The Years 1953-1971

With the introduction and widespread use of antibiotics, there was a flareup of the old problem of the clinician's view of the microbial agent as the sole cause of an infection, versus the epidemiologist's perspective which recognized the heterogeneous nature of causes, with the host and the environment playing important roles as etiologic determinants. By 1953, the sulfonamide drugs had been in use for some 15 years and the newer antibiotics for 6-8 years. The miraculous effectiveness of penicillin and other antibiotics in rapidly eliminating streptococcal infections and in curing patients with pneumonia encouraged the clinician's tendency to regard every infection as being due to a single agent, which, if it could be found, could yield to a single specific drug. But practical and realistic as this philosophy was therapeutically, the idea of a single etiology did not fit with a doctrine which epidemiologists had been trying to promulgate for years-namely, that the causes of disease were, in general, multiple. These involved complex patterns of host resistance , ways of living, and various sociological and environmental influences. This difference in point of view was to drive a temporary wedge between the philosophies of epidemiologists and clinicians. In 1938, the author, sensing a unilateral trend, had occasion to make a plea before an audience of clinical investigators about the morality of championing a single cause as the realistic or final determinant of human illness. He said that conservative opinion which did not allow anything to be really considered as legitimate etiology in this technical age was based on a false premise: Of late years conservative opinion does not allow anything to be really considered as etiology unless we can succeed in getting it (i.e., the cause) into a test tube, unless we can precipitate it-unless we can crystallize it, as it were. This is due, of course, to our current methodology which has become more of a religion than most of us realize. I think it may have led to a slightly narrow interpretation of clinical investigation on our part-for clinical investigation certainly should be given the opportunity to spread up into philosophy, if it will, or down into the basic sciences (1). This plea fell on deaf ears, probably because the audience and those members of the medical profession who read the article, recognized in it the voice of the evangelist. And yet, gradually some realization of the epidemiologist's point …