Why was gout so prevalent in the past among rich people?

Question

I'd like a general explanation about this fact.

I know it's a big error to judge behaviors in history with the current knowledge we have now, but for gout, people could have easily got to know that people that didn't eat as much meat or that had a more active life-style didn't suffer it.

They could have copied those behaviors to avoid it, and as they were rich they wouldn't have problems in getting other food they wished, or have time to do some physical exercise.

Despite that, it looked like they preferred getting gout.

What are the main reasons for this? Maybe it has to do with that it was considered "a commoner behavior" to eat little meat and do physical exercise?

Answer 1

There's a few different things going on here. First, to get it out of the way, we've known that gout was linked to lifestyle since the beginning of medicine. No less a person than Hippocrates made this connection:

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].

Now the first thing to realize is just because people tell you that something is bad for you, does not mean that people will stop doing it. It is trivial to find behaviors we know for a fact damage your health that millions of people still do.

But with that out of the way, we now know that gout is caused by foods high in purines. That connection was never made so specifically. Why? This is likely due to the cultural biases of Europe in those eras. (Gout is mostly a European disease due to differences in diet between Europe and other regions.) In Europe, there have been generally two overarching theories about why people get sick.

The four humors. The ancient greeks saw illness as an issue of the four difference substances that power the body being "out of balance". For them, this would be the cause of all disease, including gout. So they would generally look for ways to put the humors in balance. They were more likely to give you a purgative or bleeding.

Religion. The church saw at least some illness as punishment from God. The way to the cure was prayer, and, of course, to stop sinning. Ironically, this would likely be more effective than the "scientific" four humors at stopping the actual disease as it would blame the "intemperance" of heavy eating and alcohol.

This irony shows clearly why scientific advancement is so hard. As Pieter Geerkens points out in the comments, there is a disease called hemochromatosis where the modern treatment is bleeding, in common with the sorts of treatments someone operating on the four humors paradigm might prescribe. So basically theories that are wrong can still lead to results better than chance.

So consider if you're a medieval doctor: You have two theories of disease. Both work in some cases. You have no alternate theory. In that situation, you can easily be misled to believe that those two theories are correct. In other words, these weren't irrational, superstitious people making wild-ass pointless suggestions. These were rational people, making suggestions based on the current best theories about how the way the world operated.

It takes a particular sort of person to create entirely new theories of the way the world works. There were many intelligent, rational people in the 17th century, but only one Isaac Newton.

It was only after these two theories of medicine lost their dominance that Europeans were able to see past to the idea that particular foods have particular effects. Remember, scurvy was rampant until the 19th century, and the dietary connection there is quite a bit easier to make than with gout. This was very difficult, because those older theories were quite entrenched by millennia of practice and, yes, success.

Interestingly, when I was researching this, I ran across this paper, which talks about an Islamic physician, Abu Bakr Mohammad Ibn Zakariya Razi, who while still operating in the "four humors" realm, offers relatively good advice:

“Gouty patients should forsake camels meat, beef, namaksud (salted jerked meat), as well as died game meat and all kinds of jerked meat. As regards fish, it is advisable to avoid all kinds of salted fish, as well as stinking rigid-flesh unsalted fish. Dairy products should be all forsaken except for small amounts of milk, cooked with rice and sprinkled with pinch of tabarzad (solid white sugar) sugar

How many of his patients followed that advice when it is time for dinner, who knows. My doctors tells me I need to lose weight and drink less, but there's a Russian Imperial Stout in the refrigerator that is calling to me...

Answer 2

First of all the disclaimer: all but a bit of general knowledge I have about gout is from looking through a bunch of papers as the question triggered my curiosity. So please the following with the appropriate caution, and take this more as points to start thoughts than as ready-made answer.

---

Some background:

From Doherty: New insights into the epidemiology of gout unless source linked separately:

• Acute gout is caused by shedding of sodium urate crystals into joints.
• The crystals may form over decades in the cartilage without leading to problems.
• High uric acid levels are thus the primary risk factor (and used for diagnosis).
• Only about 10 % of the people with hyperuricemia develop gout, the risk increases with increasing levels of uric acid, though.
• High uric acid levels are in most patients caused by too low renal clearance.
• (Acute) gout has a very strong correlation with age and sex:male. fig. 1 and 2 in the Doherty paper. Gout below age 45 is unusual. This paper about the relation between gout and obesity reports an average age at onset of about 60 years and 48 years for those who were obese already at age 21.
• There is a hereditary component: a twin study is said* to conclude that 60 % of uric acid level variance is hereditary. There are also several genes idenified which correlate with hyperuricemia, though they explain only 6 % of the uric acid level variance.

