichperiodofintellectualdevelopmentthatbeganinthe1920s,buttounderstandmedical

sociology,

it

is

important

to

look

further

at

its

nineteenth-century

antecedents,shiftingfocusfromtheeffortstoincorporatesocialsciencewithinmed

icinetothebirthofAmericansociologyanditsdevelopmentfromthelastdecadeof thenineteenthcenturytillthefirstworldwar.

SummaryThe early history of medical sociology, from antiquity to thebeginning of thetwentiethcentury, isricher,morecomplex,andmorerelevanttomoderntheoryand methodology than hasbeen generally perceived. Its highlightscanbe summarizedinthefollowingpropositions:

Social factors in health and illness havebeen recognizedby physiciansformostofcivilizedhistory,goingbackat leasttoHippocrates.

Theactualmenaceofillnesscausedactionrelatedtothesocialconditionsof disease; that is, such events as epidemics caused the introductionoforganizational structures for public health,especially inurbansocieties,includingeffectivesanitationandsewersystems.AncientRomeisagoodexample.

Social medicine emerged in the nineteenth century as a movement toinvestigatemedicalproblemsinthelightofsocialscience,butitsearliervariantssuch as the efforts of Frank, Virchow, and Neumann in Germany, Guerin in France, and Chadwick in Englanddidnotgetbeyondprovidingaddedthrusttothepublichealthmovement;thatis,elaboratingtheinfrastructureofsanitationandvariousorganizedeffortstocleanuptheworstpocketsof industrialexploitationofthepoorerclasses.

What was most consistently lacking until the appearance ofmedicalsociology was the effort to develop a systematic theoreticalbasis for theadministrativeprogramofpublichealth.

The nineteenth century movement that developed under the bannerMedicine is a social science did not achieve its goals. It was strongenough to forceadialoguewith thebiomedicine thatemergedfrombacteriologicalscience,butthenewgermtheorysodominatedmedicinethatthedevelopmentofagenuinesocialmedicinewasaborted.

WithGrotjahn,intheearlydecadesofthetwentiethcentury,socialmedicine revived. It continued, however, tobe dominatedby abiomedicalorientation.

It

was

pragmatic

and

applied.


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2AmericanSociologybefore1920

FromSocialAdvocacytoAcademicLegitimacy

Theemergence ofmedical sociology canonlybeunderstoodwithinthecontextof the American university. Even though the English and German universitieswere, in many ways, the models for American institutions, a more organizedsocialsciencewasproducedinAmericanuniversitiesthananywhereelseintheworld, and medical sociology developed as an intrinsic part of its parent discipline.ThecharacterofthishistoricdevelopmentdidnotbecomeclearuntilaftertheAmericanCivilWar.

Atthattime, inthe lastquarterofthenineteenthcentury,bothsocialscienceandmedicineintheUnitedStatestookgreatleapsforward.Beforethat,theywereintellectually dependent on European scholars. To be professionally current,many Americans studied at the universities of Germany, France, and England.Separationfromthesescholarlyrootsandindependentnationalgrowthwasonlypossible with the radical reorientation of American universities away from thescholasticismoftheirChristiantheologicalsourcesandtheirtransformationintosecular,empiricalsciencebasedinstitutions.Thishappenedwhenthefirstgeneration of college teachers with Ph.D. degrees werebeginning to make theircareerswithinthenationsuniversities.1 Bothintellectualdevelopmentandtheinstitutional arrangements were fundamentally changed. The research universitywasborn,andallofthemajortypesofintellectualactivitywereincludedinthistransformation,includingbothsociologyandmedicine.2

This was also the period when the modern medical school first emerged intheUnitedStates.Medicaleducationbecamecloselyalignedwiththeuniversity,graftingthebasicbiologicalsciencesofthegraduateschooltothebedsideteaching model of the English hospital schools. Medicine, during the prior century,hadbeen dominatedby clinical private practice. Even medical education waslargelyprivateandforprofit,inschoolswherelocalclinicianslecturedforafee,followed or paralleledby individually supervised apprenticeship towardqualification. There were some university medical schools as early as the 1770s,buttheywere fewandwerepoorlysupported.Notuntilthelatenineteenthcentury

23


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24 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 didmedicaleducationbegingrafting thebasicbiologicalsciencesoftheuniversitygraduateschooltoclinicalinstructioninteachinghospitals.3

Inasimilarway,theuseofsocialsciencebymedicinebegantochange.Insteadof

the

ad

hoc

efforts

of

physicians

themselves

to

create

a

social

science

of

medicine, there was a new differentiation of tasks. Out of the universitys graduate

schoolaspecializedsubfieldbegantoemerge,asociologyofmedicinethatcompetedwithpublichealthandsocialmedicine in theeffort tounderstandtherelationofsocialfactorsandproblemsofhealthandillness.

