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Lessons from 18th Century Medical History

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Yglesias has been reading Middlekauf and tries to learn lessons on modern health care from the disastrous medicine of the time:

I think discussions of health care economics pay far too little attention to the question of pre-modern health care. People have been earning a living as medical professionals for a long time. And yet everybody knows that the invention of actually useful medical treatments is pretty recent development. Surely this tells us something about the nature of the health care consumer’s ability to find and purchase cost effective treatments.

I don’t know. I certainly respect the goal to take lessons from the past for the present–I am essentially a presentist in my work. I also don’t really agree (regardless of the reality of modern America) with Yglesias’ general philosophy of finding ways to make neoliberal free market capitalism work more efficiently and with somewhat more generosity and somewhat more equitable dispersal of resources (if any of you see this as a mischaracterization of his overarching line of thought, including Matt himself, let me know). I see the current system of extremist capitalism as a complete disaster that is leading our nation back to the Gilded Age. But let’s leave that aside for the time being.

I’m just having trouble finding any real lessons for modern health care out of 18th century medicine except to say that bleeding is a really freaking bad idea. I don’t think the desire for more efficient markets really drove the 19th century medical reforms that created modern medicine. It had a lot more to do with the fact that a) most of the patients were dying, b) there were lots of opportunities to experiment thanks to Civil War casualties, c) improved drugs, and d) evolving technologies. My sense is that consumer choice really didn’t drive any of this–although I should read up on the debates over bleeding when it went out of fashion. In any case, with the development of the smallpox vaccination in the 18th century, I’ve always thought it was more or less forced upon a suspicious and superstitious population from on high until it was proven far more effective than not getting it at all, even with the very real chance of death.

That said, it’s a bit out of my time period, so I’d be curious to see a) what others think and b) if others believe that these changes had anything do with patient preference.

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  • Walt

    I thought this was kind of a weird reading of Yglesias’ post. His point is that while capitalism works well for goods that consumers can evaluate correctly, it works badly for goods that customers can’t. The fact that in the 18th century people voluntarily underwent procedures that not only provided no benefit but also increased their chances of dying shows that health care is a good that customers are terrible at evaluating.

    • Maybe. But if that’s the point, there’s a lot of reading back into history. That’s not surprising of course, but I think it would also assume that people had some kind of alternative and assumes that they thought it was going to kill them. People died left and right during these years and it’s really hard for modern people to understand how normal death was. It also ignores how people conceptualized their own bodies in the 18th century. Which one wouldn’t expect the average intelligent person to know, but also goes to my point that I don’t think there are any useful lessons here.

      • Walt

        So people are now so much better informed that they are immune to quackery in a way that they weren’t in the 18th century? Maybe we really should privatize health care, then.

        • Certainly not, but what seems like quackery in the 18th century was not considered that way at the time. Perhaps you all are right about Yglesias’ larger point, but I still have trouble with it in part because everyone mischaracterizes 18th century medicine. Sure it wasn’t effective medicine. But it was also the best medicine available at the time. A consumer implies that one has a choice. And I suppose these people did–to die or to probably die. Both the medicine and the market were so vastly different between 1775 and today that comparisons just don’t have a lot of value. And for them to have that value, we have to understand both 18th century medicine and 18th century proto-capitalism.

          • Walt

            I’m not sure how the context helps. Ordinary people bought “the best medicine at the time”, even though it was completely ineffective. Ergo, people could not evaluate the effectiveness of medicine. Either you think that ordinary people can now evaluate the effectiveness of medicine, or the context doesn’t matter.

            People did have a choice. They could refuse treatment. Instead, they opted for useless or harmful treatment because it felt better than doing nothing. This is a fact of human nature that is just as true today, and is why a centrally planned medical system is cheaper than one that relies on individual decisionmaking.

            • I feel that this argument is very quickly taking on a historian vs. social science-policy texture. I’d argue that without the context, such comparisons are superficial and lack useful meaning, you’d argue (I think) that the example, context or not, goes to prove some larger policy point. I don’t see it. In the end, I am a historian joining what is essentially a policy blog and I imagine this isn’t the only time we’ll see discussions like this. I understand your point and I don’t necessarily disagree–certainly I believe that a centrally planned medical system is cheaper than one that relies on individual decisionmaking–but I also don’t see that looking at bleeding in the 18th century helps us understand that.

