Gout: The Patrician Malady 
by Roy Porter and G.S. Rousseau.
Yale, 393 pp., £25, September 1998, 0 300 07386 0
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Ideally, one should be at the peak of fitness before starting to break the heads of Scots barbarians. The Emperor Severus, who undertook this necessary task in AD 208, suffered from gout. It is daunting to think that a man gripped by a malady so exquisitely sensitive to every bump of travel should have been carried in a litter all the way from Rome to Britain, then hoisted over the Hadrian and Antonine Walls to pursue a lot of hairy predators into the Hyperborean wastes. The campaign is described in Gibbon’s Decline and Fall, which I was belatedly reading when Gout: The Patrician Malady arrived for review. Strangely this book does not mention Severus, who is surely one of gout’s great heroes, but it confirms that Gibbon himself was suffering severely from gout while writing his ‘damned thick’ books about Rome. In later life he suffered also from a testicle swollen to the size of a melon, ‘which he did his best to ignore’, as one hopes everyone else did.

Gout, the ancient podagra, has been called a disease of civilisation. According to this book a disorder traditionally linked with the cities of the West is now spreading in the more developed parts of the Third World. Yet gout seems never to be discussed in television’s endless medical programmes. No bad-tempered old men on gout-carriages are to be seen clamouring for attention in our casualty wards, or writhing in front of those over-size notices saying DO NOT GO TO THE TOILET BEFORE YOU HAVE SEEN THE DOCTOR. Gout is not even mentioned in Pears Cyclopaedia, the resident doctor in which has always had a crusty, no-nonsense attitude to those who bleat about their non-lethal and non-infective conditions, of which gout is one. Nor do Professors Porter and Rousseau tell us anything about the present-day treatment of gout, under the National Health Service or otherwise. Perhaps they should have spared a leaf or two from their 100 pages of notes and bibliography to do so.

This is a cultural history, concentrating on the 18th and 19th centuries, replete with insights into medicine, history, manners and politics; it deals also with the influence of gout on fiction, metaphor and art. One half-expects to find a rerun of the theory that it was the Earl of Chatham’s gout which cost us the American colonies. Instead, we read how gout forced the Holy Roman Emperor Charles V to abandon his proposed siege of Metz, the key to Lorraine, and probably led to his abdication. The book is warranted to expand the lay vocabulary, peopled as it is with humoralists as well as humorists, with iatrophysicists and iatromathematicians as well as phlebotomists; and there is a pervading assumption that we all know the difference between a nosologist, a taxonomist and a teleologist. If the authors have a pet word it is ‘ludic’, and a tiresome little pet it is; I felt that if I could pick up £1 for every time it is used I could winter in Marrakesh. All of which raises the question of what sort of reader the authors have in mind. There were times when, resisting an elaborate conceit or a strained analogy, I felt a snatch of Chesterton surfacing: ‘I cannot yield assent to this/Extravagant hypothesis,/The plain shrewd Briton will dismiss/Such notions ... ’ The plain shrewd Briton may well feel a drowsy numbness when faced with a sentence like this: ‘Gout also appealed to the rhetorical frame of mind, tapped into its already acculturated versions of analogy and personification by creating a new discourse of the fallen.’

But it is not all like that. Obviously the authors have a higher form of life in their sights than the plain shrewd Briton, though even the half-tutored peasant, unfamiliar with the horrors of gout, will find much of the information in these pages riveting. Gout was likened by Sydney Smith to walking on his eyeballs. It not only created fiery anguish in the big toe but caused a white precipitation at the knuckles. Horace Walpole wrote of ‘chalky rills running from the fingers’ and ‘a hail of chalkstones and liquid chalk’, as if from a burst pipe. The authors have spotted in a Sherlock Holmes story an old man ‘cram full of gout’ of whom it was said that he could chalk his billiard cue with his knuckles.

Relief from gout was sought in many ways, often heroic, sometimes idiotic. The New Testament injunction ‘If thine eye offend thee, pluck it out’ must have caused many sufferers to wonder whether the big toe would be better struck off. The feet could be plunged in icy water or boiled horse dung, or even plunged into a fire burning in a hole in the ground (a method recommended by the sorely-tried slaver, Thomas Phelps, on the Barbary coast). The affected part could be scourged with a whip of nettles or painted with caustic; or tiny bonfires of moss could be started in strategic parts to drive the pain elsewhere. As an alleviating drug, colchicum enjoyed a long popularity, and there were any number of quack pills on the market. The rich, we are told, expected to have their gout reduced with medicines, preferring to take a vomit rather than undergo exercise. Part of the trouble was that there were so many forms of gout, each calling for a different treatment; the range ran from flying gout to windy gout, from recurrent, retrocedent, irregular and suppressed gout to imaginary gout. Wilkie Collins claimed to have gout in the eyes, curing himself of gout in other places by visits to European spas. Tennyson’s gout covered a wealth of debilitations and was not helped by heavy drinking. It was also possible to be ‘gouty without having gout’.

What caused gout nobody knew. If it was an excess of uric acid, what brought on the uric acid? The disorder was hereditary, or perhaps not. Was it caused, as the Romans were not alone in surmising, by ‘making the body a larder or a cellar’ (Sydney Smith again), by venery after meals, or venery at any time? Hippocrates helpfully pointed out that eunuchs, like women, did not contract gout. Some said it was caused by too much thinking.

