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No apology is needed for writing the history of a malady and its cultural representations. It is now agreed that understanding ailments in historical context requires more than epidemiological and clinical expertise. Discourse about disease goes beyond recognizing the powers of pathogens: it may be freighted with associations like disorder and dirt which embody value judgments and emotive charges.
What diseases are and where their boundaries lie are matters of controversy. Disputes rage as to whether pregnancy, menopause and ageing should be viewed as pathological states. There is still no consensus as to what is to count as disease, as distinct from sickness, affliction, weakness or sin: is it a state of mind as well as a process of Nature? -- a point underlying Alexander Pope's reference to 'this long Disease, my life'. Morbid processes involve certain natural manifestations, but they don't qualify as diseases until so denominated by medicine, science and society. Conditions like neurasthenia have come and gone; the same may happen with RSI (repetitive strain injury) and ME (myalgic encephalomyelitis, 'yuppie flu' or chronic fatigue syndrome). Diseases, to employ Rosenberg's helpful expression, become diseases for us only when they are 'framed'.
And even once particular diseases have been framed and named, disputes persist respecting what they mean to sufferers, to employers and insurers, to law courts and the community at large, as is obvious from the fact that terms like leper possess solid scientific meanings while simultaneously serving as stigmas ('moral leper'). AIDS has tragically underlined all these truths through the epidemic of infamous victim-blaming cliches like 'gay plague'. One consequence of these verbal imbroglios has been the divergence between arcane professional jargon and the lay languages of medicine.
In recent years, literary scholars, biographers, psychohistorians and other humanists have been drawing attention to illness experience and body awareness as facets of identity and the thread of the narration of one's life. Pathography may be the key to biography:
-- I'll tell it, cried Smelfungus, to the world.
You had better tell it, said I, to your physician was Laurence Sterne's comic suggestion -- at the expense of the splenetic surgeon and writer, Tobias Smollett, about whom we have much more to say below in Chapter 7 -- that a life could be read through diagnosis of its morbific humours. It is needless to labour this point: decoding disease is integral to the understanding of culture, society and biography.
But why a book about gout? Is that not (one anticipates the objections) a rather trifling condition? Perhaps comic, a topic tailor-made for the belles lettres of a bygone age but not for sober medical history. Nowadays gout provokes the enormous condescension of slimline political correctness. Wasn't it, surely, a disease of the ancien regime and the Old World? Didn't the idle and licentious bring it upon their own heads, or rather feet, by outrageous overindulgence, while they shrugged off responsibility by the solemn palaver of dignifying their condition as 'the gout', as if it were some boon companion or noble foe to whom it was a great 'honour' to fall martyr? He and his physician 'were very well satisfied with the proceedings of the Gout', Edward Gibbon explained to his step-mother: 'he had behaved like a fair and honourable Enemy'. Recycling that stock simile, the Revd Sydney Smith quipped that gout was 'the only enemy that I do not wish to have at my feet'. By means of this grim rigmarole, gout's sting was drawn, just as, in Shakespeare's time, one had to jest with death. 'I enjoy all the dignity of lameness,' bantered the gouty Samuel Johnson, making a virtue of necessity. 'I receive ladies and dismiss them sitting. Painful pre-eminence.'
Gout thus yields medical anecdotes and biographical insights. Does it offer more? We believe so, as we document in these opening chapters and in more theoretical form in Chapters 11 and 12. For one thing, the glaring neglect of gout draws attention to biases in medical history. Scholars have chiefly studied lethal, epidemic diseases: plague and smallpox, yellow fever and typhoid fever, tuberculosis and AIDS. Such afflictions invite cathartic involvement: we share the horror, we pity the victims. But this concentration on killer epidemics arguably creates an imbalance that needs redressing. For the diseases causing most pain have not been apocalyptic; sickness has typically been less like the Holocaust than an interminable succession of stumbles and muggings -- but no less agonizing for that. Historical pathology mainly consists of chronic conditions, attacking the musculoskeletal system, the respiratory system, the nervous system, and of course the brain -- not in themselves fatal but incurable, typically debilitating, sometimes crippling and inordinately painful.
