Gout: A rich man disease through the ages

I know I usually don’t post about medical stuff – unless discussing troubling issues like Depression, Dementia or Diseases transmitted by mosquitoes or bugs. Some of them have been written for the Mental Health Awareness Month like May 2017 and some of them came out during research for a book I was reading likeThe Munchausen Syndrome by Proxy.

This is the case now. I’ve started reading Alvin Journeyman (from the Alvin Maker series by Orson Scott Card) and in one of the chapters, Calvin, Alvin’s brother, goes to see Napoleon Bonaparte who is said to suffer from gout.
He does not know how to heal him, only how to offer a brief pain respite by numbing the nerves controlling the pain in the leg.

This is the point I got curious. What is gout? Did Napoleon Bonaparte really suffer from it? Is it a rich man’s disease? What causes it? Is there a treatment for it? Does nerve pinching work? Or is it symptom alleviation rather than a cure.
I’ll try to answer these in the following article.


Introduction

Gout

Gout is a disease that involves the build-up of uric acid in the body. About 95 percent of gout patients are men. Most men are over 50 when gout first appears. Women generally don’t develop gout until after menopause. But some people develop gout at a young age.

This guide will help you understand

  • how gout develops
  • which parts of the body are affected by gout
  • what can be done for the condition

History

Like melancholy in the Renaissance era, or tuberculosis in the Romantic era, it even managed to acquire its own social cachet. It may have contributed to dramatic changes in world affairs dating back to Roman times.

Evidence of uric acid deposition in joints has been found in mummified Egyptian remains in Philae dating from approximately 4000 years ago. However, Hippocrates was thought to be the first person to accurately describe it c. 400 BCE. At the time, the prevailing orthodoxy sought to ascribe physical manifestations of disease to an imbalance, or dyscrasy, in the four main humours of the body – black bile, yellow bile, blood and phlegm. Hippocrates felt that gout resulted from an abnormal accumulation of one of the humours in the joints. He was in no doubt about its severity, writing, Persons affected with the gout who are aged, have tophi in their joints, who have led a hard life, and whose bowels are constipated are beyond the power of medicine to cure.

At the time, and for many centuries thence, gout was thought to be the result of an intemperate, bacchanalian lifestyle. A popular Greek legend at the time had it that the goddess Podagre was born through the seduction of Aphrodite by Dionysius (the Greek god of wine);
Homer’s Iliad tells the story of the Trojan Anchises, who began to limp after having been struck by a thunderbolt from Zeus.

The Romans, by all accounts, felt similarly.
Galen, the celebrated Roman physician of Greek origin, wrote prolifically on all matters medical. He is said to have opined: ‘Gout is the daughter of Bacchus and Venus.’

Seneca, Nero’s tutor in the 1st century AD, purportedly saw gout in women as a particularly vituperous consequence of the depravity generally practised by the populace, and questioned ‘. . . why need we be surprised at seeing so many of the female sex afflicted with the gout?’
Roman literature is littered with descriptions of gouty epidemics among the aristocracy. However, it seems that such attacks may have carried with them a darker subtext, and contributed to the demise of the Roman empire.

The British aristocracy of the 1600s were staunchly conservative when compared to their Roman counterparts; however, they too were not spared the tender ministrations of gout. Once again, lead may have been a contributing factor. In the late 1600s, the English Parliament sought to limit commercial competition by the Dutch fleet by banning the importation of French wines, a cargo not carried by the British, in favour of Spanish and Portuguese wines. Port was particularly popular, but also happened to be rich in lead. This may explain the large number of people suffering from
gout seen in caricatures of the time. Perhaps unsurprisingly, many of the detailed descriptions of gout come from this era onwards. Thomas Sydenham, himself a sufferer, chronicled his attacks in
the late 1600s as being

‘. . . so exquisitely painful as not to endure the weight of the clothes nor the shaking of the room from a person’s walking briskly therein . . .’

