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  • American Medical History: Still Waiting for the Next Big Synthesis
  • Theodore M. Brown (bio)
John C. Burnham. Health Care in America: A History. Baltimore, Md.: Johns Hopkins University Press, 2015. 592pp. Illustrations, notes, and index. $34.95.

Two earlier reviewers of this book have compared it favorably to Paul Starr’s multiple award-winning The Social Transformation of American Medicine (1982).1 Their comparisons are based on the vast scope and interpretive ambitions of the two books and the sheer volume of scholarship consulted and masterfully synthesized in each. But two other reviewers have been more critical. One calls Burnham’s narrative of American medicine “mostly triumphalist and top-down” and regrets that it largely leaves out the voices of African Americans, women, Native Americans, and unorthodox practitioners.2 The second notes that Burnham fails to develop “a daring or innovative interpretive scheme,” tries too hard for “dispassionate balance,” and thinks of “historical narrative as a river [but] largely avoids side eddies and countercurrents.”3 A true assessment of Health Care in America: A History lies, I believe, somewhere between extravagant praise and sharp critique. This is a valuable and in many ways admirable book and the product of an enormous amount of work by a mature and accomplished scholar, but it has its frustrating shortcomings and cannot be seen as a legitimate successor to Starr’s brilliant Social Transformation.

Burnham begins by framing his narrative as a story of “modernization” and divides the four centuries between the early seventeenth and the early twenty-first into three “epochs.” The first two epochs are clearly enough defined: “traditional health care” (c. 1600–1880) and “modernizing health care” (c. 1880–1980). The third epoch is loosely sketched, characterized as “new” and “disjunctive,” and said to be marked by genetic medicine, managed care, and a transformation in the doctor-patient relationship. Burnham suggestively labels this third epoch “desktop medicine” but does little more than gesture to what that might mean and offers no real explanation of its origin or likely trajectory.

Burnham then fills in each of his epochs, or at least the first two. He tells us that during the long reign of traditional medicine, American practitioners well into the nineteenth century but especially in the eighteenth looked to the [End Page 208] past for guidance in theory, therapy, and care. He recounts ideas of nature and of the human body’s relationship to it; describes common fluxes, fevers, dysenteries, and terrifying epidemics; and catalogues the medical substances and procedures that produced observable changes in bodies, interpreted as sure signs of their therapeutic efficacy. He also notes the steady incorporation into the existing framework of new materia medica of both European and Native American origin (foxglove, cinchona), plus some technical innovations like smallpox inoculation and vaccination. But these were minor additions of no great theoretical or behavioral challenge, and Burnham asserts that, by 1800, “almost nothing had changed in the two centuries since the first colonists had landed” (p. 34). He supports this claim convincingly with a detailed narrative of the brutal but entirely traditional treatment of George Washington’s last illness in 1799.

In Burnham’s account, several changes characterized nineteenth-century American medicine. One was flirtation with theoretical and therapeutic fads and the pursuit of both narrow medical sectarianism and ambitiously synthetic conceptual systems with their sometimes vigorously “heroic” practices. A second was a countervailing fascination for heterodoxy in the form of homeopathy with its alternative medical worldview and accompanying therapeutic moderation. A third was a passion for self-help and personal hygiene, balanced by commercial medical marketing and the appeal of patent medicines. For elite physicians and their patients, there was growing dependence on novel European ideas, first French, then German. This elite practice was influenced by a changing understanding of the human body and a new orientation to both anatomically localized specific diseases and organ-system pathologies with clusters of general symptoms. A growing respect for surgery was notable in a century also marked by increasing medical professionalization, reflected in the formation of medical societies, schools, and hospitals, along with the growth of medical publications and an ultimately successful push for licensing.

In the second half of the...

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