The Madness of Childbirth

The North Wales asylum made its way into my life by accident. The history department at Bangor University secured a grant to look at the social impact of the asylum. Looking at the records they collected, it was striking how people declared their madness a century ago – they tore off their clothes and escaped through windows, which they never do now.

a quixotic database

But when we set about entering North West Wales records from the asylum in 1896 to compare with admissions in 1996, something more startling became apparent – we admit 15 times more people with serious mental illness now, and compulsorily detain 3 times more people (Healy et al 2001). This prompted a quixotic adventure – why not enter all records from North West Wales between 1875 and 1924 and build a modern database covering admissions from 1994 to 2010?

This was quixotic because no-one wanted to fund us. Grant-giving bodies in history were not able to see the value in quantifying records or in having modern data. Modern epidemiologists could not see the value in historical records. So over 15 years and without support we put together easily the largest body of historical epidemiology in existence – we had no competition, no-one else thought this made sense.

Made by God – or maybe Tolkien

North West Wales is uniquely suited to what we did. It’s surrounded by the sea on 3 sides and the mountains on the fourth. The population remained almost exactly the same between 1896 and 1996. It was then and is still now almost exclusively Welsh. It was rural and never urbanized. The people are poor and so there is no private care. There was then and is now only one place to go for a hospital admission. In the case of the few people who left the area, through the National Health Service we have been able to track everyone down so not a single person is lost to follow-up.

Almost God-given for our purposes. This is where Tolkien set Middle Earth. To the South East looms Mordor which casts a long shadow – suggesting a Pharmageddon to come.

The response from some experts to our findings has not been unlike the dismissive attitude of Orcs or Black Riders to Hobbits. They sneeringly fall back on the fact that we have made diagnoses based on century old records. One hostile reviewer argued that when black men in America in the 1960s could be detained compulsorily and diagnosed as having schizophrenia, what chance is there our records have it right. Others are sure women with unwanted pregnancies were incarcerated in mental asylums and diagnosed as schizophrenic.

The ultimate proof that out methods are right lie in a set of  bricks and mortar developments, as will become clear.

the madness of childbirth

Postpartum (or puerperal) psychosis was one of the severest mental illnesses ever. It accounted for the admissions of one in ten of the women of child-bearing years admitted to the old asylums between 1875 and 1924. It came in two forms. The most dramatic form happened in women who had never had a hint of mental illness before, who were stably married and well-placed who within a week or two of giving birth to their first or fourth or other child went floridly mad. These women with de novo onset postpartum psychoses accounted for 4 out of every 5 cases. Their psychosis looked completely different to either schizophrenia or manic-depressive illness.

The second group were women who had had a previous mental illness who after giving birth might have a further episode of essentially the same illness they had before. Their illness typically looked like a further episode of manic-depressive illness.

When the asylum closed it was replaced by 3 district general hospital units, across North Wales, the Hergest Unit in the West, Ablett and Llyn-y-Groes in the middle and East. All 3 had mother and baby units. This units were opened up because of the rates of admission for both kinds of postpartum psychosis in our asylum records – these map directly onto what was in 1993 the accepted rate for the occurrence of post-partum psychoses.

a vanishing disorder

Hergest was the first of these general hospital units to open but within 3 years of opening, the mother-and-baby unit closed. There were no cases. The Ablett mother and baby unit had just opened up and this is where Cora went (see Cora’s Story)– and going there may have partly caused her loss of life. All 3 mother-and-baby units have now closed.

Our historical and contemporary databases bring this out perfectly. De novo onset postpartum psychoses have vanished – the manic-depressive type remains (see Tschinkel et al 2007). These are not disorders you can treat in the community. They are the most high risk in all psychiatry.

But when we came to report the findings we were in for a surprise. No-one it seems wanted to hear about a disorder vanishing – not the postpartum experts whose careers depend on it and are still busy portraying it as commoner than ever. Not the health service managers whom one might have thought would have an interest because of the budgetary implications. Nor the researchers you might have thought would be interested in the implications for theories of mental illness. Not the historians specializing in postpartum psychoses or women’s mental health. It was difficult to get published.

abuse of psychiatry – a twentieth century phenomenon?

