Why is it that some diseases evoke laughter instead of sympathy? I know a man who tells the story of how, when he was 24 and attending a board meeting in Los Angeles, a telegram arrived for him that was intercepted by the chairman who, upon reading it, immediately burst into laughter. “Gentlemen,” the steel-haired captain of industry said upon recovering, “this telegram should be entered into the records. It is from the doctor back in New York of our young friend here. It informs him that, no doubt due to an excess of high living made even more remarkable by his tender age, he has contracted gout.” The rest of the board found this pretty hilarious stuff too, and they all took turns slapping him on the back and calling him things like, “You young rascal.”
A more appropriate response would have been a commiserating handshake and a few kind words. For the gout sufferer, the disease is anything but a source of humor. In fact, attacks of gout are so painful that they are described as being comparable only to the agony of childbirth. Sufferers say it’s like being jabbed with a “million tiny white-hot needles.”
The problem is that gout is widely misperceived as a self-inflicted disease that affects only the upper classes. It has been referred to, maybe a touch inaccurately, as “The disease of kings and the king of diseases.” English caricaturists like William Hogarth, George Cruikshank and James Gillray took special pleasure in portraying the Tory squirearchy of the 18th century as universally debauched, periwigged and gouty. In the next century American humorist, Ambrose Bierce, defined gout in his Devil’s Dictionary as: “A physician’s name for the rheumatism of a rich patient.”
The reason for this misperception is that overindulgence in food and wine has long been thought to be the primary cause of gout. While it is true that diet is related to gout, the notion that only the rich get gout is not. Gout, in fact, strikes many people of all social and financial backgrounds, currently more than one million people, almost all of them male, in the U.S. Women rarely develop gout and, then, only after menopause. The disease usually appears between the ages of 40 and 50, although it can occur both earlier and later.
Gout is essentially a form of rheumatic arthritis characterized by recurrent episodes of joint inflammation. The pain and swelling of gout are caused by uric acid crystals that deposit in some joints, most notably the big toe, but the disease can also strike the knee, ankle, foot, hand, wrist and elbow. Most men contract gout for one of two reasons: First, it is a hereditary problem, like baldness, and if your father had it you probably will too (thanks Dad!); and second, because they have a diet high in purines. Normally uric acid passes out of the body through the kidneys in urine. An excess of purines causes the body to make more uric acid than the kidneys can dissolve, a condition called hyperuricemia. (It is possible to have hyperuricemia without having gout, however.) In addition to the two causes mentioned above, hyperuricemia can also occur from using diuretics, which can impede the kidney’s ability to remove uric acid.
Dr. Theodore R. Fields of the Hospital for Special Surgery in New York, and a leading authority on gout and other rheumatic diseases, says that only about 10% of gout cases are caused by overproduction of uric acid. The other 90% generally produce normal levels but excrete too little of it in their urine. It is possible to have high levels of uric acid in your blood for many years without realizing it. Gout only attacks once the sodium salt of uric acid crystallizes into needle-like deposits in the joints. Although you may never contract gout, the odds of doing so increase with the amount of time that your uric acid level remains high.
The word “gout” is derived from the Latin gutta, meaning “a drop,” and reflects the ancient belief that the disease was caused by a malevolent fluid dropping into the weakened joints. The problem was that no one really knew what caused gout. For years people attributed it to all sorts of things; Saint Gregory the Great viewed his own gout as a form of mortification visited upon him by the Lord. Less lofty souls simply used their eyes and saw that most gout sufferers tended to be heavy eaters and drinkers who, as was often the case, happened to be either priests or members of the aristocracy.
Debauching yourself does not necessarily mean that you’ll get gout. It’s possible that a combination of heavy drinking and a poor diet will result in gout but it is far more likely that you’ll die of cirrhosis of the liver or heart failure long before your big toe starts to throb. Ironically, thanks to genetics or a diet rich in purines, some poor souls will get gout even if they have never had a drink in their lives. (Which is a little like a virgin getting venereal disease from a toilet seat.) There is a comforting air of good old-fashioned Protestant predestinationism about gout: You are either going to get it or you aren’t, although in this case the wicked tend to suffer a bit more.