Gout falls into the category of non-infectious, non-lethal ailments. Though widely associated with the olden days -- with Christmas-card scenes peopled by ruddy-faced Mr Pickwicks drinking toasts -- in truth gout is very much still with us; it continues to threaten males in the developed world, and globally it is spreading.
During the last century and a half, epidemic disorders have been receding, resulting in the West being worse afflicted with chronic and degenerative disorders -- partly, of course, consequential upon greater longevity. Among the diseases besetting large numbers of people today, articular ailments are highly prominent: arthritis, rheumatism, sciatica, gout and related conditions. Their neglect by historians appears rather myopic.
We also have another goal in this book: to demonstrate why the 'gout diagnosis' triumphed over its competitors. In this respect our project resembles the explanatory agenda of those contemporary histories of science aiming to show why particular theories or paradigms win out over others. Gout had its competitors in dropsy, ague, fever, inflammation, sciatica, vapours, spleen, all the class of rheumatics and many others. Until approximately the mid-eighteenth century it remained such an unstable medical condition that it bled into other diagnoses with such seeming ease that these maladies were to a degree interchangeable.
Yet somehow the gout diagnosis prevailed and established itself. The tensions and resonances implicated in the 'somehow' constitute a major portion of this book. By the nineteenth century gout had installed itself. The upper-crust Regency gentleman who assumed he would in due course become 'gouty' as part of the normal life-cycle made a cultural assumption whose lineage requires unravelling and decoding. In addition to chronicling gout's internal medical histories we attempt to describe the strategies of rhetorical persuasion and figurative and visual representation of those constructing its rise and fall. Gout's cultural representation constitutes one focus of our task, as gout entailed much more than a torment in the toe, painful though those attacks were.
Gout afflicts the joints of the extremities, classically the great toe. They become swollen and inordinately painful (it felt, remarked Sydney Smith, 'like walking on my eyeballs'), and tophi sometimes form, chalky concretions routinely likened to crab's eyes, which, unlike the swellings, are painless. The paroxysm was described by the illustrious seventeenth-century clinician Thomas Sydenham, himself long-suffering. 'The regular gout generally seizes in the following manner,' he recorded:
The patient goes to bed and sleeps quietly till about two in the morning, when he is awakened by a pain which usually seizes the great toe, but sometimes the heel, the calf of the leg or the ankle. The pain resembles that of a dislocated bone ... and this is immediately succeeded by a chillness, shivering and a slight fever. [The pain] grows gradually more violent every hour, and comes to its height towards evening, adapting itself to the numerous bones of the tarsus and metatarsus, the ligaments whereof it affects; sometimes the gnawing of a dog, and sometimes a weight and constriction of the parts affected, which become 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. [Things worsen] till after twenty-four hours from the first approach of the fit ... the patient is suddenly relieved ... And being now in a breathing sweat he falls asleep, and upon waking finds the pain much abated, and the part affected to be then swollen; whereas before only a remarkable swelling of the veins thereof appeared, as is usual in all gouty fits.
It has been recognized since the nineteenth century that gout is brought on by an abnormally high concentration of uric acid in the blood (hyperuricaemia), which provokes deposition of sodium urate in the joints, either through increased synthesis of uric acid, or through decreased capacity of the kidneys to excrete such acid. Hyperuricaemia may also occur for other, extraneous reasons, for example blood diseases, producing 'secondary gout'.
Not in itself harmful, uric acid is normally absorbed in the bloodstream. But under adverse circumstances it may escape and crystallize, forming monosodium urate crystals in the sinovial fluid and so creating inflammation. It still remains unclear why this occurs predominantly in joints, most commonly in the feet or knee. Various clinical manifestations distinguish gout from other joint diseases. Unlike most arthritic complaints, the great majority of patients are male -- ever since the Hippocratic writings it has been observed that gout rarely develops in women before menopause. The first attack typically occurs in middle age. About half the sufferers develop tophi; kidney stones are common. Though the historical incidence is impossible to quantify, contemporary studies suggest that up to one in a hundred males in Europe and North America may be disposed to gout.