What our critics fail to realize is that we are not going on historical or contemporary records. Doctors in the nineteenth century made diagnoses based on how the patient looked when they walked in the door but we have had the entire lifetime medical record of these patients available to us and could base our diagnoses on these.

Doctors today don’t make diagnoses on the patient as they walk in the door. When the patient is discharged, the ward clerk or someone with no medical training typically enters the diagnostic code into an administrative database. This can work very well in medicine, but doesn’t make sense in psychiatry. A great deal of modern psychiatric epidemiology is based on diagnoses like these – close to useless. Other studies are based on diagnostic interviews instead, which are also close to useless. Almost 50% of cases of schizophrenia, as clear cut a condition as psychiatry has, get a different diagnosis during their first year or two of admission. It takes time for the nature of the illness to become clear. And this is where our approach scores for both historical and modern cases – we make our assessments based on the full clinical record with input from everyone who knows the patient.

There has been extensive work by others on historical records at this point. These have revealed several famous examples of individuals who may not have been made and who have protested against their incarcerations. But these are exactly the cases that we do not diagnose as having a psychosis. If a Black or Irish man had been inappropriately incarcerated in North West Wales in 1896 we would have spotted it. In fact the asylum records show clinicians sensitive to issues of whether this patient was “a knave or a fool”.  They were very reluctant to admit and quick to discharge knaves. There was not a single admission for unwanted pregnancy or ethnic factors, and in cases where there was domestic or other abuse, these issues were clearly flagged up, making it possible for us to take this into account retrospectively.

The abuse of the asylum by doctors was a mid-twentieth century phenomenon – a telling example of how medicine can turn to the dark side rather than sustain progress. But just because the Nazis exterminated mental patients and psychiatry acted like an agent of the State in both the Soviet Union and the West in mid-century doesn’t mean it was always this way. Life in the Shire, if not perfect, was once good enough. The challenge has always been to keep it that way – although a case can be made that things are getting even worse now.

where did postpartum psychoses go?

So what happened postpartum psychoses? We have no idea. This is in complete contrast to catatonia which has also vanished and we are certain we can explain this. It’s also in contrast to schizophrenia, where we have some good ideas.

What could have happened? The postpartum psychoses look more like steroid psychoses than schizophrenia. Perhaps their disappearance stems from the active management of labor now which means few women get as fatigued as once happened, or the use of pain relief like Heroin (see Tschinkel et al 2007). If post-partum psychoses are related to catatonia, the availability of benzodiazepines might be expected to make a big difference.Whatever the reason, our best guess is this condition began to disappear somewhere between the late 1970s and the 1980s. We want any suggestions anyone can offer.


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Pharmaceutical companies have hijacked healthcare in America, and the results are life-threatening.

 

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Comments

  1. I had episodes of postpartum or puerperal psychosis in 1978 and 1984, after the painful births of my second and third sons. I didn’t have it in 1976 after the birth of my first son, when I had good pain relief, a spinal anaesthetic injection at Ninewells Hospital, Dundee. All of this happened in Scotland and I am Scottish.

    With every childbirth I was induced, because I was overdue but also to bring about the births during the day shift when more nurses were on duty. In 1978 and 1984 I gave birth in a local small hospital in Lanark, very little pain relief, with induction chemicals pumped into my veins. The labour pains were immense, like being halved up the middle. The actual childbirth was fine. But the trauma of the labour induction and pain meant I had a psychosis, in 1978 13wks after childbirth. In 1984 one day after coming out of the maternity hospital.

    I went voluntarily into the psychiatric hospital, had to leave my babies at home, very difficult as I was breastfeeding. Grabbed and jagged on both occasions, forced to take the chlorpromazine, then in liquid form then in pill form when obedient. It took me a year both times to get of the drugs and get back on with my life.

    I was then in good mental health for 18yrs. I’m an upbeat sort of a person, strong and resilient. Then in 2002 aged 50 I started the menopause, was in a busy job where a bullying issue was rife in the organisation, although I wasn’t bullied. Other pressures also. Hormone imbalance brought on another psychosis. Went voluntarily into the local hospital, Stratheden, NE Fife. Took a look round the mixed ward, decided to leave, was sectioned for 72hrs.

