Episode 54: Gout - A Fashionable Disease? - Anatomy Of Illness

Episode Transcript
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(00:00):
You woke up in the middle of the night to what felt like a stabbing pain in your big

(00:04):
toe.
As you dare to touch it, the sharp agony radiates like electric sparks, revealing a toe that
has mysteriously swollen its hue, a fiery red that stands out starkly against its sleepy
neighbours.
You tried to go back to sleep, but the pain somehow intensified as the hours passed, leaving
you staring at the ceiling and constantly shifting positions in hopes it would get better.

(00:26):
When your alarm finally went off, you decided that it was time to make an appointment with
the doctor.
Hello and Welcome to Anatomy Of Illness.

(00:47):
Today's episode is about gout.
Before we get into the condition, we are going to start with the history.
So why do we know gout exists?
We begin with the ancient Egyptians in 2640 BC.
They first called the condition podagra.
This specifically referred to acute gout in the first metatarsophalangeal joint.
So this is the big toe.
Now we move to Hippocrates in the 5th century BC.

(01:10):
Hippocrates referred to gout, which again was podagra at the time, as the unwalkable disease.
He would also note the links between gout and a life without moderation.
He would call this condition arthritis of the rich and conditions like rheumatoid arthritis,
arthritis of the poor.
We take a quick pit stop to the rule of Nero between the years 54 to 68 AD, where we meet

(01:32):
Seneca.
He was the first to discuss that gout could in fact affect women.
“In this age, women rival men in every kind of lasciviousness.
Why need we then be surprised at seeing so many of the female sex afflicted with gout?”
Now we jump forward to Galen between the years 129 and 216 AD.
Galen was the first person to describe the little crystals that occur in gout called tophi.

(01:57):
He recognized that in some cases of gout, these could be hereditary, so passed down in families.
However, like Hippocrates, he also recognized the fact that debauchery and intemperance could
cause the condition.
Now we jump to between 525 and 605 with Alexander of Tralles.
He is credited with the first use of colchicine scene as a treatment for gout, which apart from

(02:20):
a small time period has been a common treatment for the condition throughout history.
Now we move to between 1197 and 1258 with Dominican monk Randolphus of Bocking, the domestic chaplain
to the bishop of Chichester.
He was the first person to use gout to describe podagra, specifically in the phrase “gutta quam

(02:41):
podagrum vel artiticam vocant”, or the gout that is called podagra or arthritis.
Gout or gutta in Latin meant drop at the time.
This was due to the belief in the four humours theory.
The four humours theory was the theory that had four fluids in the body, which when balanced,
everything was healthy.
When one was too high, things were unhealthy or too low as well.

(03:03):
With gout, it was thought that one of these humours would drop or flow into a joint, causing
swelling, inflammation, and pain.
Now we move to between 1624 and 1689 with Thomas Sydenham, who was a famous English physician.
He also happened to have gout.
Sydenham would describe the sudden onset of gout attack symptoms.
“The patient goes to bed and sleeps quietly, until about 2 in the morning, when he is awakened

(03:26):
by a pain that usually seizes the great toe, but sometimes the heel, the calf of the leg,
or the ankle.
This pain resembles that of a dislocated bone, and this is immediately succeeded by a chillness,
shivering, and slight fever.
The pain, which is mild in the beginning, grows gradually, more violent every hour.
So exquisitely painful as not to endure the weight of clothes, nor the shaking of the

(03:49):
room from a person walking briskly therein.”
We now move to 1679 with Antoni van Leeuwenhoek.
He was the first to observe the tophi from gout under a microscope.
And in 1776, the chemical composition for uric acid, which causes tophi, was discovered by
the Swedish chemist Scheele.
Gout throughout history has been referred to as a disease of kings.

(04:10):
And in some periods, it has been seen as a sort of status symbol.
This is evident in a comment in the London Times back in 1900.
“The common cold is well-named, but the gout instantly seems to raise the patient's social
status.”
However, with the passing of time, there would be less of an air of status with gout.
This is evident in 1964 with a quote from Punch.

(04:33):
“In keeping with the spirit of more democratic times, gout is becoming less upper class and is
now open to all.
It is ridiculous that a man should be barred from enjoying gout because he went to the wrong
school.”
Personally, I have not experienced gout, but from the sounds of it, I don't think of it
as an enjoyable experience.
It actually sounds pretty uncomfortable.
So what actually causes gout?

(04:53):
Gout occurs when urate crystals accumulate in the joints.
These crystals cause pain and inflammation during a gout attack.
Now, these crystals are not the valuable crystals like diamonds.
No, these crystals are not the ones you want, as they cause pain.
Speaking of valuable, you should check out our merch store, merchanatomy.com, for great
designs and great merch.
We don't have crystals, but we also won't give you gout.

(05:15):
Anyway, back to what causes gout.
Uric crystals are caused by high levels of uric acid in the blood.
Uric acid is a naturally occurring substance.
This happens when our body breaks down purines.
Purines are naturally occurring chemicals in some foods.
When your body produces too much uric acid or your kidneys excrete too little in the urine,
you can end up with sharp little uric crystals in the joints, which are not fun.

(05:37):
There are also some risk factors when it comes to developing gout.
These include diet.
Having a diet high in red meat, certain seafoods, as well as beer consumption,
can increase uric acid levels and increase the risk of gout.
Family history of gout.
Those who have family members with gout are more likely to develop the condition.
Age and sex.
Gout primarily affects men.
This is in part due to women having lower uric acid levels until menopause.