There have always been various therapies. Some are essentially prophylactic. Dietetic attempts to prevent or treat the condition have been based on belief in the virtue of moderation and the supposition that gout is caused by rich food and alcohol. Among treatments, colchicum in the form of extracts from the bulb of the meadow saffron (Crocus autumnale) was known from Antiquity, though it came into widespread use only around 1,800. It is highly effective in relieving the acute attack.
In the 1910s, cinchophen was introduced. Being not only effective in the acute attacks but, unlike colchicine, also an analgesic, cinchophen virtually replaced colchicine until it became evident in the 1930s that it caused liver damage. Colchicine returned. Two pharmaceutical breakthroughs date from 1951. Probenecid was found to accelerate excretion of uric acid; the frequency of gout attacks diminished and tophi shrank. The other discovery was phenylbutazone, with therapeutic effects similar to cinchophen. It proved toxic, however, particularly hindering blood-cell formation in the elderly. Allopurinal arrived in 1963. That drug lowers uric-acid levels and is effective in renal failure, also decreasing uratic kidney stones. Though acute attacks are thus now more treatable, gout remains incurable; nor can its initial onset be predicted or prevented. Moreover underlying trends are not encouraging, in view of the protein- and fat-rich diets now typical of Western populations. This is borne out by studies revealing highish uric-acid levels and tendencies towards hyperuricaemia. American surveys have found that executives have higher urate concentrations and a greater incidence of hyperuricaemia than blue-collar employees. There seem to be links between hyperuricaemia, hypertension and obesity, findings underscoring the traditional gout profile.
Whatever the First World situation, occurrence of gout is rising worldwide, as a consequence of the Westernization of diet and habits. Though rural Third World peoples have suffered from various arthritic conditions, they have never been gout-prone. There is no evidence till recently of gout in Africa, in South America or in Asia. In 1952 it was said to be unknown in China, Japan and the tropics, and rare among blacks. But non-Western peoples are now experiencing a rising incidence, as a result of 'improved' diets containing higher proportions of fats and proteins. Studies in Tokyo in the 1970s showed uric-acid levels to be the same as in Caucasian populations, and gout in Japanese men has increased. In South Africa the lowest uric-acid values are found in tribal populations, and the highest levels, equal to those of urban whites, in Soweto. Numerous 'diseases of civilization' are currently being exported to the Third World.
So gout cannot be shrugged off as if it were a trivial complaint, an archaic disease, an ailment of the elite, a condition inconsequential because self-inflicted. Gout has been, and remains, a major cause of human suffering, and for that reason it is worthy of attention. Yet it is also, as this book explores, an intriguing example of a malady whose very specification has been marked out with medical, cultural and social meanings. Gout early acquired a personality.
Most spectacularly, gout's ascribed characteristics have been associated with the great and their glamour. The following chapters will probe its mythologies with respect to consumption and luxury, situating it within debates over the relations between wealth and health, civilization and disease. Prophets and politicians have always given medical events moral meanings, changing morbidity has been seized upon as a prime symptom of social progress or pathology.
The framing, naming and blaming of disease involves many other elements, not least gender. It was always observed (or stipulated) that gout was a male condition. This may well have been the case; but it was also a conclusion entailed by models of maleness and femaleness and of the gendering of disorders. Thus, if a woman's functions were essentially reproductive, it was natural that disease would principally assail her central organ, her womb: hence hysteria. Men, by contrast, were made for action. Their diseases would more likely hit at their mobility: hence gout.
Another parameter has been rank. In medical discourse, gout has traditionally hobnobbed in high society. So pressing has been the ideological need to reinforce hierarchies of social distinction that the upper crust has even been eager to flaunt marks of debility to signal its exclusiveness -- a foible inviting satire. Gout thus affords a valuable opportunity to trace the use of illness as insignia. And the links between gout and greatness run deeper, for it has often been maintained that gout goes with genius. Such beliefs tell us about the privileges and penalties of pre-eminence within a Christian moral scheme that took suffering as a mark not just of sin but of superiority, sanctity and spirituality. The story of gout thus throws light on philosophies of disease-meaning and distribution: who falls sick, who gets which disease, and why.