    Knew I would have to take the drugs or be grabbed and jagged. So swallowed the risperidone. It brought me quickly out of the psychosis, as usual the neuroleptic depressed me. Was only in the acute ward for about a week. I was put on venlafaxine for the depression, it depressed me more, I overdosed. Got back from Ninewells, the psychiatrist put me on maximum venlafaxine. Still flat and unmotivated. But taking an overdose had scared me, very unlike me and I seemed to do it on impulse, I made conscious efforts to not do it again.

    The psychiatrist decided to put me on lithium, to ‘augment’ the venlafaxine. He tried to diagnose me bipolar, I resisted, so he put schizoaffective disorder on my notes. Although I disagreed I wasn’t listened to. Eventually I decided to take charge of my own mental health, started doing various volunteering activities. Not easy as I was very unmotivated, sluggish, mornings were worst.

    Gradually started to feel better, by this time the psych had taken me off the risperidone. So I started tapering the venlafaxine, got off it OK, this was in 2003/4. Which left the lithium. I told the psych that I’d be reducing and coming off it. He said I had a lifelong condition requiring it. I disagreed and decided to taper at 200mgs a month, I was on 800mgs/daily. I got off it all without any side effects. And got back on with my life.

    The schizoaffective disorder label is still on my notes, sticking like glue and affecting the psychiatric treatment of my sons who also have experienced psychotic episodes, and completely recovered. But I am now an activist and campaigner in mental health matters. Changing and improving the psychiatric system where I live and trying to have an influence nationally.

    I’m 60 now and a granny and I don’t want to see my grandchildren having to go through what I did in a flawed psychiatric system. Being forcibly treated and paternalistically patronised.

  2. These two cases known to me may be interpreted in several ways but the similarities are suggestive of post-partum psychosis exacerbated by societal influences. Both women were pediatricians, one already qualified, the other still in residency. Each had a first child. The younger, the resident, told no-one of her distress, took some substances from the hospital when on duty on nights, went home and committed suicide in her kitchen as her husband and child slept upstairs.
    The second was identified as “different” after giving birth but had no intervention. One morning, she took her child and jumped in front of a subway train – that by horrible coincidence, I was riding, on my way to work.
    Part of the issue in these tragedies is the fact that they were physicians and female at that, driven by the all too common conviction that they must never show “weakness” or admit to mental distress. Had they confided in colleagues, I am sure that they would either have been told to “suck it up” or medicated inappropriately.
    Where does help lie for such women? Darned if I know.

  3. kt.bar.the.door says:

    There are significant changes in both the attitudes toward and the management of childbirth between the late 1970′s and 1980′s here in America. As a nursing student in the Washington, D.C. area in the early 1970′s, I was horrified to witness forceps deliveries that resulted mainly from overmedicating mothers with nasty drugs like, scopolamine. There was little to no pre-childbirth education. I saw varying degrees of difficulty in the mother/child bonding postpartum period that seemed related to the mom’s suffering both drug effects and trauma from the childbirth experience.
    After graduation, I encountered two cases of postpartum psychosis. One involved a mother whose pregnancy was managed by the obstetrician who came once a week to a rural clinic I worked in.(1974) She came in for one postpartum visit with her baby, 2 weeks after delivery, and then became a tragic enigma, as the story of her having suffocated her newborn son was widely circulated amongst attempts by the medical staff in the clinic where I worked to ‘educate the public about postpartum psychosis’.

    A few years later (1976), working as a nurse in a warm and fuzzy pediatric practice in the Wash DC suburbs, I encountered a new mom exhibiting the ‘madness’ that distinguishes postpartum psychosis. I still get queasy feelings and child as I recall escorting this mom and her 6 week old son into an exam room. She very cheerfully showed me a quarter sized hematoma near the baby’s right temple, then explained that the baby got a bump on the head because “He keeps asking to be in his swing…. in and out… can’t decide… so silly, don’t you think?” It was our practice to weigh babies on a calibrated scale located in another room. I quickly facilitated this , not bothering to undress and wrap the baby in a blanket before exiting the exam room, baby in my arms, in search of one of the pediatricians on duty that day. The mom’s bizarre affect was the distinguishing symptom for postpartum psychosis, I was told. I was 22 at the time and no psych experience save for child psych in nursing school. I would have simply said:”She looks like she has gone mad!”