The Reverend Sydney Smith, considered to be one of Britain’s greatest wits of the 19th century, had a more economical but no less colourful description, likening attacks of gout to ‘. . . walking on eyeballs . . .’
Nonetheless, the notion of gout as an affliction of the privileged, and therefore highly desired, had a strong foothold.

Walpole considered podagra to be a natural result of the body’s attempt to expel ‘depraved humours’ to the extremities, and Sir Arthur Conan Doyle published an article in The Lancet in which he paid as much attention to non-arthritic gout as Sherlock Holmes would to the whorls on one’s fingertips.

Anatomy

What is gout?

Gout was the first disease in which researchers recognized that crystals in the synovial fluid could be the cause of joint pain. Synovial fluid is the fluid that the body produces to lubricate the joints. In gout, excess uric acid causes needle-shaped crystals to form in the synovial fluid. Uric acid is a normal chemical in the blood that comes from the breakdown of other chemicals in the body tissues.

Everyone has some uric acid in his blood. As your immune system tries to get rid of the crystals, inflammation develops. For the person with too much uric acid, this inflammation can cause painful arthritis.

Gout

The first attack of gouty arthritis usually happens in just one joint. Half of the time, gout affects the metatarsophalangeal(MTP) joint. This is the joint at the base of the big toe. Eventually, 90 percent of people with gout will have pain in the MTP joint. Other joints that are commonly affected include the mid-foot, ankle, heel, and knee joints. Less commonly gout affects the fingers, wrists, and elbows.

Over time, patients with gout can develop tophi, or lumps that grow around crystal deposits in joints or near pressure points. Tophi most often occur in the fingers, wrists, ears, knees, elbows, forearms, and heels. Tophi can also grow in the kidneys, heart, and eyes.

Causes

Why does gout develop?

Hyperuricemia

The underlying condition that causes gout is called hyperuricemia. It means that you have high levels of uric acid in your blood. This can happen for two reasons: (1) your body creates too much uric acid, or (2) your kidneys don’t excrete the uric acid effectively. Whether or not you will develop gout is related to how bad your hyperuricemia is over time.

For people who create too much uric acid, the cause is usually genetic. Some rare genetic and metabolic disorders can cause overproduction of uric acid, which can eventually lead to gout. The breakdown of purines in the body also releases uric acid. Purines are ingested through certain types of food such as sweetmeats (e.g., liver, kidney, brain) and seafood. The increased intake of fructose-sweetened soft drinks has also been linked with an increased risk of gout. Usually the excess uric acid is then passed out of the body through the urine.

More than 90 percent of people with gout have kidneys that don’t effectively get rid of uric acid. Sometimes this is caused by certain kinds of drugs, such as diuretics, cyclosporine, and low-dose aspirin. Other medical conditions, such as obesity, hypertension, and diabetes, can also make some people more likely to develop gout.

Many gout patients have a combination of overproduction and under-excretion of uric acid. Their bodies create too much uric acid and have problems getting rid of it. This combination of problems happens with drinking alcohol, especially beer. The more alcohol the patient drinks, the worse the problem is. Alcohol both raises uric acid levels in the body and impairs the kidneys’ ability to excrete the buildup.

Acute Causes

Attacks of gouty arthritis seem to be caused by sudden increases in the amount of urate (a solid form of uric acid) in your synovial fluid. This rapid change can be caused by injury to the joint, alcohol use, or use of certain drugs.

An injury that can trigger gout can be very slight. Even gentle exercise can cause inflammation in the joint, although you may not notice it. Once the joint is at rest, the body absorbs some of the water in the synovial fluid. This leaves the synovial fluid more concentrated with urate, which may allow crystals to grow.

Other Factors

Heredity plays a role in gout. In some families, hyperuricemia tends to develop into gout, while in other families it doesn’t. But genes alone don’t account for gout. The rising number of people with gout since World War II suggests more than just a genetic or hereditary basis for this condition.

Dietary changes may be the major difference over the last 60 years. Food scarcity during the 1940s was followed by an increased intake of carbohydrates and especially carbohydrates containing high-fructose corn syrup. The increase in obesity (another risk factor for gout) during the same time supports this idea.

