Gout: The Patrician Malady

  • Roy Porter &
  • G. S. Rousseau
Yale University Press: 1998. 393pp. $35, £25
Rich man's illness: gout has long been associated with the leisured classes, as seen here by Hogarth. Credit: BRIDGEMAN ART LIBRARY

Gout is a great subject for showing how the perception of illness is determined by social preoccupations. Most recently, the public's preoccupation with AIDS as a ‘gay plague’ reduced awareness of other types of transmission, just as in the past there were stereotypes of the ‘consumptive’ personality. Gout, although it is a widespread malady which causes great pain and can only be relieved, not cured, is still associated with a social profile developed most vigorously during the eighteenth century. It is an ailment chiefly associated with older males, and, by long-standing convention, with the rich.

Although Roy Porter and G. S. Rousseau note the current expansion of gout to countries where it was once little known, as a ‘disease of civilization’, they are less concerned with its modern position than its cultural heritage. Their book therefore mainly examines the work of medical theorists and the often detailed introspections of patients. Gout has a tremendous cast of characters: on the arts side there are Samuel Johnson, William Cowper, Edward Gibbon, Horace Walpole, Tobias Smollett and many more. On the science side are Francis Bacon and William Harvey (possibly), Thomas Sydenham, Benjamin Franklin and generations of Darwins.

The Greeks had been concerned about gout, though they did not distinguish it from arthritic problems. ‘Podagra’ was a suitably vague description, placing gout in its usual location, the foot, but the ailment was also suspected of mounting internal attacks, sometimes described as ‘flying’ or ‘wandering’ gout. The Greeks saw gout, like many other diseases, as due to an internal imbalance in the body, although the question of external influences was often raised.

Sydenham's Treatise on the Gout (1683), set the seal on gout's long-term definition as a disease of the wealthier classes. He also placed it as an imbalance of the constitution rather than an infectious or externally conditioned disease, holding that gout was related to luxurious living and overindulgence in alcohol. The logic of this type of analysis was that the body reacted to the morbid humours within itself by banishing them to the extremities, where they could do relatively little harm. Gout was not a fatal malady; indeed, it was believed to be a sign that the body was insulating itself against more serious illness. Nervous and sensitive temperaments, as many creative patients agreed, were likely to be most susceptible. They could also use their malady as an excuse for retreating into their sedentary work.

In 1771, William Cadogan's influential book on gout claimed that it was preventable and not hereditary, and that its predisposing causes were “excess and idleness”. Porter and Rousseau show that the current language of gout reflected the political theories of the day; the same language was applied to disorders of the body and the body politic. The higher-class theorists offered impeccably logical explanations but not much hope of a cure. Sydenham recommended opium and digestives, Cadogan concentrated on regimen. But this did not prevent gout from becoming a lucrative field for the medical profession. The whole medical armoury was tried at one time or another: heat, cold, bleeding, cupping, purgatives, and more exotic personal remedies such as boiled horse dung and oil extracted from human bones. There were also many secret remedies. Some of these included colchicum (often called autumn crocus), which is effective in relieving gout. George IV demanded it in place of the violent remedies suggested by his physicians.

Although this is a very cheerful book — ‘ludic’, to use a favourite word of the authors — it also has some of the problems common to most works that try to hammer out signs and signifiers over the centuries through the examination of stray references. This is most apparent in the chapters on the nineteenth century, where the literary manifestations are considerably less interesting than those of the eighteenth. Gout still appeared as a rich man's malady and hence a convenient shorthand for the dissipated habits of the ruling classes, but writers who endured the condition were much more reticent, leading Porter and Rousseau into much discussion of “suppressed” gout. The gouty Wilkie Collins afflicted the enervated squires in his novels with a gout-like, but nameless malady. Joseph Conrad, another martyr to gout, never mentioned it in his fiction. Neither Jane Austen nor Thackeray afflicted their upper classes with gout. Eliot's baronets are also in prime condition, and lazy mentally rather than physically. Gout was losing its imaginative hold. But gout remained a refuge for the writer, and an excuse for retreat from the world. This was particularly obvious in Coleridge and Tennyson, but also in Darwin, who named gout as one of the many ailments that allowed him to avoid society and concentrate on his books.

Sometimes the line of argument on suppressed gout, fascinating though it is, fails to convince. Admirers of George Eliot's Middlemarch will not recognize Porter and Rousseau's imaginative interpretation. They will not think of the small town of Middlemarch as antithetical to the surrounding country, but of the “movement and mixture” between them that Eliot describes; they will expect to find Lydgate the nephew, not the son, of a baronet (indeed, in Gout he appears as both son and nephew in the same paragraph); they will be irritated by the references to “Ros”, since Rosamund was never so abbreviated by her creator; they will think that the solitary comment on gout as a disease with “a good deal of wealth on its side” appears at the end of the book, not at the beginning; they will believe that Mr Casaubon was called Edward, not Isaac; that Lydgate does not retreat from medical practice to write on gout, but uses the reputation he has gained from his treatise on the subject to attract wealthy patients; and that he does not die of a possible “suppression” of gout, but of diphtheria. Perhaps the authors have not been using the standard 1874 edition, but it will be hard to convince Eliot's admirers that gout is a culminating symbol of this mighty work.

Scientific sources for the nineteenth-century, however, are more plentiful, and the scientific discussion is straightforward and absorbing. In mid-century, Alfred Baring Garrod showed how to detect uric acid in the blood, and linked it clearly with gout. Garrod was also firm on the role of alcohol. But, as the authors show, his work did not stifle the debate on how far hereditary factors were involved, nor on whether gout was treatable.

The last two chapters are not chronological but discursive, analysing the language of gout in terms of contemporary political and social perceptions and through the visual heritage. The excellent illustrations are concentrated on the eighteenth century, and reflect the comic, aristocratic and self-indulgent themes of the narrative. There is only one twentieth-century cartoon, more meaningful in the American context, again suggesting that gout is a financial boon to the medical profession.

Susan Sontag argued, at the height of the AIDS panic, that illness should be seen as a scientific category, not a cultural or moral stigma. In their brief epilogue, Porter and Rousseau argue the contrary, that social metaphors may enable the patient to cope with disease. The pain of gout was bearable because of its excellent pedigree and its apparent promise of insulation from worse maladies. Yet the book also shows how regularly, and erroneously, medical men believed that they had understood this elusive complaint. Underneath its fashionable phraseology, which the reader will appreciate according to taste, this entertaining book succeeds very well as an old-fashioned treatise on medical hubris.