Saturday, February 25, 2006
Gout and Pseudogout: The Cult of the Virgin Mary
Gout is the “disease of kings,” or so it was known because it was erroneously associated with of overindulgence in food and wine only the rich and powerful could afford. What is not in dispute is gout gives exquisite pain which renders the affected area untouchable.
In Victorian times the cartoon depictions of elderly gentleman in wheelchairs with one foot bound in a beehive bandage was a metaphor for aristocrats and their misspent youth. In truth many had syphilis but gout was also prevalent and eminently more acceptable as a reason to the prudish society.
Probably the most famous person to suffer gout was Henry VIII (although it is likely to have been syphilis) and the King of England wore Bearspaw shoes (Duck Bill shoes) to comfortably accommodate sore plus bandages.
The soft upper was slashed to further accommodate the bulk within. Slashing garments had become fashionable in the 16th century in part this was to display what lay beneath flaunting sumptuary laws which prevented the less privileged from sporting regal clothing as outerwear.
The slashed garments also had religious significance and were worn by secret societies that followed the Cult of the Virgin Mary. The slits symbolically represented the vulva, replacing the long toed shoe (phallus) which had been the prevailing style for the last four centuries.
Broad toed shoes as a fashion came to an end when Bloody Mary (daughter of Henry VIII) banned them by law. This is thought to have been a gesture to the Pope when Mary became a catholic.
Back to gout, suffrage became a figure of fun suffice gout sufferers received little sympathy which is quite unmerited. The condition occurs when uric acid crystals are deposited in the joints due to elevated blood level of uric acid (hyperuricemia). Uric acid is a normal waste product of the body which is passed out through urine but when the liver produces more uric acid than the body can excrete in the urine, or when a diet high in rich foods (e.g., red meat, cream sauces, red wine) produces more uric acid than the kidneys can filter from the blood then serum uric acid levels increase.
As uric acid in the blood crystallizes and monosodium urates crystals lodge in the joint spaces this causes swelling, inflammation, stiffness, and pain. Gout usually affects the first metatarsal phalangeal joint of the big toe (hallux) or the ankle joints. Symptoms are exquisite pain. The condition is more common in men between the ages of 40 and 50. In women the incidence increases after menopause and it is very rare in children and young adults. Many people who develop gout have a family history but other diseases may increase the risk. These include diabetes mellitus, obesity, kidney disease, and sickle cell anemia. Alcohol adversely interferes with the removal of uric acid from the body as can other factors including, a purine rich diet (e.g., cream sauces, red meat, sardines, liver, scallops), medications which interfere with remove of uric acid from the body and exposure to lead in the environment. Demographic surveys indicate a significant rise in reported cases of gout.
Painful symptoms are often sudden and come on, overnight. The effected parts such as the great toe (unusual to have more than one joint involved) is swollen and tender with touching or moving the big toe intensely painful. Frequently gout sufferers will report extreme discomfort even from a bed sheet. If left untreated, gout can damage joints and cause osteoarthisis. People with gout have elevated blood levels of uric acid, but this condition may not always be present during an acute attack.
A simple set of tests and physical examination will confirm diagnosis. Treatment involves reducing the levels of uric acid in the joints and the physician may prescribe non-steroidal anti-inflammatories (NSAIDs) to treat the pain. Until recently treatment for acute gout consisted of colchicine which was effective early in the attack. However, colchicine can cause nausea, vomiting, diarrhea and other side effects and now most physicians prefer to use anti-inflammatories. They too have side effects for some. Pharmaceutical care also depends on co-morbidities and polypharmacy. Small doses of NSAIDs, colchicine, or allopurinol may prevent continued accumulation of uric acid in the joints and further attacks. Avoiding alcohol and rich foods that are high in purine are also recommended to normalise blood uric acid levels. What works well for one person may not work as well for another, so decisions about when to start treatment and what drugs to use have to be tailored by the physician, and depend on kidney function and other factors. According to experts it is possible in almost all cases to successfully treat gout.
Pseudogout (calcium pyrophosphate deposition disease) is a type of arthritis where calcium crystals accumulate in joints capsules causing severe localised pain and swelling, similar to gout. Pseudogout is a condition which is often mistaken for gout and diagnosis is important if treatment is to be effective. The incidence of pseudo gout increases with age and diagnosis depends on analysis of the crystal found in affected joint. Treatment usually involves prescribed anti-inflammatory medications. Unlike gout which tends to affect the feet and ankle pseudogout affects the knees, wrists, shoulders, ankles, elbows or attacks can last for days or weeks. The cause of calcium pyrophosphate deposition disease remains unknown. The condition sometimes runs in families and hence genetic factors are suspected of contributing to the disorder. According to medical text severely underactive thyroid (hypothyroidism), excess iron storage (hemochromatosis), an overactive parathyroid gland, and other causes of excessive calcium in the blood (hypercalcemia) may contribute to the development of pseudogout. In some people, attacks of pseudogout may develop following joint surgery or other surgery. Because many older people have calcium crystal deposits in their joints, any kind of insult to the joint can trigger the release of the calcium crystals, which then induce a painful inflammatory response. Unfortunately there is no treatment to dissolve the crystal deposits but symptoms may be relieved and the progress of the condition slowed down by small doses of prescribed anti-inflammatories.
If you think have any of the above symptoms then please consult your physician for diagnosis and treatment.
National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
The Arthritis Foundation