    When I became pregnant in the beginning of 1978, I was determined NOT experience childbirth as a ‘patient’. I became one of the outrageous pioneers of home birth under the care of nurse midwives. I began to notice many shifting attitudes with respect to trauma, pain and the maternal/child bonding process in connection with what became known as abusive obstetrical interventions. A process that began evolving i the late 1970′s and was approaching state of the art by 1990 here in America,

    I am currently influenced by 24 years as a psychiatric nurse whose professional development has centered on trauma informed care . I would suggest that trauma, the evolutionary fear response accounts for both postpartum psychosis and catatonia. More knowledge about trauma response and attention to prevention, especially in the education and support of natural childbirth experiences, may well account for the disappearance of these psychiatric conditions in addition to the popular use of benzos, of course!

    • David_Healy says:

      Trauma may have played a part in some cases but seems unlikely in others where the mother was giving birth to a third or fourth child without a prior history of traumatic labors and knew what to expect

      • kt.bar.the.door says:

        Dr Healy,

        As I reflect more deeply on the two cases of postpartum psychosis I encountered as a young new grad RN, I have to say that my sense of the ‘traumatic’ aspects of the birth were more about the maternal/child bonding experience, or rather the lack thereof, as opposed to the actual pain of the labor and delivery.

        When I was a nursing student I was very much effected by the condition of the mother at delivery. Often so over medicated that she could not participate in the delivery. The newborn was whisked away soon after delivery , and it was not uncommon for as much as 6-8 hours to pass before the baby was brought to it’s mum. In my mind, there was a total separation between the “process” of birth and the “product” of the process. The mother and newborn were each a patient– of two separate units on the same ‘floor’ of a hospital. I did observe a number of suboptimal reunions, carefully noting responses of mother and child as this was a part of my training and documentation required as a student nurse. What strikes me about this after reading your article here, is that in the two cases of postpartum psychosis I discussed, there was a clear ‘break from the reality’ that these women were new mothers. These two mums had no clear perception of their babies as ‘theirs’.

        There are many different scenarios that could account for a split between the birth and the postpartum experience. Even preconditions involving the mother’s state of mind regarding accepting the role of mother for the first, or even the fifth time. And, needless to say, every instance of some sort of ‘traumatic’ separation that occurs after the birth of her child, that creates ambivalence or even aversion due to physical pain/trauma, does not result in postpartum psychosis.

        BUT, what if oxytocin produced after delivery has an impact? Isn’t it true that it is more common today that women receive IV pitocin after delivery to reduce the risk of post delivery hemorrhage? The same effect is produced by breastfeeding immediately after delivery. There is a significant increase in both practices over the past 30 years.

        My anecdotal and personal experience giving birth,without pain medication, leads me to believe that IF it is possible to suddenly feel like a million bucks at the moment of delivery– despite the agony that preceded that moment; and that it is the baby and that moment of welcoming him/her that wipes out the whole previously described as “I can’t do this–”, and “I’ll never do this again” ordeal, then there has to be something that interferes with that sense of completion. In my mind, ‘that something’ creates a basic disconnect in the experience. That is the key to ‘psychosis’- right?; an intense anxiety that cannot be explained by actual circumstances. Feeling completely helpless and totally responsible for a new life– without the ‘magic’ of the maternal instinct that has been explained in terms of hormone secretion, may deteriorate into an existential crisis. Might it not?

        Narcotic pain medication dampens the bonding process, slows down the breast feeding time table enough to have convinced many woman to forego it out of frustration. Today, lactation -expert nurses assist new mom’s through this. Narcotics are CNS depressants… slowing down every natural process and putting a fetus a higher risk for low Apgar scores. There are a other choices now for pain reduction that don’t carry these risks.

        I hope I am on steady enough ground as a woman and a professional, speaking to another professional, that I can simply say, no two births are alike- even for the same mum! In other words, the ‘trauma” that may cause postpartum psychosis may not be the ‘birth’ itself, but the failure of the bonding of mother and child— the ‘glue’ that binds a mother’s psyche to her noble purpose.

