gout

gout is a metabolic disorder characterized by excessive concentration of uric acid in the blood occasioning the deposition of sodium urate in the joints — particularly the extremities, and notoriously the great toe. Joints become swollen and very painful (‘like walking on my eyeballs’, remarked the Revd Sydney Smith, himself a sufferer). Chalky deposits called tophi (routinely likened to crab's eyes) often form around the joints and under the skin, especially of the ear. Thomas Sydenham, the illustrious clinician and another sufferer, gave the classical description of gout in the 1670s. The parts affected, according to Sydenham, became ‘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’. By the eighteenth century different kinds of gout were distinguished. The classic swelling of the toes, heels, ankles, and wrists was labelled ‘regular gout’. Then there was ‘irregular gout’ (also called ‘visceral’, ‘metastatic’, or ‘repelled gout’) — gout which, failing to be expelled in the standard way, allegedly rebounded from the extremities to the vital organs — head, brain, liver, heart — where it was judged more ominous. A third type was ‘flying gout’, where the pain flitted, apparently randomly, around the body.

Greek medicine had understood gout as a humoral disease, and the Hippocratic aphorisms inter alia noted that eunuchs do not get gout; nor women, unless their menses be stopped; nor even youths, till they indulged in coitus. Gout, in other words, was a disorder of mature, sexually-active males.

The sixteenth-century iconoclastic Swiss physician Paracelsus repudiated humoral thinking and sought a chemical explanation. Later developments supported Paracelsus' general outlook. In 1776, the Swedish chemist, Karl Scheele, isolated uric acid, and in A Treatise upon Gravel and Gout (1793), Murray Forbes speculated that gout was attended by an excess of uric acid. Four years later, William Hyde Wollaston obtained uric acid from a gouty tophus. And the victory of the theory was assured when, in 1859, Alfred Garrod tendered his classic analysis. In a normal healthy person, he argued, uric acid is excreted in the urine; if that process be interrupted, deposition of uric acid occurs in the form of urate of soda. Not least, Garrod devised an effective clinical test — the thread test — for uric acid. His The Nature and Treatment of Gout and Rheumatic Gout (1859) proved a milestone in the scientific understanding of the disorder.

Gout became one of those body-disfiguring diseases that acquired a distinctive personality, so much so that it could even be regarded as a desirable acquisition. It was widely viewed as exclusive to the upper classes, and therefore a mark of a good breeding, wealth, social status, and cultural superiority. ‘Gout is the distemper of a gentleman’, insisted Lord Chesterfield in the mid eighteenth century, ‘whereas the rheumatism is the distemper of a hackney coachman.’ ‘Gout loves ancestors and genealogy,’ declared Sydney Smith, ‘it needs five or six generations of gentlemen or noblemen to give it its full vigour’. Hence, like melancholy in the Renaissance or tuberculosis in the Romantic era, gout achieved a social cachet.

More singularly, perhaps, gout assumed an identity, amongst doctors and sufferers alike, as a ‘healthy’ disease which protected sufferers against the depredations of worse diseases. ‘I have so good an opinion of the gout’, remarked the long-suffering Horace Walpole, ‘that when I am told of an infallible cure I laugh the proposal to scorn and declare that I do not desire to be cured … I am serious … I believe the gout a remedy and not a disease.’ For that reason, the apparent incurability of gout paradoxically caused no problems. If gout was indeed truly protective, then a cure might be worse than the disease.

The theory underlying such views was that gout was a healthy response through which a strongly constitutioned body attempted to divest itself of morbid matter by expelling it to the extremities, like the big toe, where it could do no harm. Hence, though a chronic disease, it was at bottom a symptom of basic good health. The poet William Cowper congratulated a friend on becoming gouty, ‘because it seems to promise us that we shall keep you long.’

Gout thus affords a good instance of what Susan Sontag has called ‘disease as metaphor’, one laden with meanings that transcend strict medico-scientific bounds.

Gout is still with us, but rarely in its florid form: an excess of uric acid in the blood can be recognized and controlled by drugs which diminish its excessive formation or enhance its deficient excretion — either of which may account for the excess. The link with affluence has some foundation, since a high protein diet can be a factor; uric acid is a breakdown product of purines, which are essential body constituents — for example of DNA. Purines are abundant in a protein-rich diet, and both ingested and internally synthesized purines contribute to the turnover which produces uric acid; so a high intake combined with subnormal ability of the kidneys to handle the load can cause excess in the blood.

Roy Porter

Bibliography

Copeman, W. S. (1964). A short history of the gout and the rheumatic diseases. University of California Press, Berkeley, CA.
Sontag, S. (1978). Illness as metaphor. Farrar, Straus and Giroux, New York.