(06:00):
After menopause, it's a free-for-all.
Women's uric acid levels become similar to men's.
Men develop gout much earlier than women.
Normally developing gout between the ages of 30 to 50 years of age,
women normally develop signs and symptoms after menopause.
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How do we actually diagnose gout?
Doctors will begin the journey to diagnosis with an assessment of the symptoms

(06:23):
and by examining the affected joints.
Tests can also be done to help diagnose gout.
These tests include blood tests.
Blood tests can measure the levels of uric acid in the blood.
However, these can be misleading as some people with high levels of uric acid in the blood
may never actually experience gout symptoms
and people with low levels in the blood may experience gout symptoms.
Joint fluid test.

(06:43):
This is where fluid is taken out of the joint space.
This can be looked at under a microscope to see if there are uric crystals.
Imaging.
This can either be through an ultrasound or x-rays to detect the presence of Tophi,
which again are the uric crystals.
We'll get right into the symptoms and presentation right after this little break.
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(07:15):
What symptoms might you have if you have gout?
Well, gout symptoms normally come on suddenly and are quite intense when they appear.
These symptoms include intense joint pain.
Gout and gout pain most often happens in the big toe.
However, gout can happen in any joint.
It often happens in the ankles, knees, elbows, fingers, and wrists.
Pain with gout is normally most intense in the first 4 to 12 hours.

(07:37):
It also often comes on at night.
Lingering discomfort.
After the initial pain is gone, discomfort can continue for a few weeks.
With subsequent attacks, the pain lasts longer and can have more joints affected.
Inflammation and redness.
The joints affected can become swollen, tender, red, and warm.
Limited range of motion.
With progression of gout, the affected joints may not be able to move normally.

(07:58):
What complications should a doctor be aware of when it comes to gout?
A doctor should be aware of several complications when it comes to gout.
These include recurrent gout.
Some people who have gout will only ever experience it once.
However, others will experience symptoms several times a year.
I know, that does not sound fun.
Medications can be used to prevent these attacks.
When not treated properly, these attacks can lead to erosion of the joint and destruction of the joint.

(08:20):
Advanced gout.
When gout is left untreated, this can lead to tophi nodules.
These are under the skin deposits of urate crystals.
These can develop in several areas, such as the fingers, hands, elbows, feet, and even the Achilles tendons that are up the back of the ankle.
Usually, these aren't painful.
But, during a gout attack, they can become tender and swollen.
So, they become painful during a gout attack.

(08:43):
Kidney stones.
Urate crystals can also accumulate in the urinary tracts of those with gout.
This causes kidney stones.
These can be notoriously hard to pass.
How do we treat gout?
Well, there are several ways we can manage and treat gout.
One of these methods is through medications that manage the flare-ups.
These include non-steroidal anti-inflammatory drugs.

(09:03):
These are known as NSAIDs or NSAIDs.
These are medications like ibuprofen and aspirin that help to manage the pain and inflammation.
Some of these are over-the-counter.
Others are prescription-only.
Colchicine.
This is an anti-inflammatory medication recommended for gout that helps to manage pain.
Corticosteroids.
These are steroid medications that can help to control the inflammation and pain associated

(09:24):
with gout.
There are also medications that can be used to help block gout complications.
These include medications that block uric acid production.
These help to limit the amount of uric acid your body makes.
These medications include febuxostat and allopurinol.
Medications that improve uric acid removal.
These medications help improve the kidney's ability to clear uric acid.
An example of these kind of medications is probenecid.

(09:47):
Doctors may also recommend changes to the diet.
These include limiting alcohol consumption, especially beer and hard spirits.
Limiting organ meats.
Reducing your intake of pork, beef, bacon, and lamb.
Limiting game meats.
Reducing your consumption of anchovies, sardines, herring, mackerel, and scallops.
As all of these foods are high in purines.
Are there any famous people who have or have had gout?

(10:07):
There are several people throughout history that have had gout.
These include King Henry VIII.
Yes, the one that had all of the wives.
He was once an athetic man.
But with age, he developed gout.
Limiting his mobility.
There is also David Wells.
He was a famous left-handed pitcher in the Toronto Blue Jays and the New York Yankees.
In his autobiography back in 2003, he explained that the pain was as if somebody was drilling a hole in his big toe.

(10:32):
He had gout in both of his big toes, which obviously would have been very uncomfortable.
There are many cases where gout is mentioned in movies and TV shows.
However, most cases it is inaccurately portrayed or really treated as a case of something to be embarrassed about.
Medical conditions are not something we should be embarrassed about.
We should be seeking help and treating them as something that just happens in life.
We can't really prevent some medical conditions when they are genetic.

(10:54):
But we can focus on changing dietary and lifestyle factors when they affect it,
as well as utilising medical care to help prevent the condition from worsening.
There are not really any foundations that focus solely on gout,
but you can also go to any arthritis foundation as gout is considered part of the arthritis family.
If you want to check out the sources, social media links, or any other links, you can head to anatomyofillness.com.
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(11:15):
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Otherwise, stick around for the next episode.

(11:41):
Medical students hate the test on kidney stones. It's the hardest pass.

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Episode 54: Gout - A Fashionable Disease?

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