              • Ed Marshall

                I do not get it. Why not? Humans do what doctors tell them to do. If they believe their life is on the line, they will suspend disbelief and buy snake-oil if the medical profession isn’t giving them an out.

                This is as true today as when the Roman physicians were playing around trying to balance humours. What is the context that I am missing?

              • Walt

                It makes sense that you are a historian, since I suspect this is the characteristic historian déformation professionnelle. Historians, as a group, prefer detailed, fine-grained explanations that rely on a lot of historical specificity. I think it’s reasonable to be skeptical about grand claims about human nature, but Yglesias has gestured at a grand claim about human nature that certainly fits the facts as far as I am aware of them: people are shitty at judging the efficacy of medical care.

                It’s interesting that you are objecting to Yglesias’ post, even though you don’t know of any historical evidence that contradicts it, and I bet the historical evidence you are aware of supports it. It’s actually hard to imagine that there really is historical evidence that contradicts it, since medicine or the equivalent is a universal phenomenon, while any idea of how to judge its efficacy is a modern invention.

      • Padraig

        Actually, Yglesias’ point stems pretty logically from a few basic assumptions: if patients are able to tell useful from useless (or worse) treatments, even a little, then over time those treatments that work even a little better should win out over those that are harmful. And some treatments back then were better (or less horrid) than others. But there was no evolution towards better medicine until the top-down advances you talk about.
        So, patients aren’t able to winnow out the good treatments from the bad – not back then, but also not today. Medicine is actually too complex to understand without a lot of work and study – and the information asymmetry that results means healthcare “consumers” are screwed – market’s don’t make healthcare better, they make it worse.

        So, even though you categorize Matt correctly as a Neo-Liberal with egalitarian influences, his point is seriously valid, and should be engaged with – not sloughed off because it doesn’t flow from your particular school of thought.

    • L2P

      Right, I think Yglesias is saying the market didn’t (and historically, don’t) work; people literally bought and used poison because, hey, why not?

      IIRC, none of the major reforms were consumer driven. Hygiene went in over hospital staff kicking and screaming, vaccines forced on unwilling families (and only then because the diseases were horrific and incurable), I don’t think any of medical history could be called market driven.

      • Holden Pattern

        The purchase of lobbyists and legislators. Although, it strikes me that there’s a market failure there, because the ROI much much higher than it should be in a functioning market. The purchase price of influence should be trending closer to the actual benefit received, but it’s orders of magnitude smaller.

    • “His point is that while capitalism works well for goods that consumers can evaluate correctly, it works badly for goods that customers can’t.”

      Yes, that’s what I meant.

      • That’s fine–I accept that I did not read the post correctly, but the larger point still stands–that 18th century medicinal practices don’t really tell us anything useful about these points.

        • jhe

          18thC medicine was more of a consumer choice model while 19thC saw top-down public health initiatives (vaccination, a renewed interest in sanitation (what was that like a 1500 year hiatus?), public hospitals, public health statistics) and the emergence of doctors who told you what to do rather than acted as medical concierges. Those things worked.

          Consumer choice in healthcare (18thC medicine) seems less likely to work. Medical care comes to me in two forms – non-urgent advice/treatments that I don’t want and have to be cajoled to take because they seem to be protecting me against what seems a remote possibility or urgent care that I have to take when I’m in pain or scared or both. In neither case am I really a very good consumer.

      • Brad P.

        Matt, quick:

        Brief me on the quality processes and results that GM has pursued in the production of Cruze.

        You are describing a lemons problem where the bad chases out the good because consumers can’t differentiate between the two. However, loyalty and credibility counteract the information asymmetry problem, and often quite well.

        I would guess that you would say that used car markets function well enough, and that’s where the problem got its name. Why would you think it would be a market killing problem in health care?

  • Echoing Walt — I don’t think Yglesias meant what you think he meant. Olde-Tyme medicine is cited in a “what’s past is prologue” sense: we consumers still understand so little about effective health care that many of us may end up at the mercy of modern-day leeches. Or am I wrong?

    • DocAmazing

      Don’t knock those leeches. They’re very good for maintaining and re-establishing microcirculation.