Today,medicalsociologyisanintellectualactivitybothinsideandoutsideofmedicine. In the university college ofartsandscience, ithasachievedan institutionalstructureautonomousfrommedicine.Inmedicalschools,aparallelroleexists.Likethepreclinicalbasicsciences,medicalsociologyhasadualidentity,basicallywithinitsparentdisciplineandsecondarilyasaparticipantinmedicalinstitutions.4

Because sociology was, at the turn of the century, still in its early stages ofdevelopment as a social science, it was tobe another fiftyyearsbefore theconditions were rightboth within medical education and in sociology itself for thesubspecialtyofmedicalsociology tobegin itsmoderncourse.Nevertheless,thiswasaperiodofintensepreparation,forbothmedicineandsociology.Therewere,however, important differences in their histories. Medicine had already completed a substantial part of its intellectual journey from an empiric art into arational science5 and, as shownby the circumstances surrounding theFlexnerReport, was in theprocessof institutionalizing thenewrationalityintomedicaleducation and clinical practice. Sociology, on the other hand, was in the veryearlystagesofemergenceasasocialscience.Medicine,despiteitsalreadyestablished practice of welcoming newly emerging intellectual disciplines into researchandeducationalpartnership,wasnotyetready toextendsuchaninvitation to sociology. As I have shown, this was notbecause of any lack of interestin the relationbetween social factors and medical problems. Rather, it wasbecause the dynamism of biomedical discoveries, especially thebacteriologicalsources of germ theory, was at itsmostoverwhelming andbecausesociologyasanacademicprofessionwas in itsinfancy, tooweak tochallengethestillstrongconviction thatmedicine itselfcoulddevelopandinstitutionalizeitsownsocialscience.

Againstthisbackground,medicalsociologyshistory,bothbeforeandafterinstitutionalization, reflects the pressures of medicine as its host profession andgeneralsociologyasitsparentdiscipline.Thisgrowthcanbesummarizedinthefollowingthreepropositions.6

1. Medicalsociologyiscloselyconnectedwithandfollowsthepatternsofdevelopment in its parent discipline. Unlike somespecializedintellectualactivities thattakesharplydivergentdirectionsawayfromtheiror-igins,7 medical sociologys theory and research follow closely those ofmainstream sociology, and its institutionalstructuresimilarlyhasbeenstronglyintegratedwiththatofgeneralsociology.

2. Throughoutthedisciplineshistory,therehasbeenadualthrusttowardprogressivereformontheonehandandthedevelopmentofknowledgeon the other. The tensionbetween advocacy and objectivity,betweenappliedandbasicsciencehasalwaysbeenpresentasadialecticalchallenge.


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A M E R I C A N S O C I O L O G Y B E F O R E 1 9 2 0 253. There hasbeen, formore thanacentury, asubstantialoverlapbetween

theworkofsubgroupswithinmedicineandthatofsocialscientistswho,from roles external to medicine itself, conducted research about problems

of

medicine.

The

two

have

had

tempestuous

relations,

at

times

courtingandcollaborating,atotherscompetingorexcluding.Twomedicalspecialtieswereparticularly involved insidemedicine:communitymedicine, including public health and preventive medicine, and psychiatry,whichhastriedtofitbehavioralsciencewithinitsknowledgebase.Thisinsider-outsider8 ambiguityhasbeencentraltothestrugglefor legitimacyby medical sociology inboth the medical worldand theacademicworldofsociology.

Fromsuchdeterminants,themajorrolesofmedicalsociologistshaveemerged: Basicscientistofbehavior University teacher in sociology departments and teaching collaborator

withphysiciancolleaguesinmedicalschool Policyanalystandconsultant

Thisrangeofactivitiesandrolesemergedgradually.Todaymedicalsociologyisone of sociologys most active subspecialties. Onlyby looking in depth at itspreinstitutional history, however, can medical sociology as we see it todaybefullyunderstood.

