Social Studies

Once the Disease of Gluttonous Aristocrats, Gout Is Now Tormenting the Masses

It can be tempting to ascribe the affliction’s prevalence to our current climate of indulgence, but that’s not the full story.

Louis-Léopold Boilly’s “The Gourmand” (19th century).
Credit...Bridgeman Images

IT HAS COME for genius and aristocrat, conqueror and king. Like a succubus, it descends at night, first as a fevered dream, then pain in darkness, the body turned rude animal, reduced to its lowest, humblest extremity: the foot, red and swollen, throbbing like a heart. You are left to hobble, if that; the flutter of a bedsheet over the distended foot is anguish enough, let alone the full weight of the body bearing down. To take a step is to see the abyss. Often the pain is concentrated in the big toe, ridiculous, stubby and chubby, Napoleonic, the fat piggy sent to market. So acute is the sensitivity of this bloated hallux — “so exquisite and lively,” in the words of the 17th-century English physician Thomas Sydenham, chronicling his bouts with the disease — that the faintest footfall of a sympathetic visitor is a gunshot straight to the nerve. The American poet and novelist Jim Harrison, writing in 1991, likened his throes to those of “a wolf with the steel teeth of a trap buried in its paw.” It will not help, at such a moment, to recall that Alexander the Great, Charlemagne, Leonardo da Vinci, Isaac Newton and Henry James reportedly suffered thus, and that you have joined, in your abasement, the noblest ranks.

The disease can be chronic (the pain goes away but may return at will) and excruciating (if not fatal), yet say its name — gout — and people snicker. It has a whiff of the powdered wig, of a time when the powerful could continue to rule the world even half incapacitated, with one grotesquely tumescent foot lolling atop a dainty cushioned stool, like some priapic cartoon. The phallic symbolism is inevitable, especially since the condition predominantly afflicts men — the 18th-century British Queen Anne, shown groaning from a gout-inflamed leg in Yorgos Lanthimos’s 2018 film, “The Favourite,” was a notable historical exception — and in keeping with the belief that attacks were triggered by wanton appetite, whether in bed or at table. In fact, genetics are most often the culprit and sex has nothing to do with it, although diet can play a part: If, in breaking down food for digestion, the body produces more uric acid than the kidneys can filter out, the excess may form microscopic, dagger-shaped crystals that stiffen in the joints and trigger inflammation. The foods most likely to contribute to these inner stalagmites are high in the chemical compound purine, among them venison and foie gras, pheasant and scallops, goose and caviar. In short, a grandee’s banquet.

As the British and American historians Roy Porter and George Sebastian Rousseau write in “Gout: The Patrician Malady” (1998), the disease, cast by some as “a quasi-deity born of the union of Bacchus and Venus,” appeared to reach epidemic proportions in 18th-century England as more people attained affluence. A 1703 treaty with Portugal flooded the market with imported wines, which were stabilized for the voyage across the sea with extra alcohol, often aged in leaded vessels — just enough lead to inhibit kidney function, if not bring down an empire. A critic of the upper classes might have found gleeful rough justice in the gouty punishment of a prosperous glutton, while the victim took solace in the pain as a mark of high status. The rich are always easier to mock than overthrow.

ImageA hand-colored 1835 copy of James Gillray’s etching “The Gout” (1799).
Credit...Historica Graphica Collection/Heritage Images/Getty Images

We might dismiss gout as a specter from a fable, which it was: In the works of the 17th-century French poet Jean de La Fontaine, Gout latches onto a poor man and then, appalled by her host’s ceaseless labor, retreats to a life of idleness in a mansion. Surely it’s a relic of a less enlightened, more hierarchical age, which we can laugh at from the safe distance of the present day. But the American cultural critic Susan Sontag warned us in the 1970s against illness as metaphor. And there is no safety: The disease has not been banished to the past, nor is it any longer the exclusive insignia of rich white men (if it ever really was). From the 1960s to the 1990s, the number of sufferers more than doubled in the United States, and that’s continued to rise. If some cases seem to confirm the notion that food is to blame — the actor Jared Leto was diagnosed with gout after gaining 67 pounds for the 2007 film “Chapter 27” — note that vegans, too, have been stricken. According to data collected by the National Health and Nutrition Examination Survey (NHANES), as of 2016, around 9.2 million American adults, 5.9 million men and 3.3 million women, were living with the disease, making up 3.9 percent of the adult population, and another 32.5 million (14.6 percent) exhibited hyperuricemia, elevated levels of uric acid, putting them at risk.

