A swell disease for swell people

This learned, heavily footnoted and richly illustrated study of the history of gout is not primarily designed either for sufferers from the malady, predominantly male, or for friends of sufferers, patrician or otherwise. Divided into three parts - histories, cultures and "goutometries" (one section of the last of these is called "the rhetoric of swelling") the book stops well short of the present with the arrival of the drug allopurinal in 1963. As a "disease of civilisation", whatever civilisation means, gout has not reached the non-western world. More treatable than in the past, it remains incurable, if largely no longer glamorous. It is non-lethal and non-infectious. Medical textbooks suggest that it is not a single disease. It has never been glamorous when confounded with arthritis.

Curiosity is more likely to attract readers to this volume than pain, the intense pain of gout, often described most memorably by a distinguished if non-glamorous sufferer, Erasmus, to a fellow sufferer, writer of a treatise on gout. "This tyrant with its cruel retinue moves from the loins through the haunches to the region of the spleen. From there it goes with the intention of breaking through into the bladder, twisting and throwing everything along the way into disorder: how used to violence are princes who delight more in being feared than in being loved."

Disease as a prince carried with it more than pain. So too did Seneca's description of gout (why female?) as the rosy daughter of Bacchus and Venus. Erasmus left his gout approaching the bladder. Usually it reaches the foot. Podagra, the ancient name for it, might be "fixed in the great toes". The fact that gout was not fatal seemed less distinctive than another of its features, summarised in a memorable medieval comment of Rhazes, whom the authors do not identify: the pain of gout did not attack "those who work, only those who do not have to work". The comment may or may not be true - we never quite find out - although we are told in a somewhat pretentious brief epilogue, which contrasts with an admirably lucid introduction, that at a time (now) when "health commentators are expressing deep anxieties about the diseasification of everything; it is particularly illuminating to study "the eligible malady par excellence, the patrician malady to top out all others, a malaise one would want to possess even as it possessed one's own body".

According to the authors, diseases qualify as such only when they are named "by medicine, science and society"; and certainly in the case of gout (from the Latin gutta , a drop) society, even after the identifications of the roles of uric acid in the making of the malady, has had a bigger share in the processes of interpretation than doctors or scientists. But the most readable sections of this volume are those that deal with medicine rather than history or literature, although the latter affords a whole anthology of gouty references.

Yet there is a sense of unity in The Patrician Malady , a considerable intellectual achievement. After a brief trip through antiquity, where we meet Podagra, we turn to booklore as much as to folklore until after brief encounters in modern times with Wilkie Collins and Joseph Conrad we reach in the last chapter - in many ways the most interesting - "The visual heritage". The terrifying image of gout on the front page of the dust-cover (pictured above) may be compared with the slightly more reassuring picture of a gouty gentleman with his slightly less huge foot poised on a stool, surrounded by a formidable range of possible remedies. The latter is given a title to which avid readers of this book should doubtless aspire - An Exquisite Taste with an Enlarged Understanding .

Perhaps because the Victorians were less interested in exquisite taste than in enlarged understanding, the chapter called "Indian summer: Romantic and Victorian gout" is somewhat disappointing. There is too much speculation concerning "likely candidates for gout" rather than its victims or heroes. The chronology is strange too. Disraeli, who contracted gout after having written about it in others, comes before Scott and Thackeray before Coleridge. Thackeray did not found Punch, as is claimed, and more could have been said in this chapter about "the dozens of cartoons about gouty men" in Punch. The conclusions seem mainly sound, however.

When this chapter turns from literary expression to medical diagnosis (with various versions of psychology pervasive) it is more illuminating than when it dwells at some length on a bridge fictional figure, Dr Tertius Lydgate in George Eliot's Middlemarch , who retreats from active medical practice to "the miserable writing of a treatise on gout". Many other doctors dealt with gout when examining, as they did in other medical fields, the influence of heredity on maladies. The last word should surely be with Sydney Smith, who had his own personal history of gout and who fancied himself as a medical authority. "Gout loves ancestors and genealogies I It needs five or six generations of gentleman or noblemen (not the same) to give it its full vigour."

Lord Briggs was formerly provost, Worcester College, Oxford.