There are several other risk factors for gout. These conditions do not cause gout, but they are closely related to severe hyperuricemia. The risk factors include metabolic syndrome, kidney problems, high hemoglobin levels, high triglyceride levels, and hypertension (high blood pressure). About 14 percent of hypertension patients have gout. A combination of factors such as eating lots of organ meat, a sedentary lifestyle without exercise, and drinking lots of alcohol increases the risk for symptomatic gout.

It is important to note that hyperuricemia alone doesn’t cause gout. Most people with high levels of uric acid in their blood never develop any symptoms of gout. At least five percent of Americans have at least one period of hyperuricemia as adults without showing any symptoms of gout. And most people can tolerate fairly high levels of uric acid in their bloodstream without damage to their kidneys.

Symptoms

What does gout feel like?

Gout causes attacks of very painful joint inflammation. This pain is often described as burning pain. Early gout attacks usually affect only one joint. This joint is most commonly the MTP joint at the base of your big toe. The joint becomes swollen, warm, and red within eight to 12 hours. Most of the time the attacks happen at night. Patients say the pain is so bad the joint can’t even stand the slightest touch. Even the weight of a sheet causes excruciating pain. Walking and standing are almost impossible if the legs or feet are affected. Many patients have flu-like symptoms, including fever and chills. The pain may go away on its own in a few hours, or it may take a few weeks.

Gouty arthritis attacks come and go. There may be months between attacks. Over time the attacks happen more often, last longer, and involve more joints. Eventually the pain doesn’t ever completely go away. The joints stay swollen and tender even between flare-ups, and the flare-ups start to happen every few weeks. Eventually, some patients develop tophi on joints or pressure points and kidney stones.

Treatment

The treatment of gout has run its own tortuous course. Colchicine was first used as a treatment for gout around 500 BC, but with cathartic rather than antiinflammatory intent. The meadow saffron, Colchicum autumnale, originated in the town of Colchis on the Black Sea, and was renowned as a laxative. It was not until 1763 that the Viennese physician Baron von Storck began to use colchicum extract specifically for terminating acute gouty attacks. Around the same time, a French military officer, Nicholas Husson, formulated a colchicum-based preparation innocuously known as ‘Eau Medicinale’. This was used to treat various ailments, including gout. Some 30 years later Pelletier and Caventou isolated the active alkaloid colchicine, at which point it became more widely used. The product is thought to have been introduced to America in the late 1700s by Benjamin Franklin, himself a sufferer of gout. In the late 1800s, it was discovered that high-dose salicylates were an efficacious remedy for acute gout. Fifty years later, the period from 1948 to 1963 saw the introduction, in rapid succession, of corticotropin (ACTH), prednis(ol)one and
allopurinol.

Other Conditions With Symptoms Similar to Gout

The symptoms of gout (warmth, pain, swelling, and extreme tenderness in joints) may be related to other medical conditions. Some of the conditions that can have symptoms similar to those of gout are:

Rheumatoid arthritis (RA). But rheumatoid arthritis affects more than one joint and generally affects both sides of the body. RA especially affect the hands and wrists. Most of the time, gout affects only one joint and is more common in the feet or toes.
Osteoarthritis. Osteoarthritis develops slowly and is ongoing, while a gout attack develops quickly and you may not have symptoms between attacks.
A joint infected with bacteria (much less common than gout). The treatment of an infected joint requires intravenous antibiotics and hospitalization, so talk to your doctor if any of the following signs or conditions are present:
Treatment with medicines that suppress your immune system
HIV infection
Diabetes
Recent bacterial pneumonia
Kidney or skin infection
A swollen prosthetic joint
Fever
Pseudogout, a disease in which calcium deposits collect in and around joints. Pseudogout may show up as a swollen, painful knee, ankle, or wrist in older adults.

 

Sources

http://onlinelibrary.wiley.com/doi/10.1111/j.1756-185X.2009.01381.x/pdf

Advertisements

One thought on “Gout: A rich man disease through the ages

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s