Not everyone agreed that gout was a malady, or a bad thing. Some saw it as Nature’s warning, or as a deliverance from worse afflictions (it was better than haemorrhoids, for instance), and had no desire to be cured of it. As this book says, it was often regarded as a life assurance, not a death sentence. Gilbert Sheldon, Archbishop of Canterbury under Charles II, ‘supposedly offered £1000 to any person who would “help him to the gout”, looking upon it as the only remedy for the distemper in his head, which he feared might in time prove an apoplexy; as in fine it did and killed him’. William Cowper congratulated a friend on contracting the disorder, ‘because it seems to promise us that we shall keep you long’. Hester Piozzi’s husband grew worried and alarmed if his gout did not return regularly.

Besides, gout was very much a mark of status. Lord Chesterfield said it was ‘the distemper of a gentleman, whereas the rheumatism is the distemper of a hackney coachman’. It attacked not only the wealthy but the creative, which meant that no man of letters could afford to be without it. Some thought it was the hallmark of genius, a view obstinately perpetuated by Havelock Ellis. In short, it was an honour to have gout and the phrase ‘the honour of the gout’ was in free use. The authors quote Earl Nugent’s apology to the Duke of Newcastle for failing to wait on him: ‘He received the Honor of His Grace’s card here, where he has been detained by the Honor of the Gout.’ For a person of the lower orders to aspire to the honour of the gout was unthinkable. Artisans and crofters did not know their luck; hard work every day kept uric acid at bay. ‘Live upon sixpence a day – and earn it’ was the cure for gout advocated by the surgeon John Abernethy.

The traffic in quack cures for gout in the 18th century well merits the description ‘Aesculapian bedlam’. But gout did not monopolise the scene. In the 1740s the gout wars were heavily overshadowed by the pamphlets of Bishop Berkeley, the philosopher-quack who urged the use of tar water, internally or externally, for everything from gout in gentlemen to glanders in horses, from taedium vitae in scholars to the vapours in women and stupidity in infants; as a healing cordial it was perhaps an improvement on red cow urine, which footmen used to bring home from the cow-houses of the capital to their mistresses. Was there, then, no sane voice ever raised in bedlam? Intermittently, yes; and one which emerged in the gout wars in 1771 was that of the fertile pamphleteer, Dr William Cadogan, who insisted that the prime causes of gout were idleness, intemperance and vexation. This not very original theory roused a predictable fury.

In the turbulent last decade of the 18th century, the authors say, ‘the gout war was being waged in a climate of mounting alarm respecting threats to the British Constitution.’ Revolution was in the air. ‘Old Corruption assailed by reformers, aristocracy threatened by liberalism; indeed, the gout debate is unintelligible unless its politics are foregrounded.’ As in these words:

In such electrically charged ideological climates it became a badge of loyalism to vindicate the ‘honour of the gout’ as supportive of the status quo and rally to the defence of its ancient constitution no less than the British. It was not hard for conservatives to descry in Cadogan’s almost Rousseauvian call for an end to high living and a grand purge of luxurious lifestyles an assault on everything English, a threat to the established constitution and a questioning of the old order.

Not hard to descry? Well, that Chestertonian jingle surfaced here. And it surfaced again in the face of an attempt to interpret the growth of early newspapers in terms of the physical excesses of gout, with news dependent on ‘acts of verbal bloating’ and the puffing of intelligence. Gout certainly enriched the vocabulary of the newspapers and of society at large. But so did those other disorders. The actors in Restoration plays rushed round crying ‘A pox on’t’ not ‘A gout on’t’ (though Lady Mary Wortley Montagu wrote: ‘People wish their enemies dead – but I do not; I say give them the gout. Give them the stone!’).

The last really gouty hero of literature, we are told, was Smollett’s Squire Bramble, with all that ‘ludic ebullience’ which is to be found in Humphry Clinker. Jane Austen admits no gouty males to her novels, not even in Bath. In George Eliot’s Middlemarch gout ‘becomes a symbol for an entire society’ and poor Dr Lydgate ends up miserably writing a treatise on the subject. The authors expected to find plenty about gout in Conrad, who suffered diabolically from the malady, but found not a word.

They also – and this is the measure of their industry – ‘searched without success in several continents’ for ‘visual representations’ of gouty women, or even one gouty woman. For reasons not wholly clear, women have always preferred to take up other maladies. The diverting illustrations which have been unearthed are subjected to relentless exegesis. One of them, a satirical print showing a gallant major with an apparently bursting bladder, is said to be of ‘gout’s old ludic vintage’, a ‘urinating irony’, and carries the additional gloss ‘Ludos (play) and Eros (desire) mix here through micturition.’ A reliable fount of gouty jokes was Punch (which, by the way, was not founded by Thackeray). The jacket of the book features James Gillray’s cauchemar study of a black devil clawing at a vastly swollen big toe. This could stand as a symbol of the 18th century, which saw, as the authors put it, ‘the high noon of gout’.

Roy Porter, who teaches at the Wellcome Institute in London, is uncommonly lucky to have that Institute’s grand library at his feet. But, as one might have guessed, ‘perhaps the largest collection of primary material about gout in the world’ is housed in Houston, Texas, and the authors are suitably indebted to it. Unlike poor Dr Lydgate, who set out to write his definitive treatise on the malady in the throes of world-weariness and disillusion, they have tackled their multiple themes in a positive, scholarly, all-questing and all-questioning spirit, keeping their amusement at all times under control. Again unlike Dr Lydgate, neither of them appears to suffer from gout.

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