The Age Before Miracles

THEY WERE, IN THE FIRST instance, weapons part of the arsenal of democracy, defending American troops against hostile germs, whether contracted heroically at Omaha Beach or less so in the fleshpots of San Diego. After the war, antibiotics became one of the paradigmatic American technologies of the 1950s: efficient, deadly and, generally, cheap. For four decades, life without them has been as unthinkable as life without, say, the atom bomb.

Yet it goes without saying that millions of people were born, lived and died without penicillin, breathing and eating and copulating in a swarm of microbes-microbes which, until almost the end of the 19th century, were regarded by most reputable physicians as creatures of science fiction. One might suppose that before antibiotics, doctors didn't bother treating things they couldn't cure. But the very opposite is the case. True, 19th-century medicine knew only a handful of useful treatments for specific diseases-cinchona bark for malaria, mercury (generally but not invariably in nonlethal dosages) for syphilis. digitalis for heart failure. But doctors had plenty of useless remedies to choose from. With no understanding of infection, physicians often regarded disease as the sign of an organism whose inner workings had mysteriously gone out of balance. In the first half of the 1800s, patients were often viewed as "overexcited," and treated with bloodletting or powerful purgatives. By the latter decades, medicine had progressed to the point where "exhaustion" was the diagnosis of choice, meaning that doctors could now prescribe whisky instead. An 1866 medical text recommends treating pneumonia with, among other things, castor oil, chloroform, ammonia, poultices of linseed or turpentine, cold water, brandy and the popular, although useless, opium. "By the time they got through all of these," says Dr. Paul J. Edelson, director of Medical History and Epidemiology at Cornell University Medical College, "the patient either died or recovered on his own, leaving plenty of room for the conclusion that at least something had probably worked."

Yet even as American doctors were torturing their patients this way, Pasteur and Koch were laying the groundwork for our modern understanding of infectious disease. This was the real revolution in medicine, and the benefits would remain with us even if antibiotics stopped working tomorrow. Doctors didn't eliminate cholera, typhoid and typhus in the United States by battling germs one patient at a time; better nutrition, pure water and pasteurized milk did it for them. Immunizations, not antibiotics, wiped out smallpox and all but eliminated deaths from diphtheria and tetanus. Childbed fever and other postsurgical infections declined when doctors began washing their hands between patients.

To be sure, if you managed to contract one of these diseases anyway, medicine wasn't much help before antibiotics. A few infections could be treated surgically, and by the 1920s hospitals could give oxygen to people with pneumonia, but in the fight against infection as such the patient generally was on his own. This, however, was not as one-sided a struggle as we perhaps have come to believe. The very power of antibiotics has obscured the truth that most infections are self-limiting, running their course and then departing. Only a few, such as bacterial meningitis or endocarditis, kill almost everyone who gets them. Much more common are diseases like pneumococcal pneumonia, which most otherwise healthy adults usually survive even without treatment. Of course, that sounds like good odds only to someone who doesn't happen to have pneumonia. Antibiotics take the sting out of words like "usually." But it's worth remembering that a million cases of pneumonia treated with antibiotics does not translate into an equal number of lives saved. Some pediatricians now routinely give antibiotics for a sore throat-which may be caused by a strep infection, which sometimes leads to rheumatic fever, which can damage the heart valves. Lives are saved at the cost of oceans of penicillin wasted on kids who didn't have strep throat,

The unexplored significance of antibiotics is how they changed expectations of medicine. A doctor became someone who treated disease, rather than patients. David J. Rothman, professor of social medicine at Columbia University, astutely links the development of penicillin with the decline in house calls. Now doctors could stay indoors and let the patients come to them; if they caught pneumonia on the way it was easy to cure. More generally, he says, antibiotics shifted the emphasis in medicine toward acute, crisis-oriented treatments. But the emergence of AIDS, an incurable infectious disease, has caused some doctors to rethink the value of long-term, supportive care. "For too long," says Edelson, "we have framed the relationship of humanity to disease as a war. For the duration of human existence, there will be disease. The doctor can't say, 'I'll only deal with those I can cure.' Doctors will rediscover that the real work of medicine starts when the drugs no longer work."