Nurses vs doctors

Medicine, the things that doctors do, was an ineffective pseudoscience until fairly recently. Until 1800 or so, they were wrong about almost everything. Bleeding, cupping, purging, the four humors – useless.   In the 1800s, some began to realize that they were wrong, and became medical nihilists that improved outcomes by doing less.  Some patients themselves came to this realization, as when Civil War casualties hid from the surgeons and had better outcomes.  Sometime in the early 20th century, MDs reached break-even, and became an increasingly positive influence on human health.  As Lewis Thomas said, medicine is the youngest science.

Nursing, on the other hand, has always been useful.  Just making sure that a patient is warm and nourished when too sick to take care of himself has helped many survive. In fact, some of the truly crushing epidemics have been greatly exacerbated when there were too few healthy people to take care of the sick.

Nursing must be old, but it can’t have existed forever.  Whenever it came into existence, it must have changed the selective forces acting on the human immune system. Before nursing, being sufficiently incapacitated would have been uniformly fatal – afterwards, immune responses that involved a period of incapacitation (with eventual recovery) could have been selectively favored.

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65 Responses to Nurses vs doctors

  1. I have put the break-even point for doctors at 1942 – as good a year as any to mark the beginning of penicillin use. I’m curious what makes you push it back earlier. Quarantine?

    • JayMan says:

      Looking at causes of death over time is telling. “Basic” infectious diseases tended to bow out in the 1930s, giving way to the more modern stuff.

    • Anonymous says:

      Lewis Thomas (“The Youngest Science”) is a good source. Once doctors had a few good treatments, it was easier for them to scale back the harmful practices on other diseases.

      Also, there were topical antibiotics in the 30s before penicillin.

    • Perhaps the discovery of insulin?

    • gcochran9 says:

      I’d guess the 1930s. Lewis Thomas thought that he was living through big changes. They had a working serum therapy for lobar pneumonia ( antibody-based). They had many new vaccines ( diphtheria in 1923, whopping cough in 1926, BCG and tetanus in 1927, yellow fever in 1935, typhus in 1937.) Vitamins had been mostly worked out. Insulin was discovered in 1929. Blood transfusions. The sulfa drugs, first broad-spectrum antibiotics, showed up in 1935.

      • The fourth doorman of the apocalypse says:

        The first time I got a Tetanus injection was after I stepped on a rusty nail. Must have been around 1960.

    • Dale says:

      Though it may be worth separating “doctoring” (the treating of the individual patient) from “public health” (collective actions that reduce the incidence of illness). My impression is that public health started having significant benefits some decades before doctoring did.

  2. The fourth doorman of the apocalypse says:

    So, rather than mounting an all-out defense that might fail, does this entail a lower-level defense over a longer period of time that exhausts the pathogen?

    Or, does it entail an all-out-balls-to-the-wall defense that can last longer because the sick individual is getting cared for?

  3. Rum says:

    I have it on good authority that it was the year 1910 when organized Medicine in this country began to do more good that harm. There were many factors. 1. Germ theory and anti-septic technique had taken hold, 2. Serologic testing for many diseases had become practicable, 3. Anesthesia was becoming survivable. 4. Americans Doctors were streaming to Berlin and London to learn how the Pros did it, and 5. John Hopkins Medical School and a few others had developed real Infectious disease labs.
    Modern Nursing is just a little older. Clara Barton invented the field during the Crimean War in the mid 19th century.
    Today, real infectious disease labs are about to be tested. I mean, if even one care giver or associate of that Liberian Patient Zero in Dallas turns up Ebolized… it is over. Turn out the lights and oil up the chainsaw.

    • Peter Lund says:

      Johns. The American Civil War, not the Crimean War. And no, she didn’t seem to have.

      • Jabberwocky says:

        Clara Barton started the Red Cross, and was active in the American Civil war, but her status is contested.
        Florence Nightingale did establish modern nursing practice, was active in the Crimean war, and was a remarkable woman, a force of nature, in medical and social reform. She should get much credit.

