When gout was first described by the Greek physician Hippocrates (460 B.C.-377 B.C.), it was believed to be a status disease that ran in noble families. In many cases, that was true. Charles V of Spain had it, as did his son, Philip II. Other famous sufferers were the elder and younger William Pitt, Benjamin Franklin and his son, William, Alexander the Great, Charlemagne, Martin Luther, John Wesley, Dr. Samuel Johnson and Johann Wolfgang von Goethe.
Gout is a type of arthritis characterized by disturbance in the body's production of uric acid, a breakdown product of the body's waste which is discharged mostly in the urine. The sources of uric acid range from diet to the body's normal breakdown of cells. When the disease is present, the body is slow to release uric acid (underexcretion) or improperly metabolizes protein, resulting in an excessive concentration of uric acid in the blood (overproduction). Either way, uric acid crystals form around joints, often on a single joint such as the big toe, causing pain and swelling. After numerous attacks, a joint may become permanently deformed, and the risk of damage to the kidneys by crystals forming into stones is increased.
In early times, it was thought that the burden of officeholding or professional life took its toll on the high and mighty, resulting in gout. In reality, high living, while not causing the disease, often predisposed the elite to painful attacks. Overindulgence in wines, malt liquors and meats such as kidney or liver (which produce the proteins that induce the highest concentrations of uric acid), combined with sedentary living, eventually were pinpointed as aggravating factors.
It was the pain of the disease that baffled early victims. Often it starts without warning in the middle of the night, making it difficult for the individual to find a comfortable position to sleep. The pain (usually in the big toe, sometimes in the knee and ankle) can be so intense that the victim is unable to stand on the affected foot or bear the weight of bedclothes on it. A fever may be present. While the attack usually subsides after a few days, it can last as long as several weeks, and may recur. The word gout is derived from the Latin gutta, meaning drop. Early medical officials believed that a decrease in one of the four body humors (blood, phlegm, black bile, yellow bile) precipitated symptoms.
But they paid more attention to relieving pain. Hippocrates stressed a diet that was thought to keep the body humors in balance. In more serious cases, sexual activity was suspected as inducing attacks and castration was proposed. Hippocrates reasoned that the disease was absent in eunuchs, youths who had not experienced sexual intercourse and pre-menopausal women. Other remedies focused on purgatives, under the assumption that flushing out the system would relieve the pain. And when all else failed, stopping the flow of the blood to the affected joint would be attempted by burning the exterior of the adjacent veins with lighted raw flax.
By the 16th century, however, such heroic therapies decreased. One distasteful remedy was for the victim to consume a meal of roast goose stuffed with chopped kittens. Ben Franklin's prescription was much simpler. "You inquire about my gout," he wrote to Alexander Small from Paris on July 22, 1780. "Finding one night that my foot gave me more pain after it was covered warm in bed, I put it out of bed naked; and perceiving it easier, I let it remain longer than I at first designed, and at length fell asleep leaving it there till morning. The pain did not return, and I grew well."
Hydrotherapy was widely employed in the 18th century as a pain reliever, especially in high-class resorts in Baden-Baden, Germany, and Bath, England.
After 1848, when English physician Sir Alfred Garrod identified uric acid as the critical factor in gout, medical researchers slowly had other insights into the disease. Professor Emil Fischer of Berlin won the Nobel Prize for Medicine in 1902 for his work on proteins and their relation to gout. A half century later, a byproduct of research on penicillin brought about agents for treating the disease. And other drugs would follow to limit the production of uric acid, to speed up its excretion and to ease the duration and pain of an attack. Today, the newest class of agents to treat gout are various nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and aspirin-like products.
Yet gout has not been cured in the sense that it can be eliminated by taking certain drugs or maintaining a strict diet. It can be controlled, once precise knowledge about the patient is well-established. For example, some cases arise as a complication of kidney disease. Others are believed to be caused by an inherited chemical anomaly that increases uric acid. Diets rich in taboo food and drink may precipitate an attack, but not always.
Gout is most common in temperate climates, especially in the spring and fall. Ninety-five percent of the nation's estimated 1 million gout cases involve men, mostly in middle age. Rarely does gout affect an individual under the age of 30, although about half of all gout victims are overweight. Some people with high concentrations of uric acid experience no symptoms.
Asymptomatic periods of a few weeks to several years may follow the initial attack, but only half of those suffering an initial attack will experience a second; once a second has occurred, recurrence is likely. And according to Current Medical Diagnosis and Treatment (1993), "patients with gout have an increased incidence of hypertension, renal disease . . . diabetes mellitus . . . and atherosclerosis, although these relationships are not well understood."
One thing that is understood is the timeliness of the recommendations of the sage Alexander of Tralles in 580 A.D.: Gout sufferers should eat little meat, drink no alcohol, and, in the event of an attack, eat the underground stems and seeds of colchicum (autumn crocus). Today, the drug colchicine, whose chemical ingredients mimic the plant's make-up, is employed to diagnose and treat the painful disease.
Thomas V. DiBacco is a historian at The American University.