By the time Mark Twain was born, in 1835, the political forces of Jacksonian democracy had created an era of unregulated medical practice in the United States. Licensure laws were almost nonexistent, and any citizen could practice medicine. Regular ("allopathic") medicine was competing with at least two dozen other sects, including homeopathic, botanical, and hydropathic medicine. Although allopathy presented itself as the "scientific" branch of medicine and proclaimed the practices of the other sects to be "quackery," its therapies were aggressive and toxic and had no proven advantage over the treatments used by competitors. Through the efforts of the American Medical Association (AMA), allopathic medicine eliminated its competition by promoting the reestablishment of licensure laws in the late 1800s. In a continuation of the same endeavor, the AMA sought to identify weak and inadequate medical schools and commissioned Abraham Flexner to write the famous Flexner report of 1910 (the year of Mark Twain's death). Twain, an insightful political observer and social critic who was familiar with the competing medical systems and the medical politics of the 19th century, questioned the wisdom of limiting patients' medical options. He doubted the competence and intentions of physicians as a group even as he maintained confidence in the abilities of his own physicians. He was critical of the empirical medical practices used during his youth, but he saw hope in the new scientific orientation of medicine in the early 20th century. Twain's commentaries provide a unique perspective on pre-Flexnerian medicine in the United States.