      Sir Isaac Newton acknowledged that he saw further because he stood on the shoulders of giants. So it is with medicine; we have a long and colorful literature of previous errors to keep us on the right path. We still use poisons that we probably shouldn’t, and won’t as soon as effective alternatives are available.

      There is still a very strong role for oversight of patients who wish to treat themselves. Leave aside for a moment the ability to tell effective treatment from ineffective, and to read and make sense of medical research; there are things people do that adversely effect the community as a whole. Some things are obvious, like vaccine refusal that chips away at herd immunity; another problem is misuse of antibiotics (which I have to confront constantly) that exacerbates the problem of emerging antibiotic resistance; people like to dump their old medications down the sink or the toilet, releasing bunches of still-active drugs into the sewer (more antibiotic resistance) or water table (measurable quantities of Ritalin in the water in some communities). As much as I hate the paternalistic model of medical care, turning people loose in some Emporium of Health Care and telling them to choose and be well is hyperoptimistic and more than a little dumb.

  • Lemur

    My reading of it was similar to those of the previous commentors. When I read Yglesias’s post, it seemed obvious to me that his point was that consumers were willing to spend a lot on medicine–enough for people to have made a living on it–even when the treatments they were paying for largely had negative effectiveness. And so it appears that consumers in a free market, which the Eighteenth Century healthcare market certainly was, are often incredibly bad at evaluating what treatments are worth their money.

  • Gilmore

    You don’t need to reach into history to show that consumers are totally unable to evaluate medical products intelligently. How many people purchase Zicam(tm) ?

  • gimmeliberty

    Yep, Matt is definitely pointing out that we can’t expect the free market to be successful with regard to health care because of poor consumer understanding of outcomes – almost the opposite of how you read him.

  • Warren Terra

    My understanding of the difference between pre-modern (say, 19th century) and modern medicine has to do with adoption of the scientific method, and also of increased anti-fraud regulation.

    A lot of the nonsense in past medical treatments cam about because those treatments were dictated by weird philosophies (bleeding, most luridly) or were recommended on the basis of anecdotes (blue light as a sovereign cure for all ailments, for example, one of the stories in Paul Collins’s enjoyable book Banvard’s Folly). Once we had the idea of standard medical practice based on properly controlled and reproducible experiments, we were on the right track – and so, long before we had miracle drugs, obstetricians learned to wash their hands after conducting autopsies, saving untold numbers of lives (true story!).

    Of course, we still have people advocating useless and harmful medical treatments based on outre philosophies and on anectodes. But at least now those charlatans and lunatics are exiled to the world of “alternative medicine”, and occasionally repressed when their false and unsupported claims go too far and cause too much damage.

    • DrDick

      Much of 19th century medical practice was based in the science of the time, though there was little regulation of medicine. The real breakthrough leading to modern medicine was wide spread acceptance of the germ theory of disease. A much bigger problem is that large numbers of people only went to the doctor for severe problems, if then. Most medicine was, in practice, folk medicine and relied heavily on the infamous patent medicines of the time (snake oil anyone?).

      • Rob

        Hey if alcohol and cocaine couldn’t cure you what use is living?

        • Holden Pattern

          Cocaine… It’s a hell of a drug.

    • Ken

      Indeed. I don’t know why people keep saying “19th century medicine” when there’s plenty of current examples of consumers choosing to spend their money on ineffective treatments. The Respectful Insolence blog at scienceblogs.com has a “Weekly Dose of Woo” devoted to the topic, and that well never runs dry.

      As Orac (the blog owner) notes, one commonality is that the woo-meisters reject testing for efficacy, claiming that it cannot show that their treatments work. Hmm, let me rephrase that; of course it cannot show their treatments work, because the treatments do not. Rather, they say testing will not show it – what they sell works, but the kind of double-blind trials and statistical tests used by mainstream medicine will not show this because – well, the reasons are never clearly stated, although they apparently involve using the phrases “quantum” and “big pharma” and “natural” and “holistic” and “detoxification” as many times as possible.

  • I certainly respect the goal to take lessons from the past for the present–I am essentially a presentist in my work. I also don’t really agree (regardless of the reality of modern America) with Yglesias’ general philosophy of finding ways to make neoliberal free market capitalism work more efficiently and with somewhat more generosity and somewhat more equitable dispersal of resources

    So you’re against social democracy, and you have a horrible methodology of history. Good to know.