One false belief was that only port and other fortified wines caused gout. England saw a dramatic rise in gout after 1703 when Pedro II, king of Portugal, decided to ally himself with the British in the War of the Spanish Succession. This resulted in a treaty that allowed Portugal, in exchange for buying British wool, to export its wines to Britain at one-third the tariff imposed on French wines. Everyone, except the French of course, found this an advantageous development and soon Britain was importing Portugal’s finest wines in unprecedented volumes. These wines, like many wines at the time, were subject to spoilage and the shippers “fortified” the wines by adding brandy and then stored them in lead casks. Lead, however, is soluble in alcohol and an epidemic of saturnine gout–this is a particular kind of gout that is also found among moonshiners in the U.S. whose stills are also often lead-lined–erupted across the British Isles. This breakout was compounded by the fact that physicians at the time believed that while port caused gout, other forms of alcohol did not and prescribed liberal doses of whiskey, small beer and punch to their suffering patients. The fact that their remedies did not have the desired therapeutic effect seems somehow to have escaped the doctors’ notice.
Although Hippocrates accurately described the misery of gout, modern clinical history of gout begins with Thomas Sydenham, an Englishman whose thirty-four-years of suffering from the disease gave him a wealth of personal experience from which to draw. He wrote A Treatise on Gout and Dropsy in 1683 that clearly differentiated gout from other articular disorders. But the presence of hyperuricemia in gout sufferers was not established until 1848, by Alfred Baring Garrod, who clearly defined the disease as a form of arthritis. Once this root cause was isolated then it became easier to treat. By the end of the twentieth century the pain of an acute attack can be nearly completely avoided with proper medication.
Despite all the medical evidence to the contrary, not to mention the considerable physical anguish involved in a gout attack, the disease is still burnished with the patina of aristocracy. Unlike the gin blossoms that appear on the nose of the drunk at the local bar, gout has a certain soigné rakishness about it. It implies a grand life spent drinking the finest wines, not cheap rotgut. (The road to hell is paved with good vintages.) Kings and saints alike have suffered from it. So have great artists. Some sociologists have linked gout with the pathology of genius. Of course, this is all coincidence. Gout is not a measure of your breeding or status. There have been plenty of aristocrats and geniuses who have never had gout–but then again the European upper classes were so inbred that if they didn’t get gout they contracted just about everything else.
So, if one evening you wake up in the middle of the night with agonizing shooting pains in your big toe, it doesn’t necessarily mean you’re either a boulevardier of the highest order or have blue blood flowing in your veins. The only thing flowing in your veins is too much uric acid so contact your doctor immediately and he’ll get you started on a program of medication that will keep your gout under control. And if it happens to slip out in the locker room or the bar that you’ve got gout and all your buddies think it’s classy, let them. Just because you’re suffering, doesn’t mean you can’t have a little fun with it.
In the old days, treatment of gout was no less primitive than most other forms of medicine. After all, remember that for centuries doctors firmly believed in the healthful benefits of leeching and trepanning (a particularly painful operation, usually used in connection with bad headaches, that involved boring a hole in the patient’s skull). Not surprisingly, the survival rate was depressingly low and even though gout was rarely a fatal disease, because there was nothing doctors could do to treat it, many of their patients may have wished they were dead.
The closest thing to a remedy was “flannel and patience.” The affected joint, most often the big toe, would be propped on a stool and swathed in flannel and the sufferer would simply have to wait in pain until the attack subsided–which could often be up to two weeks. The pain could be so great and the skin so sensitive that even the weight of a bedsheet could send the sufferer into agonies. It was believed that only port and other fortified wines were to blame for the gout but small beer, punch and whiskey were considered therapeutic. Doctors prescribed these in liberal doses although it never seemed to strike them as odd that their patients only got worse.
In the early part of this century a fashionable treatment was to encase the sufferer’s foot in a glass boot and use vibration-generated heat to reduce the pain. Unfortunately, more often than not it had the opposite effect: The vibrations would dislodge the uric acid, which immediately went to the kidneys and frequently resulted in kidney failure and sometimes death.
These days, luckily, gout is no longer known as Opprobrium Medicorum, the Reproach of Physicians. Doctors now know what causes gout and are able to design a diet and system of medication to reduce the likelihood of gout attacks. There is, however, no cure for gout, but with proper medication it can be controlled. It is important to emphasize that while many long-time gout sufferers have learned how to self-medicate themselves, because many of the medications are so strong one should never, particularly if one has had gout only recently diagnosed, attempt to treat gout unless under a physician’s care.
Medications To Treat Acute Attacks
An alkaloid obtained from the seeds and corms of Colchicum autumnale, the autumn crocus. Colchicum has been used in the treatment of various medical complaints for centuries (the earliest mention of it is in the Ebers Papyrus c.1500 B.C.). It is only since early in the nineteenth century that it has been recognized as one of the leading remedies for acute gouty arthritis.
