Gouty arthritis was among the earliest diseases to be recognized as a clinical entity. First identified by the Egyptians in 2640 BC [1
], podagra (acute gout occurring in the first metatarsophalangeal joint) was later recognized by Hippocrates in the fifth century BC, who referred to it as 'the unwalkable disease'. Some of Hippocrates' remarkable clinical perceptions in relation to gout are preserved in aphorisms, which are as true today as they were 2500 years ago (Table ) [2
]. Hippocrates also noted the link between the disease and an intemperate lifestyle, referring to podagra as an 'arthritis of the rich', as opposed to rheumatism, an arthritis of the poor. Six centuries later, Galen was the first to describe tophi, the crystallized monosodium urate deposits that can follow longstanding hyperuricemia. Galen associated gout with debauchery and intemperance, but also recognized a hereditary trait [3
] that had previously been referred to by the Roman senator Seneca [4
Five aphorisms of Hippocrates on gout
The first person to use the word 'gout' to describe podagra (gutta quam podagram vel artiticam vocant
– 'the gout that is called podagra or arthritis') was the Dominican monk Randolphus of Bocking, domestic chaplain to the Bishop of Chichester (1197–1258) [5
]. The term is derived from the Latin word gutta
(or 'drop'), and referred to the prevailing medieval belief that an excess of one of the four 'humors' – which in equilibrium were thought to maintain health – would, under certain circumstances, 'drop' or flow into a joint, causing pain and inflammation. Later, gout was described by Thomas Sydenham, the famous English physician and proponent of hippocratic medicine, who was himself disabled by gout and renal disease [6
"The patient goes to bed and sleeps quietly until 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 ..., which is mild in the beginning ..., grows gradually more violent every hour ... so exquisitely painful as not to endure the weight of the clothes nor the shaking of the room from a person walking briskly therein."
Throughout history gout has been associated with rich foods and excessive alcohol consumption. Because it is clearly associated with a lifestyle that, at least in the past, could only be afforded by the affluent, gout has been referred to as the 'disease of kings'. In some eras gout was perceived as socially desirable because of its prevalence among the politically and socially powerful. In his classic monograph on the history of gout [5
], Copeman refers to a comment in the London Times
in 1900, "The common cold is well named – but the gout seems instantly to raise the patient's social status", and to another in Punch
in 1964, "In keeping with the spirit of more democratic times, gout is becoming less upper-class and is now open to all ... It is ridiculous that a man should be barred from enjoying gout because he went to the wrong school."
In earlier times, attacks of gout were also seen as a prophylactic against more serious diseases. According to the writer Horace Walpole [7
], gout "prevents other illnesses and prolongs life ... could I cure that gout, should not I have a fever, a palsy, or an apoplexy?"
In recent decades, however, the diet and lifestyle that predispose individuals to hyperuricemia and gout have become increasingly common. The role of excess dietary purines (derived from meat, seafood, and beer) in the development of gout is illustrated by the disparity between the incidence of gout in Asia and Europe. Traditional Asian diets, based on rice and vegetables, are low in dietary purines, and gout has been relatively rare in these cultures. In contrast, European and American diets, which are high in meat and certain seafoods, are associated with hyperuricemia and gout [8
]. Increasing affluence has also led to an expansion in the number of people following a westernized diet and lifestyle, and this has been paralleled by an increase in the incidence and prevalence of gout worldwide.
Historically, gout has been considered to be primarily a male disease. The fact that women can also develop gout was first recognized during the reign of Nero (AD 54–68) by Seneca, who observed, "in this age, women rival men in every kind of lasciviousness ... why need we then be surprised at seeing so many of the female sex afflicted with the gout?" [4
]. In the modern era, although gout remains primarily a disease of men in middle age, it has become increasingly more frequent in women, particularly after the menopause.