    • “So you’re against social democracy, and you have a horrible methodology of history.”

      Both of these points are objective true….

      In all seriousness, at least half of U.S. historians are “presentist” in the sense that they are looking to the past for answers to modern questions, so to say that such a thing is “horrible methodology” lacks all legitimacy.

      As for the issue of “social democracy” as you put it, I categorically reject free market capitalism as a positive force in this world. And that is going to be expressed in my posts. So get used to it.

      The old blogosphere adage that this site is “Lawyers, Guns, and Centrists,” which never made any damn sense anyway, won’t hold a lot of water anymore. And not in some half-baked “capitalism sucks” way, but in actually trying to think through these issues in a serious way.

      Some people probably won’t like these posts, but so be it.

      • Walt

        Serious question: what do you mean by “free market capitalism”? All capitalism? Post-Reagan neoliberalism?

        • I have to run and have like 30 seconds here, but essentially the extremist globalized Friedmanesque capitalism that seeks to reinstitute the Gilded Age. I know that’s vague as all heck, but it’ll come out in the posts or when I have more time to expound upon it.

          Essentially I probably come down as some sort of left New Dealer. Would I support a 100% tax on all money made over 1 million dollars? Yes. NAFTA–a disaster of epic proportions for all three nations and their environments. Etc. Etc.

          • Walt

            I’m surprised this is a position that you expect to get much pushback on. Is anyone in favor of this? (Other than the wackjobs on the right, of course.) Even with his obsession with neoliberal-inspired tinkering, I doubt even Yglesias would be in favor of this.

            • Malaclypse

              Is anyone in favor of this?

              Read Brad’s comments, then get back to us ;-)

      • Malaclypse

        The old blogosphere adage that this site is “Lawyers, Guns, and Centrists,” which never made any damn sense anyway,

        I thought it was “Lawyers, Gays, and Marriage,” or, alternatively, “Lawyers, Gays, and Murder,” both per the Donalde’s Machiavellian elan.

  • There was, also, a different understanding of what doctors were supposed to do at the time. See Charles Rosenberg, The Therapeutic Revolution.

    • Charles Rosenberg is such a fantastic historian. The Cholera Years still holds up so well.

    • herr doktor bimler

      Could you indulge a non-reader and provide a bullet-point summary of what service people were expecting from doctors, if not to keep them alive & healthy?

      • The core of Rosenberg’s argument is that American and European medicine prior to the middle of the nineteenth century is best seen as a kind of liturgy, with the doctor as priest.

        The doctor could do all kinds of things that worked–that is, that were visible: blood-letting, administering emetics or laxatives. So no one doubted that the doctor had power, and knew what he was doing.

        At the same time, no one expected doctors to cure every case. Whether one lived or died, that was up to God. The doctor’s role was not to cure, necessarily, but to provide the conditions under which a cure might take place–not unlike a priest, who could not save souls, but could put someone through the appropriate rituals needed so that one could receive grace.

        • Tirxu

          And how is that different from now? We still believe in our physicians, and accept that there are things beyond their power.

          The only difference is for the physicians themselves, who (I believe) have much more efficient ways of curing people. This is a veryy important difference, mind you: even if medicine is as much of a black box for me as it was for a regular person in the 18th century, what matters most is the inside of the box.

          But I am inclined to think that it means that it is a terrible idea to rely on the customers, rather than the medical community, to regulate the health market.

  • Flowers

    No one is going to bring up the rise of professionalism of medicine and the decline of midwifery and traditional medicine?

    Medical science and minorities have a really bad history. “Advances” are often, “Oh yeah, it looks like the women were right after all.” I’m not too keen to put the blame of bad medicine on consumers being uninformed, when the regulating of the medical field was pushing important knowledge underground.

    There’s reasons from the past to inject government into health care, but there are also reasons to keep it out of health care. I don’t think the past should be used as talking points for either policy decision.

    You can get back to your regularly scheduled male privilege now.

    • DocAmazing

      Speaking as a physician with deep roots in the alternative medicine communities and who works very closely with midwives on a day-to-day basis, I’m going to call bullshit. While it is certainly true that a number of folk practices and approaches have a great deal of merit which was overlooked in the rise of technological medicine, it is equally true that technological medicine has provided a whole bunch of things that have both prolonged life and improved its quality. If we’re going to talk about midwifery, we should also talk about how it has become professionalized, and how pretechnological midwifery had about the same rate of complications, puerperal fever, infant mortality and death in childbirth as pre-Lister obstetrics.