Usually taken orally in several small doses every day, Colchicine relieves the pain and swelling of acute attacks. It works best if taken during the first two days of an attack but its side effects include diarrhea, nausea and abdominal cramps.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Used to relieve the pain and swelling of an acute attack, NSAIDs usually begin working within 24 hours of taking them. These medications are as effective as colchicine but may have less side effects. These include stomach upset, headache, skin rashes and sometimes ulcers.
These medications (such as prednisone) are similar to a naturally occuring hormone in the human body. They may be taken orally or are sometimes injected directly into the inflamed joint.
Medications Used To Control Uric Acid Levels
Allopurinol (Lopurin, Zurinol, Zyloprim) reduces the amount of uric acid in the blood and urine by slowing the rate at which the body produces uric acid. It is recommended for people who have kidney problems or kidney stones caused by uric acid. Side effects can include skin rash and stomach upset.
Probenecid (Benemid, Parbenem, Probalan) is commonly used to lower uric acid levels in the blood by increasing the amount of uric acid passed in the urine. They are effective at dissolving tophi and preventing uric acid deposits in joints. They are taken orally and side effects include skin rash, nausea, stomach upset and headaches.
Acupressure, accupuncture, herbal therapy, homeopathy and reflexology are sometimes used to treat gout in the cases of allergic reactions to medication or unpleasant side effects. As is often the case, many doctors who practice conventional medicine are less enthusiastic about these treatments but many patients have reported positive reactions to them.
If you suffer from gout you should be careful to avoid foods that contain purines. Purines are organic compounds that increase the body’s production of uric acid and when you read the list below you’ll be surprised to see how many foods contain purines which, in the non-gout sufferer, are not necessarily so bad when taken in moderation. The good thing for the gout sufferer is that most of the foods that contain the highest concentration of purines are also the most disgusting. If only you had known about this stuff as a kid then you could have said “Sorry, mom, I can’t eat your sheep heart stew. It’s loaded with purines.”
In addition to the foods listed below, remember that all alcoholic beverages can lead to gout.
Foods that contain very large amounts (150-1000 mg) of purine bodies in 100 grams:
|Heart, sheep 174|
|Meat extracts 236-356|
|Herring roe 484|
Foods that contain a large amount (75-150 mg) of purine bodies in 100 grams: anchovies, bacon, codfish, goose, grouse, haddock, liver, kidneys, mackerel, mutton leg, partridge, pheasant, pigeon, salmon, scallops, trout, turkey, veal, venison.
Foods that contain a moderate amount (up to 75 mg) of purine bodies in 100 grams: asparagus, bass, beef, bouillon, brains, chicken, crab, duck, eel, halibut, ham, kidney beans, lentils, lima beans, liverwurst, lobster, mushrooms, mutton chop, navy beans, oysters, peas, plaice, pork, rabbit, roe, shrimp, spinach, tongue, tripe.
Foods that contain an insignificant amount of purine or no purine:
1. Beverages: Carbonated, Chocolate, Cocoa, Coffee, Fruit juices, Postum, Tea
Sources: Hench, P.S.: In Cecil, R.L., and Loeb, R.F. (eds.): Textbook of Medicine, 9 ed; Bridges, M.A.: Food and Beverage Analyses 3 ed. Philadelphia, Lea & Febiger, 1950
Unfortunately for most people, diagnosing gout means you don’t know you have it until it strikes. If your father had it then you probably will too and can start taking certain precautionary steps, such as avoiding purines, but that won’t preempt a gout attack. It just means you’ll know what the heck is going on when you wake up in the middle of the night and your toe feels like its been dipped in molten lead.
For the rest of us, do what you can to avoid gout. It is a preventable disease, but once you get it, it is incurable. Mainly by applying common sense, just like your mother told you, you will not only reduce your chances of getting gout but also lead a healthier life in general. That means watching your diet, reducing purines, moderating your alcohol intake, avoiding stress and taking regular exercise. People who are at particular risk are those who simply eat and drink too much. Obesity can be linked to high uric acid levels in the blood. However, drastic diets or fasts–especially if you use diuretics–will only increase the chances of gout.
If you think you are in a high risk category for gout see your doctor. He will ask you to describe your symptoms and may take a blood test to measure the amount of uric acid in your blood. Remember, having a high uric acid level does not necessarily mean that you have gout. If your doctor tells you that you have gout he will prescribe a regimen of medication that will help prevent further attacks.