A third parameter entails the metaphoric and visual heritages, less 'concrete' than those of class and gender. We show that gout, especially in its 'podagra' incarnations, has borne a particularly complex relation to the development of 'play', the homo ludens about which the Dutch historian Johann Huizinga wrote so eloquently in his classic monograph of that title (1944); and we develop this 'cultural history' and cultural profile in Chapters 11 and 12. Gout: The Patrician Malady is a book with a 'thesis' about illness and its metaphors. Almost from the start of its discursive representations gout was viewed in ludic -- playful -- contexts: as if to suggest the internal contradictions between its chronic afflictions and basic insulation from effective calamity. Alone among diseases, gout bore this relation to play. Why so? How did the foot and the limbs become metaphorized and visualized within the tropes of play?
Study of gout is no less interesting for what it reveals about changing ideas of disease. For long, historians took little interest in the history of disease theory, for it appeared easy to posit the progress over time from error to science, from supposedly vague, verbalizing conceptions of sickness (Greek humoralism) to 'specificity'. The new accent on anatomy and physiology fostered by the Renaissance; the mechanical philosophy; Enlightenment taxonomy and nosology; early nineteenth-century pathological anatomy; the deployment of the microscope in the laboratory; the triumph of bacteriology -- all such developments appeared to reveal the true 'scientific' nature of disease and to lead to identifications of specific diseases: it might be called the transition from 'dis-ease' to 'disease', and from 'Disease' to 'diseases'. Armed with Koch's postulates, the twentieth century dawned with the hope of finding the micro-organism that was the cause of each and every individual disease, the vaccine that would prevent it, and the 'magic bullet' to cure it. Books with titles like Microbe Hunters and Virus Hunters reinforced Whiggish recitations of the advance of medical science.
But, in truth, the definition and understanding of disease remain contentious to this day: the rancorous row as to whether HIV is the cause of AIDS is only the most spectacular instance nowadays of profound uncertainty. More generally debates as to whether it is possible to be sick without being diseased or to have a disease without being sick still carry major theoretical and practical implications. Doctrines of susceptibility and immunity are highly intricate and, some would say, inherently question-begging. And, in the end, who has the right to pronounce someone ill: the sufferer, the physician or society?
On top of this, the crossing between mind and body in sickness remains a minefield. How far may disorders be thought psychogenic or at least to have a psychosomatic component? Not least, larger questions loom about the organism: what is to count as healthiness and what as sickness? what is 'normal', what 'pathological'? It is no easy matter to judge which biomedical events truly help or harm: is fever a disease, a symptom or the body's (and so Nature's) way of fighting sickness?
As this book will demonstrate, such vexed questions have been endemic to attempts over the centuries to define or design the disease called gout. Was gout to be envisaged as an occasional event ('gutta' means a 'dropping', that is of matter from the body's vitals to the extremities), or was it an underlying fate (being gouty), or was it a disease in the sense of a causal agent? Was it an injury to the body, or a bodyguard, the system's attempt to expel a threat? What were the relations between gout (or goutiness) and the broader health or sickness of the organism and its constitution?
These questions have prompted disparate answers from sufferers or their physicians, from regulars or irregulars. And such responses have hinged upon wider, extra-medical doctrines respecting order and harmony, good and evil, and pervasive beliefs about the economy of Nature, the purposes of Providence and the meaning of life, beliefs articulated in the West within the frameworks of Classical metaphysics and Christian eschatology.
The point of raising such issues is not to challenge the reality of gout or to deny that modern scientific medicine has advanced understanding and provided relief. Old ideas about gout cannot, however, be understood in isolation from wider belief systems; and in certain respects the models and metaphors buoying up those beliefs have continued to shape scientific theories in the twentieth century: much vintage metaphysical port has been poured into new scientific bottles.