AmericanSociology:TheBeginningsThebeginningofmodernAmericansociology isusuallydatedtothecreationoftheAmericanSocialScienceAssociation(ASSA)in1865.9 Thegeneralmultidisciplinary character of thisorganizationand itsexpansivesocialreformistobjectiveisevidentinitsownstatementofpurposes:

ToaidthedevelopmentofSocialScience,andtoguidethepublicmindtothebest practical means of promoting the Amendment of Laws, the AdvancementofEducation, thePreventionandRepressionofCrime,theReformationofCriminals,andtheProgressofPublicMorality,theadoptionofsanitaryregulations,andthediffusionofsoundprinciplesontheQuestionsofEconomy,ofTrade,andFinance.ItwillgiveattentiontoPauperismandthetopicsrelatedthereto. . . . [It willaimtoobtain]bydiscussionoftherealelementsofTruth;bywhichdoubtsareremoved,conflictingopinionsharmonized,andacommongroundaffordedfortreatingwiselythegreatsocialproblemsoftheday.10

BoththetimeofitsfoundingandthebroadreformistmandateoftheASSAreflectthe social impact of the CivilWar. In the mostdetailedstudyof theASSAconducted to date, Mary Furner wrote, The industrial America that grew up afterthe CivilWarmade peopleconsciousofsociety innewways.The factories,thecorporations, the railroads, theburgeoning citiesthose powerful totems of amodernagehadseemedsopromisingonebyone.Consideredtogether,theyhad


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26 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 amoreominouslook.11 Toanswerthesocialquestionsposedbyindustrializationbecame the need and opportunity that spawned the modern social scienceprofessions.

Inthe

beginning,

the

recruits

to

social

science

were

concerned

citizens

from

variouswalksoflife,amateursfor themostpart,energizedmorebyhumanitarianism thanby the drive to contribute tobasicunderstandingofsociety.AndsotheyremainedforthemostpartintheASSAforthenexttwodecades.Gradually,however, some ASSA leaders and the new universities shifted their attentionfrom the unfortunate victimsofsocialchange toprocessesaffectingsocietyasawholeandthenembarkeduponempiricalstudiestodiscoverhowsocietyworked[and] took the first tentative steps toward professionalization as social scien-tists.12

Inevitably, the ASSA was toobroad in its scope to satisfy the needs of thevariedinterestsofitsearlymembership.Itbegantospawnnew,morespecializedorganizations.Initially,thesewerestill,inemphasis,groupsinterestedmainlyintheapplicationofasocialperspectiveonpublicpolicy.In1874,forexample,theNational Conference of Charities and the American Public Health Association(APHA) were created. The former was tobecome, in1918, the NationalConference of Social Work, while the latterbecame the major professionalassociationofpublichealthspecialistsinmedicine.

Gradually,thoughnotwithoutmuchinternalandpublicstruggle,therewasashift away from the advocacy of the reformers, and academics emerged as theleadersoftheASSA.Unliketheantebellumcolleges,whichplacedprimaryemphasis on transmitting a cultural tradition and developing the civic moralityofstudents, the emerging universities developed an ethos of their own whichstressed the creation of new knowledge above everything else.13 Forboth nonacademicandacademicsocialscientists,tensionbetweenreformandknowledgepersisted,but the impulse toward professionalization was inexorable. Like thereform-oriented professions of social work and public health, the university-trained disciplinesbegan tobreak away from ASSA. Beginning in 1884 whenASSA was not yet twenty years old, the academic professionalassociationsappearedinthefollowingorder:

TheAmericanHistoricalAssociation,organizedin1884TheAmericanEconomicAssociation,in1885TheAmericanAnthropologicalAssociation,in1902TheAmericanPoliticalScienceAssociation,in1904TheAmericanSociologicalSociety,in1905

These groupsbecame the main source and expression of social science in theUnitedStates.