No one knows exactly what’s behind the numbers. The rich keep getting richer, but there’s been no corresponding spike in sales of historically gouty luxury foods like veal and foie gras; if anything, their appeal has waned with increasing concerns about the ethics of producing them. Red meat consumption in the United States has significantly decreased since the 19th century, recent fad high-protein diets notwithstanding, and Americans (or at least those with the privilege and resources to do so) have become more self-conscious about how and what they eat, both spawning and spurred on by a multitrillion-dollar wellness industry. Some scientists point to the dramatic rise in rates of obesity — from 13.4 percent of adults in 1980 to 42.4 percent in 2017-18, again per the NHANES — since excess weight depresses kidney efficiency, and to the likely not unrelated introduction, in 1967, of high-fructose corn syrup, which can cause the body to produce higher levels of uric acid, and its wholesale embrace in the early 1980s by the American food industry and then the world. Once gout was confined largely to Western civilization (with some outliers, like the Mongol ruler Kublai Khan); now its ravages are global.

THE GREEK PHYSICIAN Hippocrates in the fifth century B.C. knew the disease as podagra, from the roots for “foot” (pous) and “catching” or “seizing” (agra). Its modern name comes from the Latin gutta, a drop of fluid, a term first recorded in the 13th century by an English monk, suggesting that the body’s phlegm had overflowed and flooded the joint — not so far-off from the actual surfeit of uric acid. For early doctors, the question was: Is the condition endogenous or exogenous; does it come from within or without? A satirical print from 1799 by the British caricaturist James Gillray suggests both, showing a fire-snorting demon with its fangs sunk into an engorged foot. The rest of the body is unseen, irrelevant, without agency or personality. But as the British art critic Tom Lubbock noted in 2005, it’s not clear if the creature has sprung onto or emerged from the foot: “Tormentor and tormented are one,” he wrote.

Credit...bpk Bildagentur/Joerg P. Anders/Art Resource, NY.

The idea that the disease might be self-inflicted was a way to exert control over what was, once an attack started, uncontrollable, and to give the pain meaning, as a path to edification and redemption, since for centuries, sacrifice of earthly pleasures was the only relief. Premodern medical treatments — apart from colchicine, a plant extract applied by the Byzantine physician Alexander of Tralles in the sixth century and still used today — were largely ineffective: leeches, diuretic purges, poultices of fermented ox dung, ointments of boiled dog, glugs of treacle and, in one 1518 prescription, a roasted goose stuffed with “chopped kittens, lard, incense wax and flour of rye. This must all be eaten, and the drippings applied to the painful joints.” In Sydenham’s 1683 treatise on the disease, for the sudden onset of violent symptoms he recommended laudanum — a tincture of opium and alcohol — to take the edge off the pain; his own blend was steeped with saffron, cinnamon and cloves. Formulas like this helped spawn a market in patent medicines, sold out of suitcases by bamboozlers promising miracle cures. The British historian Richard Barnett has even traced a line from another Sydenham gout treatment, distilled alcohol laced with the likes of horseradish and wormwood — that is, bitters — to contemporary cocktail culture.

If gout is but a historical footnote (forgive the pun), it has nevertheless occasionally caused a tiny flutter in world events, because its victims have so often been men of power. In 1552, Charles V, Holy Roman Emperor, had to delay his siege on French-held Metz while he grappled with the disease, giving the enemy ample time to fortify the city. His armies repulsed, he slunk back to the Low Countries and, a few years later, gave up the throne. The British statesman William Pitt, first Earl of Chatham, was a fervent champion and defender of the young American colonies in the late 18th century, but when gout confined him at home, less sympathetic members of Parliament took advantage of his absence to rally support for the Stamp Act of 1765, imposing the first direct tax on the colonists, and then the infamous Townshend Acts, which taxed tea, among other goods. Revolution followed.