Finally, it may be helpful to clarify the relations between gout and other joints diseases that will subsequently be mentioned only in passing. 'Arthritis' is the generic medical term for disorders producing swelling in the joints and pain in the limbs, and 'rheumatism' in lay parlance describes assorted pains associated with the joints and bones. Modern disease classifications distinguish gout from rheumatoid arthritis, osteoarthritis and certain more unusual conditions, such as ankylosing spondylitis, a degenerative syndrome in which the whole spinal column becomes enclosed in a bony casing. Palaeopathological and textual evidence indicates that such diseases of the joints have been present throughout known human history.
More common than gout, rheumatoid arthritis is the major crippling illness among chronic rheumatic disorders. A systemic disease, it affects various joints -- hands, feet, hips, knees, wrists, elbows and shoulders -- with a lasting inflammatory reaction. Remissions occur, but the illness progresses to produce commonly permanent damage and deformity. Despite intensive study, its cause remains disputed.
The physicians of Antiquity delineated both gout and arthritic conditions. Soranus described a chronic arthritic state affecting people above the age of thirty-five, especially women. Perhaps the earliest known description suggestive of rheumatoid arthritis, however, is in Ayurvedic medicine, discussed in the Caraka Samhita, written in the second century AD.
In the thirteenth century, Bartholemaeus Anglicus, describing several types of arthritis, stated that 'one form of the disease is worse for it draws together tissues and makes the fingers shrink and shrivels the toes and sinews of the feet and of the hands'. Only later, however, did the differentiations standard today begin to be drawn. Guillaume de Baillou (1538-1616) and, a couple of generations later, Thomas Sydenham distinguished between gout and rheumatoid arthritis. Baillou used rheumatism not in the original sense (a defluxion of body fluid into one part) but in something nearer its modern meaning: acute joint pains (polyarthritis) independent of gout. Rheumatism, he noted, invades the whole body 'with pain, swellings and a keen sense of heat'. 'The joints are racked with pain,' he continued, describing the attack, 'so that neither foot, hand nor finger can be moved without pain and protest'. Those who suffer from rheumatism, 'unless they take care of themselves, can scarcely hope to escape chronic arthritis'.
Sydenham, who pioneered the nosological idea of a 'natural history of diseases', established that rheumatism and gout were different diseases. He offered a clinical description of acute rheumatism in his Methodus curandi febres (1666):
It begins with shivering and shaking, and presently heat, restlessness and thirst; and other symptoms which accompany Fever. After a day or two, and sometimes sooner, the Patient is troubled with a violent Pain, sometimes in this, sometimes in that Joint; in the Wrist and Shoulders, but most commonly in the Knees; it now and then changes places, and seizes elsewhere, leaving some redness and swelling in the Part it last possessed ... When this Disease is not accompanied with a Fever it is often taken for the Gout though it differs essentially from that, as plainly appears to anyone that well considers both Diseases.
Sydenham believed rheumatism had affinities to scurvy and other cachectical disorders suggestive of constitutional maladies. An admirer of Sydenham, the great Dutch physician Herman Boerhaave (1668-1738), penned a clear delineation of rheumatism ('a disease ally'd to the Gout and the Scurvy which is very common in England').
From the seventeenth century, evidence accumulated establishing the specificity of gout as a distinctive joint disorder. In 1776 the Swedish pharmacist Carl Scheele discovered an organic acid in urinary concretions which he called lithic acid. From 1848 the London physician Alfred Garrod devised tests for detecting uric acid in blood. Garrod's view that acute gout results from the precipitation of sodium urate in a joint was later confirmed. Over the centuries gout thus became recognized as distinctive from other arthritic conditions, which in turn began to be linked with infections and fevers. In the nineteenth century, both tuberculosis and syphilis were said to cause arthritic conditions, as were scarlet fever, pneumonia, dysentery and brucellosis.
