Cultural Authority and the Sovereignty of American Medicine: The Role of Networks, Class, and Community

According to Paul Starr, in The Social Transformation of American Medicine (1982), the cultural triumph of progressivism, coupled with institutional changes, established a system of authority based in the scientific profession of medicine rather than on any person who claimed to be a doctor or any type of healing based on other theories (e.g., homeopathy). This cultural authority "entails the construction of reality through definitions of fact and value" (13). While Starr rejected earlier notions that popular attitudes translated directly into status and power, he did see public beliefs and opinion as crucial to the growth of cultural authority and its conversion into the control of markets, organizations, and governmental policy (7). From this perspective, cultural authority engenders trust, compels obedience, and fosters legitimacy, thereby increasing public dependence on the profession of scientific medicine. Thus, the American public became willing to embrace and institutionalize the use of regular physicians despite the belief of many Americans that common sense was the best approach to health and healing.

Social histories of scientific medicine's rise to professional dominance often rely on this coupling of public sentiment and institutionalized sources of power. Not typically addressed, however, is whether such a recounting of causal links provides the most compelling explanation for the social and historical processes underlying medicine's documented rise. The purpose of this article is not to add new data to a richly detailed body of historical research. Rather, our aim is to marshal these accounts in support of a different, two-stage pathway to professional sovereignty.¹

In brief, we argue that a more explicit view of the "publics" that had to be won over alters the reading of the historical data. The Social Transformation of American Medicine does not make clear exactly who the public is, when and what sentiments matter, or how both came into play in establishing professional sovereignty. We argue that focusing on the profession and elaborating its publics offers a more nuanced understanding of how individuals mattered and, more important, how the social ties among them also mattered. Specifically, a closer look at what appears prominently as a disembodied public in Starr's book directs us to the professionals, managers, administrators, and academics who mobilized resources and formed a client base as the medical profession reformed and established its dominance.² From the mid- to late nineteenth century to the first few decades of the twentieth century, their middle-class values, aspirations, and energies were consistent with those of an emerging medical leadership. Their involvement in centers of power in philanthropy, industry, academia, government, and hospitals set the stage for the medical profession's consolidation of authority. Indeed, an even larger population of the middle classes opened the market by seeking services provided by medical practitioners whose science base began to replace dogma and faith, but whose practices still remained circumspect and uncertain.

Our focus on the middle classes addresses a missing link in Starr's broad historical narrative. Further, it generalizes M. Jeanne Peterson's (1978: 1) British-based argument that the rise of the medical profession is part of the larger story of the rise of the middle classes "in the wake of the industrial revolution." Extracting from what James S. Coleman (1990) calls an insufficient aggregation theory, at times Starr's narrative moves unconvincingly between two levels of analysis. On the one hand, the broad social changes of urbanization, transportation, science, and technology that accompanied the development of scientific medicine are well described. On the other hand, however, these larger, societal developments are not always linked to the behaviors of individual actors. In our current effort to lower the historical gaze (see Warner, this issue), we focus on the middle classes to provide an important link between individual or collective efforts and the broad social and institutional changes that gave rise to medical authority. It also reconfigures if, how, and when the general public embraced scientific medicine. These insights replace the notion of a wholesale cultural shift in favor of a perspective...