    • engleberg says:

      I think of a nurse as someone who puts iodine on everything alive and bleach on everything dead. Northcote Parkinson’s history teacher thought you either knew how to make bleach and could have an industrial revolution, or not. Yellow iodine, wildly unfashionable with Big Pharma, wildly underadvertised, widely available, and dirt cheap, is messy, slightly smelly, painless, and a very good antiseptic.

    • j mct says:

      The famous nurse of the Crimean War, which did predate the US Civil War and sort of was Clara Barton’s role model, was Florence Nightingale.

    • John Hostetler says:

      “if even one care giver or associate of that Liberian Patient Zero in Dallas turns up Ebolized… Turn out the lights and oil up the chainsaw.”

      I’m enough of a nihilist to almost wish you were right, but there’s no way. Africans are higher than gays on the victimology ladder, and we’ve just had a recent thread on how the medical politics of AIDS worked out.

      Admittedly, Ebola is potentially more infectious than HIV to caregivers, but with all the needles involved in modern patient care, the risk was always there with AIDS too.

      Besides, long before PC, caregivers risked their lives to work in epidemics as threatening as Ebola, or worse.

    • amac78 says:

      I have it on good authority…

      The first third of John Barry’s “The Great Influenza” (2005) is a very useful overview of the state of U.S. medicine in the runup to 1918, My impression is that Barry would place the break-even point in the first decade of the 20th century.

  4. Agree that the usual date for more help than harm was 1910, for the reasons already given. The psychological point is that doctors had organised as a profession centuries before they had any real use. You have to admire their chutzpah, or the ever-present placebo response in patients, which must antedate medicine.

  5. robert king says:

    I suspect that an awful lot of what is airily referred to as “the placebo effect” falls into this category. Its not outrageous to imagine that the body respond to social cues that one is being cared for and can then redirect resources into repair? Lots of things that we do to fight illness (vomit, cough, raise body temperature) are quite violent things to do and having cues that one can do these things and be looked after might well have been happening long enough to be evolved effects.

    • Dale says:

      It certainly seems possible. You see similar effects in other dimensions. E.g., if you physiologically need water, you will feel thirsty. If you drink water, you will stop feeling thirsty, despite that none of the water has gotten into your bloodstream. This sensation change is adaptive, but it requires complicated neural systems to construct the adaptive sensation. Similarly, one’s self-perceived healthiness/unhealthiness could well be a complex synthesis that is adaptive to the range of social/physical situations one may be in.

  6. Anonymous says:

    It’s funny though how doctors were very respectable, college educated folks thought of as experts long before medicine was any more scientific than witchcraft. Perhaps people really liked believing they had medicinal expertise available. I think something similar happened with last century’s psychology.

    • thinkingabout it says:

      You underestimate the validity of traditional medical systems. They evolved by trial and error in the absence of the scientific method. For just one example, the single best drug we have against malaria, Artemisinin, was discovered by Mao Zedong’s program to seek cures for malaria from Traditional Chinese Medicine. Artemisinin is derived from a traditional chinese herb named Qinghaosu that they have been using to treat malaria for centuries.

    • Greying Wanderer says:

      They’d need to be made ultra respectable for the placebo effect to work.

  7. Kosmic says:

    Recently the genes for the placebo effect were found and not everybody has them. Could it be that these are the genes that respond to nursing?

  8. I just read a biography of George Washington. The old man was feeling bad so they called for the doctor. Then another and another yet. Washington was very famous so he had five physicians attend him on that last day – and each one bled him.

    I understand that one of the doctors who attended Lincoln put his finger in the wound and probed for the bullet assuring that, he too, would never recover.

    There was a Edwardian murder mystery shown about twenty years ago on PBS in which the plot turn on the question of the effectiveness of medicine. There was card game wager where someone challenged a physician that he couldn’t prove that any medicine had any effect whatsoever. The doctor slipped him some laudanum (opium in alcohol) and while the he slept some one else was murdered.

    The point was that until quite recently there were only two drugs known to be effective – opium and colchicine.

    As for the value of nurses, I once dated a nurse practitioner. In sexual congress she noticed that I had an irregular heartbeat. It was a sort of stress test, a diagnostic technique unavailable to male doctors.

