Genetic Medicine: A Logic of Disease (review)

Genetic Medicine: A Logic of Disease.By Barton Childs. Baltimore: Johns Hopkins Univ. Press, 1999. Pp. xii+376. $55.

Childs challenges traditional medical thinking. He analyzes how medical care is made available and paid for, squares new procedures and treatments with ethics and social mores, analyzes the individuality of disease, and examines the rapid accumulation of information useful to students and medical practitioners. And in keeping with the title, Childs asserts that because genetics developed and prospered outside of medicine, genetics is exposing medicine to concepts that provide new ways to think about disease, its cause and pathogenesis. While once medical practitioners had only to deal with their own guilds or colleagues with respect to disease, patients, and their problems, today practitioners must accommodate their practice with administrators, social workers, governmental bureaucracy, non-physician counselors, a wide variety of ethicists, lawyers, anthropologists, and others, many of whom have never seen a patient die. In short, medicine no longer exists in isolation, and today's physician must be knowledgeable about many disciplines. In accordance with this principle, radical changes are indicated in medical education, beginning with medical students.

What is meant by a "logic of disease," the subtitle of this book? Childs introduces a logic of disease from a synthesis of conventional medical thinking with particular emphasis on the ideas of William Osler and Archibald Garrod, who were leaders in setting medical thinking.The principles of his logic of disease include individuality, remote and proximate causes, and evolution and natural selection.

Childs queries whether there are principles of disease that are predictable connections and sequences from evolution and natural selection, or whether the pathogenesis of disease is so complex and random as not to be predictable. Obviously, Childs comes down on the side of predictability. Disease is a by-product of variations to preserve species under variable conditions. Even so, although we classify disease, each individual has his or her own disease: in short, we are our own history. Obviously, the path of the species is intricate and has many pitfalls, some adaptive and other nonadaptive. But flexibility leads to continuity and survival. Childs examines the integration and interdependence of physiological homeostasis, genetic homeostasis, developmental homeostasis, sociocultural homeostasis, and finally homeostatic interactions in order to understand disease first in the context of a person's role as a member of the species. Childs next defines the gene and its variations, and emphasizes the universality of the gene concept and its importance in human disease. Developing the previous homeostatic categories, the author emphasizes that all disease is based on inborn variations of homeostasis and that it is the genetically determined congruencies that make for susceptibility.

An analysis of disease in three time frames follows. First, from a study of type 1 diabetes mellitus, the author illustrates the variable factors that are involved in this disorder. By way of illustration, type 1 diabetes involves genes (HLA-DR3, DR4S(breve), and many others); development (age, maternal age, sex of patient); and the environment (infection, season, geography, year, human milk). Next, the author stresses that events early in life influence later disease: examples are malnutrition in utero and after birth, type 2 diabetes, hypertension, atherosclerosis, phenylketonuria, lead poisoning, cretinism, osteoporosis. Finally, Childs studies the importance of biological and social history.The Human Genome Project will radically change medicine from before inception to the ends of life in all time frames.The Watson-Crick revolution is forever with us.

Childs analyzes in a concluding section how his concepts of modern medicine and disease may affect medical education and the public. Problems of health, Childs asserts, will be solved only by a concerted effort to cultivate and impose a public will.This concept is a long way from the simple doctor-patent association, which by itself may prevent, treat, or cure a particular disorder in an individual patient, but will not resolve overall problems of disease in general.

This book is highly recommended for a...