© 2004 American Thoracic Society
Rebuttal from Dr. MacklemDr. Snider has written an erudite essay. It is hard to argue with his contention that physiology, epidemiology, medical imaging, and clinical trials "do not provide information on the cellular mechanisms of disease." However, his next statement that "only [emphasis mine] cell and molecular biology...can lead to an understanding of the fundamental mechanisms of disease" does not follow either logically or factually. We know a lot about the pathogenesis of obstructive sleep apnea, but very little about its cellular basis. Avery and Mead's discovery that surfactant was deficient in the respiratory distress syndrome of infancy (1) was a huge advance in understanding the pathogenesis of this disease that led directly to successful treatment by surfactant replacement and intelligent use of mechanical ventilation. Avery and Mead did not use cell and molecular biology in making their momentous discovery (1).The rest of Dr. Snider's essay seems to miss the point. Curiously, his description of our medical armamentarium at mid-twentieth century omits aspirin, insulin, thyroxin, iodine, vitamins, laxatives, fluids and electrolytes, blood transfusions, vaccines, and surgery. He neither defends nor proves his side of this debate and is content to give examples of cell and molecular biological contributions to understanding pathogenesis of lung disease. This is not an issue. No one would deny that these disciplines contribute importantly to understanding pathogenesis. I merely claim that they are not the only ones which do so. Nor have I suggested that we should "severely limit or stop cell and molecular biology studies." What I claim is that these technologies are overemphasized to the detriment of other disciplines that are crucially important to the practice of medicine (2). Finally, in his last sentence Dr. Snider again uses the word "only" in referring to future therapeutic advances. This word is at the heart of this debate. Those who claim that only cell and molecular biology, to the exclusion of all other disciplines, can lead to understanding of pathogenesis and treatment of disease are blind to the essential contributions that other disciplines have made historically, continue to make today, and will make in the future. REFERENCES
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