More recently, after Paul Manafort, the American political consultant and former campaign chairman for President Trump, was convicted in 2018 for financial fraud, he was rolled into court in a wheelchair for a sentencing hearing, his right foot in bandages without a shoe, felled by what his lawyers described as “severe gout.” Some observers suspected that this was just a ploy for leniency; Manafort ended up getting less than four years instead of the recommended 19 to 24 (three and a half years were added later for separate charges, though he was released this past May to serve the remainder of his sentence at home, because of concerns about the coronavirus). But others saw the disease’s sudden public manifestation as an emblem of our indulgent epoch. Katy Schneider, writing in The Cut, pointed out Manafort’s fondness for fine clothes — like the $15,000 ostrich-leather jacket entered into evidence during the trial, one in a series of wardrobe purchases totaling nearly $1.4 million over six years — as part of a pattern of overconsumption. Of course he got gout.

Credit...© National Portrait Gallery, London/Art Resource, N.Y.

IT’S TEMPTING TO see gout as an avenging angel, come to condemn greed and put the lie to dreams of dominion without consequences; to strip the rich of their glamour, in this age when we worship and despise them in equal measure. Imagine Bobby Axelrod, the brazen, Metallica-shirted finance god of the Showtime drama “Billions,” losing his cool over a wayward foot, limping instead of prowling through his glass penthouse. Writing of the romantic aura of tuberculosis in the 19th century, Sontag argues that, metaphorically, gout was TB’s antithesis: The gout-ridden were guilty of consuming too much, while those dying of TB were themselves consumed, eaten away from the inside (thus the disease’s popular name, consumption). Wasting away from TB was taken as a sign of elegant, otherworldly interiority, with poets considered suspect if they weighed a hundred pounds or more, and so “it became rude to eat heartily,” Sontag writes, reinforcing a strange hierarchy in which the tubercular’s hollow cheeks and haunted mien prevailed as the desired look for women, while great men “grew fat, founded industrial empires, wrote hundreds of novels, made wars, and plundered continents.” As incidences of gout have increased, so has economic inequality: According to the Pew Research Center, in the decade since the start of the Great Recession in 2007, the wealthiest Americans, those in the top quintile, gained 13 percent in median net worth, while the rest lost at least 20 percent.

But this is coincidence, not correlation. For all its historical freight, gout cannot be explained as an indictment of a lifestyle or an era. It’s likely that in those centuries when the disease was hailed as the wages of fortune (and thus a perverse sort of honor), the anguish of the gout-ridden poor was simply ignored or credited to less distinguished causes. Misdiagnosis can still be a problem today: The Brooklyn-based composer Mark Phillips, now 39, experienced his first attack at 30 and suffered without treatment for half a decade because the doctors he saw couldn’t believe that gout would present in someone so young and lean. Friends likewise scoffed, while his agonies mounted; at one point he thought, “I don’t want to live for another 50 years with this pain.” What now holds his symptoms at bay is a daily dose of allopurinol, a drug developed in 1963 by the American biochemists Gertrude Elion and George Hitchings (who went on to win the Nobel Prize in Physiology or Medicine). For decades it has been the gold standard, even as the proliferation of cases has spurred the growth of a therapeutics industry projected to reach $10 billion by 2026.

The disease remains mysterious in its onset. Beyond genetic factors, high-fructose corn syrup poses a greater danger than a lobe of foie gras, cutting across class lines. Brewer’s yeast is high in purines, so indulging in something as populist as beer is another risk. Even an ascetic approach may not save you. Beans — a staple throughout lockdown during the coronavirus pandemic — have been known to elevate uric acid (although plant-based purines pose a lesser risk than animal-based ones, and the effect is probably outweighed by their health benefits). For those predisposed to the condition, what might be the cost of these past months as we all hunker down, forgo the perils of a questionably ventilated gym and eat and drink our sorrows away?

Still, it’s hard to resist a metaphor. It imposes order on the arbitrary, purpose where we might succumb to futility. If gout is just a matter of birth or chance, what then? One victim, who asked to be nameless, was perplexed by his fate, given his fairly temperate habits, until he read that hyperuricemia had been found in a small number of patients (less than 2 percent) in clinical trials of Viagra, approved for erectile dysfunction in 1998 but also used off-book as a recreational drug for sexual enhancement. No proof of causality exists, but the possibility, however tenuous, gave him a strange sense of relief. He could view his affliction as “karmic retribution,” he said, for leading what he called an “opulent” life. “It wasn’t opulent in the sense of eating rack of lamb and drinking 30 beers a night, like a king,” he said. “But this is my price to pay.”

Like a fugitive from another century, he accepts gout as his punishment, and through the crucible of suffering is refined. It’s the smallest of consolations. But far worse to believe that there is no moral to the story — that pain is just pain, and we have no answers.