Medical education, at this point in time, was regardedby most educators asseriously deficient,14 but it was certainly alive and active. Fully four hundredmedicalschoolswere foundedintheUnitedStatesbetween1800and1900,butmostwereprivateorproprietary(organizationsforprofit).Theyalsocameandwent, so that,by 1905, the year when the American Sociological Society wasfounded, therewere155operatingmedicalschools.Thisisstillalargenumber,substantiallymore thantherearetoday.Also,thedoctor-to-populationratiowas


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A M E R I C A N S O C I O L O G Y B E F O R E 1 9 2 0 27one to 700800, more favorable in terms of the available supply of physiciansthan today. The American Medical Association (AMA), founded in 1847, grewfrom eighty-fourhundredmembers in1900 toseventy thousand in1910. Itwasestimated

in

1901

that

approximately

six

thousand

people

were

graduating

yearly

fromthemedicalschools.15

Graduateeducationinsociology,ontheotherhand,hadbarelybegun.In1893,thefirstgraduatedepartmentinsociologywascreatedatChicagoUniversity.Following closebehind were Columbia, Brown University, Yale, and thenewstateuniversitiesof theMidwest,Wisconsin,Nebraska,andMichigan.TheAmericanSociological Society was inaugurated in 1905 with 115 members, andby 1910,only141morehadbeenadded.

It is important to keep in mind that secondary and higher education, at theturn of the century, was nothing like it is today. Less than 10 percent of highschoolagechildren,intheyear1900,actuallyattendedasecondaryschool,andthestudentsincollegesanduniversitieswereonly4.01percentofAmericansofcollegeage.16 Thesecondaryschoolsthemselveswerelargelyprivateandalmostentirely academic, geared to the classical and sectarian approaches typical ofhigher education at the time. Donald Light, in a recent discussionof thedevelopmentofprofessionalschoolsinAmerica,writesthatthroughmostofthenineteenthcenturytherewas

noacademicprofessionasweunderstandittoday. . . . The traditionalcollegesconcentratedon mental disciplineandpiety. In the1870s,PresidentMcCoshofPrincetonaffirmed:Religionshouldburnintheheart,andshine...from the facesof the teachers . . . One was to avoideducationwhichputsakeenedgeontheintellectwhileitbluntsthemoralsensibilities . . . Thismeantthatthroughrecitationoftheclassicsandpagesofdisciplinaryrules,collegesattemptedtocontrolthementalandmorallivesoftheirstudents. Theybelieved that restraint produces self-restraint, hard work produces diligence, and precise memorization and recitation produced a disciplinedmindinanyfieldofendeavor.Suchgoalsprovidednosupportforanacademicprofession.Facultiesspenttheirtimebeingdisciplinariansandhearingmemorizedrecitationsofancientlanguagesormathematics.Therewas no academic career, salaries were low, and as PresidentEliot [ofHarvard] remarked in 1869, few men of talent were attracted to theacademiccalling.17

From such abackground came virtually all of higher educations recruits, a situationthatdidnotchangesignificantlyuntilthetwentiethcentury.

When, in 1908, Abraham Flexner conducted his survey of all 155 medicalschools in theUnitedStatesandCanada, he found that theresidueof thescholasticismofnineteenth-centuryhighereducationwasstillpervasive.Flexnerwashimself a product of theJohnsHopkinsUniversity soonafter itwas foundedin1885. Like the University of Chicago and Stanford,JohnsHopkinswasa modeloftheresearchuniversitythatemergedtoreplacetheoldreligiousscholasticism,and its orientation to graduate study and the scientific method throughout thecurriculum was a radical departure for its time. Flexner, as he made judgmentsaboutthestateofmedicaleducation,sawtheuniversitythroughtheprismoftheJohnsHopkinsmodel.Therefore,hebelieved thattheproblemwithmedicaleducationintheUnitedStateswasthatitwasdominantlyproprietary.Ifithadbeen


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28 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 part of the university from thebeginning, none of the important problems thathissurveydescribedneedhaveexisted.

