“Neither repletion, nor fasting, nor anything else
Is good when more than natural.”
– Hippocrates: Aphorisms –
Errors of Metabolism
Like the inborn errors of metabolism that we met earlier, acquired diseases of metabolism result from an imbalance of the biochemical constituents of the human body. However, instead of being bestowed on the patient at birth, they are acquired through living. To maintain our systematic approach, we again divide these diseases broadly into the different materials of which the human body is composed: carbohydrates, fat, proteins, water and electrolytes, and minerals and vitamins.
In the West we are witnessing an epidemic of metabolic disorders such as obesity and diabetes. Let’s see an example of a short sieve including diseases of metabolism:You are on rotation with an old wise general practitioner. Your next patient seems an interesting case: a 50-year-old man with a painful swelling at the base of his right great toe. “OUCH! It came up quick and now it hurts so much I can’t put my shoe on,” he says. On examination, you find the area is hot and swollen, with very little movement in the metatarsophalangeal joint. Moments later, your supervising GP arrives to check up on you. She takes one look at the patient then turns to you…
“That’s a good one for you to see! What’s wrong with him?” she asks.
Gulp! No idea! You turn to your sieve…
“Well, It’s red, swollen, hot and tender so it might be an acute inflammation. Maybe it is an infection? Or rheumatoid arthritis?”
“Chuckle chuckle,” says the GP. “Maybe… but maybe not. What else could it be?”
“Hmm, well it could be a tumour but that seems less likely. It could be a degenerative change like osteoarthritis but it came up quickly. It wasn’t injured. Perhaps it’s due to metabolic problem? Aha! Could this be the ‘gout’ I’ve heard about??!”
“Of course!” says the GP. “A typical case.”
Throughout much of the early years of medical history, doctors thought nearly all illness was related to disorders of metabolism. This doctrine dated back to the Greeks and Hippocrates who believed that the universe consisted of four elements, which corresponded with four components that made up the human body.
Mucous secretion, for example, was thought to be a result of ‘imperfect mingling of humours’. The warmth at the site of a skin infection was deemed to be the result of ‘separation of hot humours’. This theory, which lasted for almost two thousand years, explains why for doctors once practised the cruel act of ‘blood-letting’ – they simply hoped to release humours responsive for the excessive bodily heat in febrile patients.
Hippocrates (c460-370BC). Few details of Hippocrates’ life are actually known, though it is understood he was a physician on the Isle of Cos (near present-day Turkey) where he healed the sick in the Temples of Asclepios. He practiced during the Golden period of Grecian thinking. Hippocrates is often regarded as the first to place medicine on a truly rational framework – denying the role of superstition and mysticism and focusing more on lifestyle and diet. Although his theories were somewhat inaccurate, his rational attempts to diagnose and treat disease were a major leap in conceptual understanding.
The famous Oath attributed to Hippocrates, is still regarded as a fine description of the ethical responsibilities of a doctor today. The Oath also testifies to Hippocrates’ deep compassion for humans and their suffering, and the care and concern he showed for his patients. Over 60 treatises have been attributed to him, though perhaps his followers wrote many. Hippocrates died in Thessaly, at an advanced age. His legacy of physical examination on the patient and a highly rational deductive framework of understanding disease through observation set the basis for modern medicine as we know it.
Hippocrates’ promoted the Asclepion way of life as a treatment for disease, which included fresh air, exercise and a healthy diet. Many of the acquired diseases of metabolism as we see them today would still benefit from a good regimen of this Hippocratic treatment. Although researchers are very busy looking at genetic and other causes for diseases such as gout and diabetes, we should again remember the work of Burkitt, who did not see them in the African peoples. His view on the matter has become famous: “If people are constantly falling off a cliff, you could place ambulances under the cliff or build a fence on the top of the cliff. We are placing all too many ambulances under the cliff.”
Dosing is a minor function in the practice of medicine compared to the old measure of Asclepios.