Exemplifying the new French preoccupation with disease localization, rheumatoid arthritis was mapped out early in the nineteenth century as a specific condition, following a clinical description by Augustin Jacob Landre-Beauvais, who dubbed it 'primary asthenic gout', distinguished it from gout proper and significantly deemed it a disease of the poor. Meanwhile William Heberden and Benjamin Brodie described long-term, chronic, debilitating diseases affecting multiple joints, including hyperextension and other deformities of the fingers.
A cacophony of names continued to denominate what we recognize as rheumatoid arthritis: rheumatic gout, chronic rheumatic arthritis, goutte astenique privative, rheumatismus nodosus, rheumatoid osteoarthritis and others. In 1859, Garrod argued that 'rheumatoid arthritis' should be used to 'imply an inflammatory affection of the joints not unlike rheumatism ... but differing materially from it'. 'Rheumatoid arthritis' did not become standard usage until the twentieth century: in 1941 the name was recognized by the American Rheumatism Association. Pathognomic signs like tophi and chemical evidence framed gout relatively early; demarcating rheumatoid arthritis (or polyarthritis) was, by contrast, more difficult. For its part, osteoarthritis became recognizable by a process of exclusion and was awarded its name in 1888 by the Bath physician, John Kent Spender. The modern distinction between rheumatoid arthritis and osteoarthritis was established by Archibald Garrod.
Around 1900 it became widely held that a poison-generating focus of infection could produce toxic elements leading to arthritis. This 'focal infection' hypothesis -- popular for explaining other conditions, including insanity--led physicians to recommend tonsillectomies, appendectomies and so forth in hopes of halting the development of arthritis. In 1940, however, researchers identified a substance similar to an antibody circulating in the blood of arthritis sufferers and which they named the 'rheumatoid factor'. Its nature remained obscure until it was shown that a group A streptococcus caused rheumatic infections.
In the light of such disease descriptions and definitions that tend to dissolve like clouds it is crucial to avoid prematurely hypostasizing past accounts as though they will map precisely on to our present disease categories. Retrospective diagnosis risks sacrificing historical understanding of past medical mentalities. Such terms as 'gutta' should not automatically be conflated with our disease entity 'gout'. Historically 'gutta' meant the process of flowing or dropping; mention of 'gutta' thus indicated that peccant humour or morbific matter had accumulated in a part or a joint. It described a disease process rather than a disease thing. The same applies to 'rheum' and to 'dropsy'. Similarly, though we may be confident that such terms as 'podagra' and 'gonagra' commonly designated cases of gout as would be diagnosed by modern medicine, their referent was not to 'gout' in the modern sense, but rather to the site of the trouble: podagra meaning a disorder of the foot, gonagra that of the knee.
The following chapters will show the remarkable range of conditions and metaphors referred to by the term 'gout': not least, diseases of the internal organs and the head which have nothing to do with modern hyperuricaemia-based theories. We might, of course, choose to regard this as evidence of the ineptitude of pre-scientific medicine. But it is better seen as epitomizing earlier disease theories, which viewed disorders as fluid. It also provides evidence of a pecking-order or hegemony among disease labels; some have been more 'imperialistic' than others. Habent sua fata libelli: the same holds true for diseases. What follows is the history of one such destiny.
Excerpted from Gout by Roy Porter Copyright © 1998 by Roy Porter. Excerpted by permission.
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|List of Illustrations|
|2||The Classical Inheritance||13|
|3||Prometheus's Vulture: The Renaissance Fashioning of Gout||22|
|4||Science and Sydenham||36|
|5||The Eighteenth-Century Medical Debates||48|
|6||Gout and the Georgian Gentleman||71|
|7||Smollett, Cadogan and Controversy||93|
|8||Change and Continuity, 1790-1850||125|
|9||Indian Summer: Romantic and Victorian Gout||143|
|10||Gout and Glory: Garrod and After||173|
|11||Podagra Ludens: Disease and Discourse||211|
|I||Podagra ludens: Ludic representations||211|
|II||The Lucianic and Menippean heritage||213|
|III||The rhetoric of swelling||216|
|IV||Homo ludens and the neo-Lucianic heritage||219|
|V||The metaphoric heritage||229|
|12||Gout: The Visual Heritage||248|