CriticsofFlexner focusedon thispoint.Duffyparticularlycriticizedwhathesaw

as

Flexners

ignorance

of

the

actual

state

of

higher

education

in

America

duringthenineteenthcentury:

InhisclassicstudyofAmericanmedicaleducationin1910,AbrahamFlexnerblamed the University of Maryland for the introductionofproprietaryschoolsa system, he wrote, which divorced American medical schoolsfrom universities and led to a progressive lowering of educational standards.Itisclear,however,toanyonewhostudiesconditionsinnineteenth-centuryAmericathattheuniversitiestowhichmedicalschoolsmighthavebeengraftedsimplydidnotexist [my emphasis].When theMarylandlegislatureestablishedtheCollegeofMedicineofMaryland,therewasnouniversity within the state. The same was true in 1845 when the Louisianalegislature transformed the Medical College of Louisiana into the medicaldepartment of the University of Louisiana. The Universityexistedonlyinname.Moreover,eveninthecaseofschoolssuchasHarvardandtheUniversityofPennsylvania, themedicalschoolprofessorscollectedtheirownfeesandremainedvirtuallyautonomousformuchoftheschoolshistory.18A close reading of Flexner suggests that hebased his judgment on the early

colonial history ofmedicaleducation in theUnitedStates.At that time,shortlybeforetheAmericanRevolutionaryWar,theearliestmedicalschoolswereindeedpart of the university. The first wasbyJohn Morgan in 1765 at the College ofPhiladelphia,latertobetheUniversityofPennsylvania,andthesecondatKingsCollegein1768,whichbecameColumbiaUniversity.TherefollowedthemedicaldepartmentsatHarvardin1783,Dartmouthin1798,andYalein1810.Thecaseof Maryland, in his judgment, interrupted this development, establishing whatFlexner called a harmful precedent.19 His opinion on this matter, as on most,wasdirectandunqualified:

Thesoundstartoftheseearlyschools[Pennsylvania,Columbia,Dartmouth]was not long maintained. Their scholarly ideals were soon compromisedand then forgotten. True enough, from time to time, seatsof learningcontinued to create medical departments . . . but with the foundationearly inthenineteenthcenturyatBaltimoreofaproprietaryschool(Maryland) . . . aharmfulprecedentwasestablished.Beforethat,acollegeofmedicinehadbeenabranchgrowingoutofthelivinguniversitytrunk.Thisorganicconnection guaranteed certain standards and ideals, modest enough at thattime,but destined to a development which medical education could, asexperienceproved,illaffordtoforego.20

Flexner was not totally impervious to the historical realities of the nineteenthcentury.Evenhadtheuniversityrelationsbeenpreserved,hewrote,

the precise requirements of the Philadelphia college would not indeedhavebeen permanently tenable. . . . The rapid expansion of the country,with the inevitable decay of the apprentice system in consequence, mustnecessarily have lowered the terms of entrance upon study (ofmedicine).


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A M E R I C A N S O C I O L O G Y B E F O R E 1 9 2 0 29Butforatimeonly,therequirementsofmedicaleducationwouldthenhaveslowlyrisenwiththegeneralincreaseinoureducationalresources.Medicaleducation would havebeen part of the entire movement insteadofanexception

to

it.

The

number

of

schools

would

have

been

well

within

the

number of actualuniversities, inwhosedevelopmentasrespectsendowments,

laboratories,andlibrariestheywouldhavepartaken;andthecountrywouldhavebeenspared thedemoralizingexperience inmedicaleducationfromwhichitisbutnowpainfullyawakening[myemphasis].21

WhatFlexnerseemedtoignorewasthechangingnatureoftheuniversityduringthe preceding centuryandespecially thepervasiveChristian traditionalismthatplaced such severe constraints on the universitys ability to open itself to therationalorientationofscience.Hisanalysisalsoneglectedtheinteractionbetweensocioeconomicandpoliticalfactorsandeducation.

WhateveronedecidesaboutthedifferentinterpretationsofFlexnerandDuffy,the conditions in whichbothsociology andmedicaleducationbegananewerawere the same: itwasa periodof intense,widespreadexpansionofeducationalinstitutions and of the intellectual standards of colleges and universities. TheindustrialgrowthofthepostCivilWaryearswithitsexplosiveincreaseoftechnology made very clear the need for a more educatedpopulation.Basically,thepioneersofAmericansociologywerepartofasocialsciencemovementthatwasseekingboth intellectual integration and social reform. It was, as the Bernardshave documented so extensively, part of a movement that was utopian in aspiration,humanitarianinidealism,anddirectedtowardestablishingrealisticprinciples of social welfare and reform.22 From the outset, however, there were differences between the primary work roles of sociology and its sister socialsciences.Sociologists,fromthebeginning,weremorepartoftheuniversity.