  9. Dale says:

    The rudiments of nursing are when other members of your social group feed you when you’re unable to forage for yourself. So we may have been nursing for millions of years.

    People have mentioned to me that cats are much less likely to show their illnesses than dogs, that when a cat is visibly sick they are very sick. That would make sense since dogs are adapted to a food-sharing social life. Taking that to an extreme, there are prehistoric human skeletons showing disabling injuries that had healed for a long time. At the other extreme, I’ve heard the phrase “falling off the perch” to describe birds dying. But if you have to be able to fly to obtain water, the malaise response to disease would be lethal.

  10. Toddy Cat says:

    I’m told that the early Christians won a lot of converts in Rome during the great epidemics by essentially providing nursing care. Don’t know if it’s true or not.

  11. Ilya says:

    Interesting post. Do you think nursing (in some fashion thereof) appeared before the discovery of controlled use of fire or after?

  12. My mother trained as a nurse in the West Midlands of England around 1930. “A nurse’s job” she was taught “is to keep the patient clean and comfortable.”
    Medical care at that point still had a big component of quackery. Mum caught the tail end of the sanatorium movement, long wards of TB patients open to the elements along one wall. “We had to brush snow off their blankets….”

    • Toddy Cat says:

      I remember reading that Richard Feynman’s young wife died of TB. Between 1930 and about 1970, things just leaped ahead in medicine, didn’t they? No wonder Progressives were able to hornswoggle so many people. It must have seemed like anything was possible.

  13. Jan Webster says:

    Every British child now knows that it was Mary Seacole, not the wicked and racist Florence Nightingale, who established modern nursing during the Crimean War. It’s a cornerstone of Britain’s Black History Month … every year.

  14. John Hostetler says:

    It’s no coincidence that in English we apply the same word to the breastfeeding of mother’s milk and the care of the sick. I doubt it’s possible to draw a firm line between primate mothering and primate nursing care – where one leaves off and the other begins. But of course, that doesn’t mean Greg’s idea about a possible effect of progressively more advanced nursing care on our immune systems at some point in time, couldn’t yield fruit.

  15. melendwyr says:

    It’s not clear to me that doctors do more good than harm even now. A lot of the improvements in our health are due to better nutrition, better dental care, and inoculations.

    • Fintan says:

      Noo… Typhoid and tuberculosis don’t respond well to treatment regimens consisting of hamburgers and braces.

      In terms of total number of deaths, antibiotics win out over anything you’ve listed. Add in a lot of Pasteurization, municipal water treatment, basic hygiene driven by germ-theory, throw some mosquito abatement programs on top, and you have the truly remarkable age we live in today.

      Look at infant mortality rates in the U.S. in the teens and twenties. The top three killers around the time were pneumonia, tuberculosis, and diarrhea, and in some U.S. cities infant mortality rates hovered around 30% (with, most likely, a majority of children born in those locations dying before reaching adulthood). Now though? We live in a world where people without the slightest conception of human health trends through history think it’s actually normal for most of one’s children to live to reach adulthood.

    • Greying Wanderer says:

      well if there was a turn around some time in the early 1900s that doesn’t necessarily mean it couldn’t have turned round again more recently or be on the brink of doing so with new improved politically correct quarantine.

    • Toddy Cat says:

      I’d say that they probably do more good than harm today, but they are certainly overrated, as is health care in general. Most of our increase in lifespan comes from basic sanitation and vaccination, with nutrition certainly being important.

  16. Regarding the much-praised nonwestern medicine, BTW…

    A physician friend whose mother is Chinese (he thus speaks good Mandarin) visited rural China two years ago, and got to speak with a few doctors there. They were very proud and anxious to show him their books with photographs of patients they had treated, before and after. The photographs seemed to be mostly of advanced syphilis, with the after not looking much different than before.

  17. The fourth doorman of the apocalypse says:

    Having just read this http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172725/ review on EBOV etc it seems that there are a lot of different mechanisms that pathogens use, however, if the numbers can be believed (and that is a big if, because I think they are under reporting at least the deaths) something like 50% of those infected with EBOV survive. At least for the current outbreak.