• While there is negative correlation with rheumatoid arthritis, there is positive correlaton with osteoarthritis. It is hypothesized that the Na-urate microcrystals may form more easily in osteoarthritic cartilage

• Renal disease (not surprisingly seeing the importance of renal clearance) is a risk factor as well, and

• there's a whole bunch of co-morbidities (which we may sum colloquially as lifestyle-related): metabolic syndrome, obesity, hypertension, ...
  With these there may also be vicious cycles: if they worsen gout, and worse gout means you cannot move that means they will get worse, and so on.

people could have easily got to know that people that didn't eat as much meat or

I don't think it's that easy for the long-term (lifestyle) consideration. There is a crucial difference between "most people who suffer from gout eat (ate) lots of meat", and "most people who eat lots of meat develop gout" (that is not the case!).

The crucial role of renal uric acid clearance means that someone with low renal clearance will get into hyperuricemia (thus greatly increasing their risk of developing gout) by eating an amount of meat that will not lead to any such problems for someone with good renal clearance.

What should have been easier to recognize (and was recognized) is that purine-rich food and alcohol are likely to trigger an acute attack in someone with gout. But so can: trauma, weight loss, illness, ... I.e. if someone has gout, they should keep a strict diet (whether they do: see also instant gratification in @LangLangC's answer). But that can only lower the risk for new attacks.

But what I've read about ancient knowledge in that respect leaves unclear whether the "gluttonous/bacchanalian lifestyle" refers to the present lifestyle surrounding acute attacks or whether also the long-term issues were recognized.

(Also consider: even today we don't bother to find out who exactly is at risk and should keep a strict diet from early age on - other than maybe taking into account family history.)

that had a more active life-style didn't suffer it.

I'm not sure we can conclude this for people back in history. I'd guess that even those who were obese and gouty at 60 probably had a far more active lifestyle for the first 40 or 50 years than we do nowadays. And please someone correct me if I'm wrong, but even in ruling dynasties or merchant dynasties I'd expect the heir(s) to undergo a training that required substantial (physical) work compared to Western lifestyle now. Also, I expect obese at age 21 (see above) wasn't much of a thing back in history.
The link with osteoarthritis also suggests that maybe not all forms of active lifestyle provide good protection against gout.

---

LangLangC's answer cites a belief of gout being protective against other diseases. I didn't see anything in the literature indicating that we nowadays think this is the case. But there are some factors here that make this hypothesis not totally implausible:

• One difference between Western lifestyle nowadays and the historic times we're looking at is that probably most people back then did get less than optimal protein. And that has e.g. the known consequence of weakened immune system. Thus, the perceived "protection" may have been caused by high (compared to poor people) protein intake - which comes at a risk for other diseases like gout later on. Still, What was the life expectancy of a Medieval European monarch? estimates life expectancy for a 20-year-old to be around 45 in general, maybe more for rulers (lots of variance here due to violent deaths). In that context, it may have made a whole lot of sense to eat all the meat you possibly can to be physically as strong as possible as long as possible. This BBC column refers to 40 as the end of the work period for the general population. Meaning by age 40, their physical condition was too bad to cope with work.
  While gout was certainly bad for those who got it, it probably didn't make sense to worry about lifestyle choices at age 20 that increase your chances to enjoy life better at age 60+.

• Two more points to consider in the context of this question are connected to hereditary traits.

  • Consider how Nuki & Simkin: A concise history of gout and hyperuricemia and their treatment describe the discovery of the hereditary nature:

     [...] William Cullen, who wrote, "The gout attacks men of especially robust and large bodies, men of large heads ... and men whose skins are covered with a thick rete mucosum with coarse surface ... especially men of a choleric-sanguine type ... [whose fathers had suffered]" [5]. In 1771, William Cadogan asked, "If the features of the countenance, the outside of the body, are often hereditary, why not also the inside?" [...]

    (my emphasis)

    Gout being linked to strong and robust people may lead to an increased prevalence of gout in (historic) rulers. The more so, as a strong and robust physique may help to become a ruler while the disability due to gout likely hits only at much older age.
    While this sounds most plausible for rulers with active military duties/carreers, I'd expect it to be true also to a certain extent, say, for merchants: The likelihood to be a BIG guy in your trade is higher for someone who is robust & strong.

  • The combination of a hereditary disease with dynasties of rulers or otherwise important/rich families means that at the very least, we'll have to deal with high variance and the consequential in the observed prevalence/incidence among rulers because instead of n rulers, we actually look at a much smaller number of families.

• When looking at prevalence of gout in the rich vs. the poor we may have to take into account that a rich person may survive gout quite long time and the onset of gout is likely to be at a time of life when they have already accumulated their wealth. Whereas a poor getting gout (at the same age) probably finds themselves unable to work, and thus in an immediately life-threatening situation.