        • David_Healy says:

          Part of the interest here is the lack of interest on the part of people who you might expect to use this example to work out what might be going on in mental illness more generally. As regards postpartum psychosis, just like catatonia, this may be a syndrome rather than a disorder in its own right. In the case of catatonia (See Cora’s story), this can be triggered by emotional shocks, other physical illnesses or by other mental disorders. So there may not be a unitary answer to what causes postpartum psychosis and is now not causing it. But there may be a unitary answer to what clears it up. In the case of catatonia, it is likely to be accidental benzodiazepine use. With postpartum psychosis, there may be other factors. The role of oxytocin seems well worth exploring.

          • Let’s not pathologise human distress and a mother’s pain at childbirth, the effects of which can lead to psychiatric incarceration and forced treatment. I managed to recover from the force, treatment and labelling. Others have not been so fortunate.

      • Psychiatrists back in 1978 said to me that my puerperal psychosis was due to hormone imbalance, they were quite clear about this, and therefore I was allowed to recover without any diagnosis or label on my notes. Same thing in 1984.

        The difference came in 2002, after a menopausal psychosis, where I was given a cocktail of drugs and diagnosed schizoaffective disorder, a label that remains to this day and which psychiatry will not remove. Although I maintain it is a wrong diagnosis and only a subjective opinion. For I recovered completely, from mental ill health, psychiatric drug use and the influence of the psychiatric system.

  4. ‘Doctor’s today don’t make diagnosis today, as they walk in the door.’

    Yes, they do.
    Or, rather, they do in Scotland, where we are, it seems.

    My childbirth experience was horrific. I was 42, an ‘elderly prim’. It was 1993, I was induced in a small concrete building, they called it a cottage hospital, in Greenock, miles away from where I lived in the country in Argyll. I was in agony for hours and hours, they put me in a hot bath, they put a tens machine on me, they acted like they had never seen anyone in agony before. I was throwing up in their faces, they offered no relief. There were others screaming in the corridor, it was a busy night, and after eight hours of the most cack handed, absurd, diabolical behaviour I finally delivered and was so traumatised, I hardly realised I had had a child. They had cut me, and nobody was available to sew me up. They called a medical student, who was asleep, he arrived, and said he had never sewn anyone up before. One prick of his needle in the wrong place and I was up on the ceiling.
    They took the baby away and all I wanted was to eat a ton of toast and sleep for the rest of my life. Two hours later I was on a ferry to Dunoon, my baby in a washing up bowl as they had nothing else suitable.

    In Dunoon, I had piles the size of bananas, had to sit on a rubber ring. Where was the joy I had been looking forward to, nothing was done. The piles had to wait and for another year this went on, until I had an operation for that.
    At the time, I thought this was normal, I had never had a baby before.
    But, looking back, this was barbaric.
    However, despite this, I got on with it and was hugely happy.

    And so it went on, when I was put on Seroxat for my airline pilot, boyfriend’s, drink driving offence. The psychiatrist never said a word about any possible withdrawal symptoms to me, it was the wonder pill. He didn’t read my medical records, where it was said, ten years previously that I was ‘vaguely suicidal’ from Lofepramine, a tricyclic; he just wrote a letter to the surgery saying I should be switched to Fluoxetine, if I ever came off it. The new lady gp, who had never met me, decided not to switch me and so after eight weeks of manic psychosis from Seroxat withdrawal, I end up admitted to a hospital from attempted suicide from Seroxat.
    The gp and the psychiatrist made an immediate diagnois the moment I walked through the door. Neither of them did anything to help me and played god with my life; this was a crazed cock up from start to finish and it was not of my doing.

    What is going on in Scotland??
    This was not inner city stuff, these people lived minutes away from me, in calm, beautiful surroundings, you couldn’t make it up??

  5. Very very interesting. It might be helpful to note/discuss the difference between postpartum depression and postpartum psychosis, which are very often conflated in popular media. Is it possible that the legalization of abortion could be involved?