This close association, in the United States,between sociology and the universitymaybeexplainedbythefactthat,initsbirthorder,itwasthelastofthesocial sciences to professionalize. Consequently, as the major chroniclersof thefield point out, the span of sociologys biography is almost identical withtheriseanddevelopmentofgraduatestudiesandtheuniversityproperinAmer-ica.23 One resultof this associationappearswhenonecompares thepresidentsof the professional societies from theirbeginnings up to 1930. All in sociologywereuniversityprofessors.TheAmericanHistoricalAssociationincludedjudges,ministers, and representatives of the army, navy, and public service. The presidentsoftheAmericanEconomicsAssociationandtheAmericanPoliticalScienceAssociationalsoincludedmanywhowerenotfromacademicinstitutions.24 TheleastacademicamongallthesocialscienceswasthenationalConferenceofSocialWork,which, in itsfirstseventy-fiveyears, includedvery fewleaderswhowerefromtheuniversities.

ThefirsthistoricalphaseofAmericansociology,however,inspiteofitscloseties with academic institutions, exhibited little of the ivory tower elitism of itsEuropean counterparts. Quite the opposite. As Lazarsfeld and Reitz tell us,[W]hen sociology first came to the United States, it was akin to a crusade forsocialimprovement.Moreover,therewasonehighlyvisibleresultofthealliancebetween social reform and early sociology: the social survey movement. In thebeginning,wagesandhousingconditionsandsocialrelationsinthefamilyweresurveyed.Thestudyofmorevariedsocialattitudescame later.25


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30 M E D I C A L S O C I O L O G Y B E F O R E 1 9 4 0 ThefoundingoftheAmericanSociologicalSocietyoccurredinthemiddleof

thisdevelopment.Themembershipwassmall,beginningwith115andgrowingto 1,021by 1920.26 For the purposes of this discussion, it is notable thatLesterF.

Ward,

the

first

president,

had

a

medical

degree.

This

should

not

be

interpreted

as more than an intriguing footnote to thishistoryofmedicalsociology,thoughitdoesindicatesomethingaboutthenatureofmedicalqualificationattheendofthe nineteenth century. Ward gained his qualification at a time when the M.D.degree couldbe obtained in as little as six months of part-time attendance atlectures. ItwaspreciselytothisshallownessofprofessionalstandardsthatFlexner directed his withering criticism of 1910. Ward was medically qualified innameonly;butthe factthathetook the troubletostudybothmedicineandlawwhile at the same time fashioning a career as a sociologist shouldbe judgedagainst the most prestigeful model, the universal scholar, that prevailed at thetime.27

In thepostCivilWarera,thesocialbackgroundsofmostleadingsociologistswereruralandreligious.OfthenineteenpresidentsoftheAmericanSociologicalSociety who hadbeenborn prior to 1880, who had completed their graduatestudiesbefore 1910, and who had achieved some prominencebefore 1920, notonehadexperiencedatypicallyurbanchildhood.28 Theywere,likemanyAmerican scholars of that time, either ministers or the sons of ministers and weredeeply committed to personal involvement in social reform. Although they didnotusesociology toendorse the ideologyandpracticesofconventional,institutionalized religion, they were almost without exception fundamentally concernedwithethicalissues.29 Thequalityoftheirreformismappearstohavedeeprootsinthiscombinationofruralandreligiousbackgrounds:

These men grew to maturity at a time when the religious and ethicaltraditionsofProtestantismstilldominatedthenation.OftentheirreformismwasasecularversionoftheChristianconcernwithsalvationandredemption and was a direct outgrowthof religious antecedents in theirpersonallives.LesterF.WardsmaternalgrandfatherandFranklinH.GiddingsandWilliamI.Thomasfathershadbeenministers;WilliamG.Sumner,AlbionW. Small, George E. Vincent, Edward C. Hayes,James P. Lichtenberger,Ulysses G. Weatherly, andJohn L. Gillin had themselves had earlier ministerial careers. This recurrent combination of ruralbackground with inculcationofreligiousidealswasanimportantpartoftheexperientialframework within which so many early sociologists interpreted and evaluatedtheconditionsandproblemsofurban,industriallife.30Wardandhismostprominentcontemporaries,Sumner,Giddings,andSmall,

present a mix of American and European approaches to scholarship. Like theirEuropeanmodels, theywere intellectuallyrootedinphilosophyandunafraidtoattemptcomprehensive theoriesofsociety.Theyalsoaccumulatedwide-rangingexperienceoutsideoftheuniversityandwereprodigiousheroicworkers,writing,editing,and joininginavarietyoflayandprofessionalorganizedactivities.They were, like their contemporary medical colleagues, emerging into a newidentity.