• Table 2 in Roddy & Choi: Epidemiology of Gout shows higher prevalence of self-reported gout compared to prevalence according to GP/health care records.
  While this is in itself no very sensational finding, together with gout being "a disesase of kings" we may need to consider whether there is overreporting for historic cases.

---

* I list Wikipedia as source as I don't have access to the papers cited there.

Answer 3

It is indeed a bit difficult to really ascertain the incidence and prevalence rates in medieval or ancient times. Wile the lives of rich people may be documented quite well, those supposedly not suffering as often poorer people left much fewer traces in the literature.

Looking at it from the top: indeed, of 86 Byzantine emperors, 14 did suffer from arthritis/gout. Calculating like milk maid that is a rate of 16%, while currently gout in the US is on the rise but only at ~3.9%, while a family history of the disease increases the prevalence to 20%. Add to that that older texts make it sometimes difficult to really distinguish things we now clearly count separately and the problem only starts.

Byzantine historians had sometimes practiced as doctors before turning to writing. In those cases

historians had excellent knowledge of the medical theories of their time: thus official opinions of diseases, and especially of arthritis, are reflected in their descriptions.

The remaining historians and chroniclers, however, reveal the most widely practised views of the age, which were not always in harmony with official scientific medicine.

In conclusion, it appears that a great number of Sovereigns of the Byzantine Empire and officials of the State and leaders of the Church suffered from a form of arthritis, which in most cases seems to have been gout. Almost all the contemporary sources support the conclusion that the latter disease was a result of overconsumption of alcoholic drinks and food. A significant role of anxiety and heredity is also stressed in most of the texts.
_{— John Lascaratos: "'Arthritis' in Byzantium (AD 324-1453): unknown information from non-medical literary sources", (Ann Rheum Dis 1995; 54: 951-957)}

So it is evident that while some theories of causes, in the form of certain food and drink, and specifically overconsumption of them, were correctly identified, and as early as the second century AD also pharmacologically treated with success and modern appearing medicine as well: colchicine — there were also bad theories out there. The already mentioned overconsumption – or just a ntemperate, bacchanalian lifestyle – is then just the sin of gluttony, some assumptions within humoral-pathology are just incorrect beliefs instead of accurate and applicable theories.

Then we have the misfortunate effect of 'delayed gratification': eat meat and drink beer, feel fine throughout the night. But after a gout attack strikes you, your physicians might tell you entirely correctly that reducing meat and beer should help. Which it will not immediately. And then he tells you to maintain that lifestyle for prohylactic reasons, but you might sin a little here and a little there, without getting punished immediately. These are two very detrimental factors for good patient's compliance.

Sometimes the rich were also insightful by themselves. Wallenstein for example was a big time sufferer, but learned that his meat mongering heavy drinking was much worse with beer than with wine. So he did indeed avoided beer…

Coming to a description of causes and contributing factors in accordance with reality is not only hampered by incorrect theories or lack of concepts like uric acid build-up and deposition. Just comparing beer and wine may lead to adequate conclusions on the one hand, but confounding factors unaccounted for may slow down insight a great deal. While clean beer (close to modern style) is usually much worse than clean wine. This is much complicated when the wine is concentrated, fortified, spiked or just contmited, for example with unown amounts of lead. When the English banned French wine imports and switched to port form Portugal, established fact/well-known 'healthier option' wine suddenly lead to increasing cases of gout, as lead was much higher in this variety. This slow burning plumbism makes uric acid metabolism problems on its own.
_{— Shom Bhattacharjee: "A brief history of gout", International Journal of Rheumatic Diseases 2009; 12: 61–63}

Combine all that with the fact that even Alexander the Great suffered from Gout and did not stop drinking. It was socially often expected, if not impossible to think otherwise, to eat copious amounts of meat and drink heavily. For social status reasons and distinctive consumption. This even went far enough that having podagora was just like brain infarcts in Japan or burn-out in the US, a kind of socially desirable disease. You are royally screwed with gout, but it is royally: the illness of the kings.

Interstingly, a sometimes widespread belief seems to have been that having gout is also protective against other forms of disease, as Horace Walpol put it:

“gout prevents other illnesses and prolongs life … could I cure that gout, should not I have a fever, a palsy, or an apoplexy?”
_{(— George Nuki & Peter A Simkin: "A concise history of gout and hyperuricemia and their treatment", Arthritis Research & Therapy 2006, 8(Suppl 1):S1})

Or

They give the sick man joy,
and praise The Gout
that will prolong his days.^{(Jonathan Swift)}

Gilbert Sheldon, Archbishop of Canterbury under Charles II, in the second half of the 1600s, was reported to have offered £1,000 to any person who would ‘help him to gout’ to protect his health.
_{— Stephan A. Schwartz: "Disease of Distinction" (PDF)}