      I’m not a big fan of an excess of technology in medicine, and I think there’s a lot to learn from traditional methods and modalities, but let’s not paint romantic pictures of the Good Old Days.

      • DrDick

        Indeed. Infant mortality rates in this country were horrendous, as was maternal mortality, in the 19th century, which is hardly a testament to pretechnological medical practice in this regard, regardless of the provider. This also highlights my point above that much of medical care before the 20th century was not provided by doctors.

  • Slocum

    I just want to say I miss Yglesias’s old comments. It was like “Who’s Who in Crazyland.”

    Now? BORING.

    • Bart

      Agreed. The new comments are tightly controlled through Facebook and three old portals including AOL(!).

      Did they do this because those four will provide income, whereas Google and Disqus did not?

      And how do you get the “Works at …” thingy?

  • BKP

    Now, granted I don’t know much about medical history, but weren’t those treatments endorsed by a lot of professionals? Yglesias seems to be implying that consumer ignorance/ineptitude lead them to less than optimal outcomes, but I fail to see what could have improved their outcomes.

    Perhaps he should look into state health and mental institutions of the time before starting to denounce the ability of the “consumer”.

    • Anonymous

      Actually, you make a good point–who will police the police? Many bad treatments of the past were approved and even encouraged by the medical authorities of the day (though all too often, those were religious and military/government authorities rather than clinical or scientific ones); we still have a brisk trade in officially approved Things Which Are Not Good For You, as demonstrated by the large number of cosmetic surgeries and damaging weight-loss treatments running around. In addition, when bodies are set up to assure the public that somebody is riding herd on health-care practitioners and keeping them from ineffective and dangerous practices, some people short-circuit the process by establishing fly-by-night competing certification bodies, like Rand Paul’s “board certification” in ophthalmology.

      Two steps forward, one step back. Same dance it’s always been.

      • DocAmazing

        Above was me. Apologies.

      • Malaclypse

        Actually, you make a good point–who will police the police?

        Pointing this out interferes with Yglesias’ brave new world of unregulated dentistry.

    • chris

      Perhaps he should look into state health and mental institutions of the time before starting to denounce the ability of the “consumer”.

      Why? His whole point is to rebut the Hayekian idea that the consumers can outthink the experts. Clearly, they couldn’t. And there’s no reason to think they can today, either.

      • DrDick

        Indeed. This highlights one of the inherent flaws in the free market model generally. Medicine is just one area, though a very notable one, where the consumers generally are forced to rely on “expert” opinion to evaluate the value of products being offered and where the experts are often either simply wrong or biased. Financial instruments is another such area.

        • Brad P.

          This highlights one of the inherent flaws in the free market model generally. Medicine is just one area, though a very notable one, where the consumers generally are forced to rely on “expert” opinion to evaluate the value of products being offered and where the experts are often either simply wrong or biased.

          I would much rather have a free market for goods than a government controlled distribution in an economy where the experts are often simply wrong or biased.

          • DocAmazing

            “A free market for goods” has nothing to do with the provision of healthcare, which is both service and infrastructure, and which is about as inelastic as anything imaginable.

            Widget-based models don’t translate well to emergency rooms.

            • Brad P.

              That is beside the point:

              Answer me this, why is it better to have centrally controlled distribution of resources rather than a market when the experts are usually wrong or biased?

              Why is that not at least an equal problem for non-market solutions?

              • I dunno libertarian, you tell me why I might give you better advice if I received no bonus for lying to you.

                • BKP

                  I received no bonus for lying to you.

                  First off, DrDick said:

                  where the experts are often either simply wrong or biased

                  He didn’t say anything about misleading.

                  Although I find the implication that government officials don’t or can’t receive a bonus for lying highly amusing.

                • Yes, quite right, that’s why the government is pushing those magnet bracelets on everyone.

                • Malaclypse

                  Yes, quite right, that’s why the government is pushing those magnet bracelets on everyone.

                  And why the hell won’t the government let me buy Laetrile? Answer that, libtards!