    • David_Healy says:

      Post-partum psychosis and post-partum depression have nothing in common. No reason to think legalization of abortion would be a factor

      • I also wonder if legal abortion, combined with the end of the worst social stigmas against unwed mothers, may have helped. Some statistician came up with a theory several years ago that legal abortion helped lower crime rates (at least until the crack epidemic), because a really desperately unwanted child, especially the child of a feared or despised father, had a higher risk of juvenile delinquency. (He was shouted down fast, but I think he might have had hold of 10% of the truth.) Being forced to give birth to that child, sometimes disowned by your own family, possibly at a maternity home which saw you as a juvenile delinquent yourself and pressured you to give your child up for adoption, could be a hellish experience – often endured by young people in the high-risk years for a first psychotic episode. To have even wrestled with the possibility of an illegal abortion, which killed 5,000 American women a year, could add to the trauma.

        I used to have a button with a wire coathanger, twisted apart, the corkscrew end hanging loose, the whole thing crossed by a determined red slash meaning NO. It’s great to realize there are now two generations who have no freaking idea what that button means. It’s also great that evicting your pregnant daughter head-first down the front stairs is now mostly understood as a crime rather than “strict parenting.” One small piece of the puzzle, maybe …

      • As a woman who has given birth 3 times I say that post partum conditions have everything in common. The pain of childbirth, especially with the chemicals sometimes forced into our body, as in induction chemicals, are both traumatic.

        You’d need to have a baby to see what if felt like. Especially to see what it felt like being induced to fit in with the nurses’ schedules and the doctors on duty. A bit like psychiatry that tries to make us fit in with the psychiatric system. A failed paradigm which has to use force to get its own way.

  6. Anne-Marie says:

    We had five mental hospitals in Epsom they have mostly all closed down now, there were a lot of patients in them that shouldn’t have been in them, some were even admitted for trivial reasons such as theft of a loaf of bread from the local shops in years gone by and ended up spending their lives in them. They have a lot of the history of the cluster of hospitals in the local museum in Ewell and even have a monument and a reef laid every year for all the patients that lived and died in them. Epsom and Surrey has one of the worst psychiatric dept’s in the country now they are more than useless and suicides seem to be a common story reported in the local papers now, a week doesn’t go by when your not reading about another person who has jumped off a bridge onto the M25 or thrown themselves in front of a train or jumped of off a car park, it amazes me that no one is speaking out about this locally. When the builders went into the old hospitals to convert them they found many patients notes just scattered about on the floor like rubbish, it ended up as a complaint in the local papers. There some very sad stories to be told in them. The old Victorian buildings have been converted into houses and flats now and they are truly horrible I don’t know how anyone can buy one and live in one. But I thought I would tell you about the local museum as it holds interesting information on them.

  7. I acknowledge that the following is not directly related to the topic of post-partum psychosis or post-partum depression but I must bring this to the attention of the group as being probably in store for the children as they enter school. This article was published in the New York Times:
    http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?_r=0
    GANTON, Ga. — When Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall.
    The pills boost focus and impulse control in children with attention deficit hyperactivity disorder. Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children•s true ill — poor academic performance in inadequate schools.“I don•t have a whole lot of choice,” said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. “We•ve decided as a society that it•s too expensive to modify the kid•s environment. So we have to modify the kid.” Dr. Anderson is one of the more outspoken proponents of an idea that is gaining interest among some physicians. They are prescribing stimulants to struggling students in schools starved of extra money — not to treat A.D.H.D., necessarily, but to boost their academic
    performance.”
    Parents interviewed described themselves as pleased with the results
    Stephen Colbert had a word of the day several years ago:
    psychopharmaparenting

  8. Tony Mach says:

    If you are looking at changes in the environment, always always always look at changes in nutrition as well.

    While I usually consider changes in nutrition to be for the worse (evolutionary novel foods, which contains substances we are not well adapted to, have the potential to cause disease, as much as any pharmaceutical product does), there might have been changes for the better as well.

    What was a traditional Welsh diet? Or rather, how did a typical Welsh diet look in 1960? How did it look like in 1980? Are there any Welsh “staple foods” that more or less vanished from the menu from 1960 to 1980? I am too young and have never been to the British Islands, but I imagine that in 1960 foods like porridge were more prevalent than in 1980. Just a guess. Would be good to have better information. The name Weston A. Price comes to my mind.

    By the way. Many thanks for your valuable work. People in medical science undervalue old medical data and put too much trust in modern studies. Good to see someone trying to tease out information how diseases changed over time.

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