  18. Mike in Boston says:

    There are claims that the selflessness of early Christians in providing nursing during second-century epidemics was a significant contributor to the growth of the Faith. For a very readable bit of argumentation see e.g.http://www.foresthomechurch.org/wp-content/uploads/2011/01/Epidemics-Networks-the-Rise-of-Christianity-by-Rodney-Stark.pdf

    Is there documentation of pre-Christian nursing on a scale larger than the family/clan, or was this truly unprecedented?

  19. thinkingabout it says:

    There seems to be a fairly widespread misconception about traditional pre-scientific medicine here. Medicine, like any other professional field before the scientific revolution, progressed through trial and error. Engineering, architecture, agriculture all existed before the scientific era. Pre-scientific socieities managed to build trebuchets, cathedrals and figured out crop selection without the aid of the scientific method. And pre-scientific societies had fairly decent methods of managing diseases too.

    • gcochran9 says:

      “And pre-scientific societies had fairly decent methods of managing diseases too.”

      Untrue. Doctors, on average, made you sicker. Poorer too, of course. Now farmers produced crops, architects built cathedrals, engineers made siege engines, but doctors did one or two useful things (treating dracunculiasis) and many stupid things that on average worsened your health and increased your chance of dying soon. I can think of no disease caused by a microorganism that was helped by Western medicine in those days. When doctors got involved in deliveries, mostly after 1800, they greatly increased the risk of maternal death – as much as thirty-fold higher.

      If you knew anything about Galenic medicine, bleeding patients, blue pill and black draught, theriac, laudable pus – you’d be somebody else.

  20. The fourth doorman of the apocalypse says:

    Gut bacteria are protected by host during illness:

    http://www.sciencedaily.com/releases/2014/10/141001133414.htm

  21. Greying Wanderer says:

    “Some patients themselves came to this realization, as when Civil War casualties hid from the surgeons and had better outcomes.”

    For a sadistic psychopath being a battlefield surgeon in pre-modern times would have been hog heaven.

    • MawBTS says:

      Only if you worked on common foot soldiers. I imagine that having a prince or a king die on your operating table could be pretty dangerous for your own health.

  22. The fourth doorman of the apocalypse says:

    There is an interesting connection between Artemisinin and DDT at least in my mind.

    One of them attacks the pathogen, one of them attacks the vector, but in both cases resistance has developed. We know something about the mechanism of DDT resistance (a subtle change to a P450 monooxygenase allows mosquitoes to metabolize DDT–actually deactivate it by binding oyygen to it) but we don’t, I believe, understand the metabolic cost of that to mosquitoes. On the Artemisinin side, we believe that the pathogen is developing resistance but have no understanding of the mechanism.

  23. Robert says:

    But there’s the increased virulence from attendant-borne pathogens. Certainly there have been unnecessary deaths from an inclination to nurse the sick.

  24. Matt says:

    On average, doctors made you worse. Some didn’t, on some occasions. There was always some crop among the weeds, to use a prior analogy from this blog – people didn’t have a good means of estimating how much (and most ideas are bad ideas, if you don’t subject them to some form of selection).

    Nursing care of some form is present in Neanderthal, from what I understand – there’s evidence of unwell Neanderthals being kept alive in ways which are improbable without care. Whether this happened when they were infected or they were shunned or left be, I don’t know.

    http://en.wikipedia.org/wiki/Shanidar_Cave

    That argues for it being either related to the pre-modern and Neanderthal divergence, or a shared (perhaps sporadic) consequence of shared species trends to enceph (this coming from Neanderthal? Probably not).

    Although, if this were an infrequent behaviour, it may not have left much of a selective legacy.

  25. Don’t have time to read all the comments, but has anyone made the point that doctors used to be confidence men? Kings and pontiffs would always go for “the best” — Maimonides for example.

    • I should make the point that doctors, especially the poorer ones, are still confidence men. I can’t count how many time surgical oncologists in the third-rate medical center where I live have hurried people I know into surgery even before the pathology report had been second-opinioned, let alone before they have explored the possibility of finding better, more experienced surgeons in the field. The first step you make in cancer treatment is always the most important one.

  26. simontmn says:

    I thought nursing-type behaviour was quite common in apes, dogs, and other mammalian group species?

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