                • BKP

                  Yes, quite right, that’s why the government is pushing those magnet bracelets on everyone.

                  Really? In an era where either a substantial portion or the entirety of the US government is fighting a drug war, the Iraq war, as well as fighting immigration, abortion, and homosexual rights, destroying thousands of lives with programs founded on lies (often from so-called experts), and you bring up power bracelets?

                • Malaclypse

                  Not to mention, two years ago the government hounded this poor man into closing his business. Sure, they peddled bogus cancer drugs, but they were a major local employer.

                • I did not say the government never lied, I simply offered a reason why operators in a government medical system might be less likely to lie to you: it’s just not in their interest.

                  But to pick abortion off your list it’s pretty clear the government is not, in those cases, listening to experts.

                • BKP

                  I simply offered a reason why operators in a government medical system might be less likely to lie to you: it’s just not in their interest.

                  There seems to be some major cognitive dissonance between this statement and characterizations around here of republican treatment of medicare reform.

                • Your congressman isn’t gonna answer the phone.

                • By that I mean that actors within the system – not those creating it – don’t have much of an incentive to grind axes.

                  You could also, you know, look at the civilized world and figure out which state-operated medical system is most tolerant to liars. (Australia does, for instance, tolerate a lot of bullshit.)

                • DrDick

                  BKP –

                  He didn’t say anything about misleading.

                  That is what is implied by the statement, quoted by you:

                  where the experts are often either simply wrong or biased

                  The problem with bias is a tendency to mislead.

      • Brad P.

        His whole point is to rebut the Hayekian idea that the consumers can outthink the experts.

        That may be the most deeply flawed characterization of Hayek I have ever read.

        Clearly, they couldn’t.

        I think the problem at the time was that the experts weren’t out thinking the consumers. Are you implying that consumers had better options but couldn’t find them?

  • arguingwithsignposts

    I’m exceedingly late to this thread, but I’d highly encourage anyone still reading to check out Barry’s “The Great Influenza,” his history of the 1918 flu pandemic.

    The first part of the book is about the efforts of a few scientists to turn U.S. medicine toward the future through germ theory and the use of research. There’s a significant portion discussing the battles that were fought to update the state of medicine, including the creation of Johns Hopkins’ medical school. Fascinating stuff.

    Prior to that, many medical doctors in the US became doctors through “apprenticeships,” and (as someone noted above) practiced “heroic” medicine. The Europeans were ahead of the US in medical research prior to the late 1800s, as well.

  • Deggjr

    From the book ‘Sick’ by Jonathan Cohn:

    “It was about the year 1910 or 1912 when it became possible to say of the United States that a random patient with a random disease consulting a doctor chosen at random stood better than a 50-50 chance of benefiting from the encounter.”

  • CJColucci

    There are a lot of products and services — health care being one of them — that consumers can’t evaluate in any meaningful way. Fortunately, most products are not like that, certain safety issues aside. In those cases, it makes sense to let the consumer do the job. No one I know of advocates a government-run clothing program. Leaving aside some issues with dangerous dyes or fire-resistance, consumers can jusge clothing well enough. The few (mentally competent) people who are inadequately clothed are inadequately clothed because they are poor, and the only thing government might constructively do to solve the problem of inadequately clothed people is to give them money (or clothing stamps) or have a social worker take them to a thrift store. That doesn’t mean that the private clothing market is in any sense “optimal.” It’s entirely possible, virtually certain, in fact, that many people overspend on shabby clothing, and a vast amount of effort and capital that could be more constructively employed goes into making this year’s ties a quarter-inch wider or narrower than last year’s, and persuading people to buy them. (Not to mention the aesthetic disasters that often result.) That isn’t to suggest that some commissar ought to curb the excesses of the fashion industry and redirect resources elsewhere, but let’s not kid ourselves that the free-market approach leads to results that are optimal in any non-tautological sense. It’s just that it’s not worth interfering with our natural desire to do our own thing for such a modest social benefit. Hence, no government-run clothing program.
    For other products and services YMMV.

  • M.

    Charles Rosenberg really has the market cornered on this. (No pun intended.)

    If you really get into the nitty-gritty details, one group of well-born medical praticioners banded together and used politics to drive the other practioners out starting around 1800. Science was a post-hoc rationalization, but it really didn’t aid practice until 1900.

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