Sociology ispresented tostudentstodaywithattributionmainlytoEuropeanintellectualorigins; it is definedasa specialscience forthestudyofsocialaggregates and groups in their institutional organization, of institutions and their


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A M E R I C A N S O C I O L O G Y B E F O R E 1 9 2 0 31organization,andof thecausesandconsequencesofchangesininstitutionsandsocial organization.31 The early models for American sociology were mainlyFrenchandBritish.FromFrance,AugustComte(17981857),inhiswritingsfrom1830

to

1854,

is

described

as

the

source

both

of

the

name

sociology

and

its

conception of society according to analogies drawn from natural science. FromEngland,HerbertSpencerstheoriesofsocialevolutionwerepairedwithComtesviews of society as a social organism. Comtesbiological analogiesfit wellwithSpencersevolutionalperspective.TheirlawsofsocietyappealedtoAmericans,especially thepurposiverationalityofComte,theindividualismofSpencer,andthenaturalistic interpretationsofboth.AlthoughSpencerstranslationoftheevolutionary doctrine of survival of the fittest into a defense of laissez-faire individualismappealedmore to industrialleadersthantothereform-mindedAmericansociologists,hiswork neverthelesswas themainpointofdeparture fortheearly pioneers, including especially Sumner and Wardbut also Giddings, Thomas,andSnaniecki.32

By1910,theinfluenceofComtefadedandwasreplacedbythatofDurkheim,who was able to take the strong heritage of the French hygienists of the earlynineteenth century and wed its empirical research methods to theory that wascomparativeandcloselylinkedwithanthropology.Germanymeanwhileassumedthe dominant position in the development of theories of socialbehavior, socialstructure, and social change. Americans like Albion Small, the founderofsociology at the new University of Chicago, received their graduate training inGermanuniversities,bringingbacktheteachingsofMaxWeberandhispolemicalexchanges with Karl Marx and the social psychology of Georg Simmel. FromEnglandatthesametimecameaninfluencestrikinglydifferentfromthatofSpencer: thedevelopmentofquantitativemethodsofsocialresearch,particularlythesurveys used for community studyby Booth and Rowntree33 and Sidney andBeatriceWebb34 andthestatisticalanalysisofPearsonandothers.35 UnlikeAmerican sociology, however, all of these developments were either outside of theuniversityorintenuous,proscribedstatusaspartnertoarelateddiscipline,suchasanthropologyinFrance,politicaladministrationinEngland,andeconomicsinGermany. Itremainedfor theUnitedStatestoprovideformalinstructioninacademic departments throughout the system of higher education. Even today, noothercountryhasgivensimilaracademicrecognitiontosociology,andtheUnitedStateswasthefirsttoofferformalinstructionleadingtoadoctorate.

ThewaysociologybeganasaderivativeintellectualchildofEuropeanthoughtbutthrivedinAmericanacademicinstitutionscanonlybeexplainedbythespecialcircumstancesofsocialscienceatthetime.FurnerdescribesthesefirstAmericans to call themselves sociologists as refugees from other disciplines. BotheconomicsandpoliticalsciencequicklyfoundafocusforharnessingtheirearlypostCivil War activism to academic research, the former oriented toward developingtheskillstoregulatetheeconomyandthelatterpreoccupiedwithshaping techniques of administration for various government functions.36 But thatleftsocialscientistswhoeitherwerecriticalofwhattheysawastheco-optationof social science, especially economics,by the entrepeneurial marketplace orwere in other ways left hanging in their search for solutions tobroader socialquestions.Inquietdesperation,writesFurner,afewserioussocialreconstructionists turned to a new alternative, sociology.37 Even Albion Small, as late as1908,admitted:Thechiefobstaclewhichspecialistsofmysortencounteristheinveterateopinionthatsociologyisme

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