“Dialogue Between Franklin and the Gout” Reexamined

Some excerpts from “Dialogue Between Franklin and the Gout”:

FRANKLIN. Eh! Oh! eh! What have I done to merit these cruel sufferings?

GOUT. Many things; you have ate and drank too freely, and too much indulged those legs of yours in their indolence.

FRANKLIN. …you reproach me as a glutton and a tippler

GOUT. …but I very well know that the quantity of meat and drink proper for a man, who takes a reasonable degree of exercise.

FRANKLIN. Madam Gout. You know my sedentary state…

GOUT. in life is a sedentary one, your amusements, your recreation, at least, should be active. You ought to walk or ride…Yet you eat an inordinate breakfast, four dishes of tea, with cream, and one or two buttered toasts, with slices of hung beef, which I fancy are not things the most easily digested. Immediately afterwards you sit down to write at your desk, or converse with persons who apply to you on business. Thus the time passes till one, without any kind of bodily exercise.

GOUT. but your insuperable love of ease.…

FRANKLIN. Oh! oh! for Heaven’s sake leave me! and I promise faithfully never more to play at chess, but to take exercise daily, and live temperately.

Excerpt from the “Poor Richard’s Almanack 1734”:

Be temperate in wine, in eating, girls, & sloth; Or the Gout will seize you and plague you both.

There were many risk factors suspected by Franklin that could have contributed to his experience of gout [Table 1] [Figure 1]. These can be classified into non-modifiable risk factors such as age and modifiable risk factors such as sedentary lifestyle, gluttony, high purine diet (red meat consumption), and alcoholic beverages.⁴

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Figure 1.

Franklin’s conception of risk factors for Gout

The incidence of gout increases with age, and it is relatively common in men of late middle-age and beyond.^5,6 Although Franklin might have experienced his first gout attack in his 40s, his earliest suffering of a severe gout attack that precluded him from his diplomatic activities happened when he was 56-years-old, as described in a letter to his sister Jane in 1762.³ Perhaps, among the modifiable risk factors was Franklin’s self-reported sedentary lifestyle. Obesity, high body mass index, and lack of physical activity are associated with increase in serum uric acid level.^7-9 A study of male runners who ran more than 4 kilometers/day or at a speed more than 4.0 meters/second showed decreased incidence of gout, although this was in part related to their body mass index.¹⁰ Portraits of Benjamin Franklin consistently reflect a large body habitus. Although the mechanisms are poorly understood, increased incidence of gout in obesity is believed to be due to increased urate production and decreased renal urate excretion.¹¹ Increased insulin resistance in obesity contributes to hyperuricemia, which along with hypertension and hyperlipidemia, constitute metabolic syndrome.¹² Franklin was famous for enjoying a high purine diet, particularly red meats, especially the salted ones, veal, fishes, and hors d’oeuvres during his sea voyages and while he was in Europe.³ Studies have shown increase in daily consumption of meat (especially red meat) and sea food (especially mussels, anchovies, sardines and scallops) is associated with hyperuricemia and increased frequency of gout attacks, owing to their high purine content, which increases serum urate levels.^11,13,14 Consumption of all alcoholic beverages, including wine, was another suspected precipitating factor for gout in Franklin’s life. Duc de Croy, a French soldier who achieved the rank of Marshal of France in the 18^th century, described Franklin’s habits in his notes after visiting Franklin in 1779. He observed Franklin enjoyed “large slices of cold meat,” accompanied by “two or three bumpers of good wine.”^3,15 Epidemiological studies since then have shown that beers, hard liquor, and high fructose sweetened drinks are associated with increased serum uric acid levels due to the high content of purine guanosine and breakdown of adenosine triphosphate to adenosine monophosphate.^5,16 Among the alcoholic beverages, beer has the strongest association with elevated uric acid levels.^5,18 By contrast, regardless of the type of wine, there is no significant association between increased level of uric acid or gout flares with moderate wine intake (which is defined as less than 118 mL serving per day).^5,17 Multiple studies have shown an inverse relationship between consumption of dairy products (including milk and yogurt) and serum uric acid levels and risk of gout,^5,19 owing to the uricosuric effect of orotic acid, casein, and lactalbumin.⁵ Tea, regardless of type, is not associated with increase in the serum uric acid level or increased frequency of gout attacks.²⁰ Teng et al. showed no significant relationship between black tea consumption and serum uric acid level.²¹

Given his multiple risk factors for gout, it was inescapable Madame Gout played an important role in Benjamin Franklin’s life! Playing chess, a sedentary game, was one of his favorite hobbies [Figure 2], which could have contributed to inadequate physical activity and worsening of his metabolic syndrome. It is suspected gout was one factor among many that debilitated Franklin to the extent of requiring him to be conveyed in a sedan chair [Figure 3] to the Constitutional Convention.²² One could also speculate whether his sedentary lifestyle further accelerated his age-related deconditioning.

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Figure 2.

Franklin and the Gout (Courtesy: Nashaat Adib, Cairo, Egypt)

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Figure 3.

Sedan chair used for conveyance of Benjamin Franklin (courtesy: Benjamin Franklin Museum, Philadelphia)

Historically, gout has been associated with opulence and wealth and has been referred to as the “disease of the kings” or the “patrician malady.”^23-25 A “patrician” was someone belonging to the elite strata of the ancient society, families of landowners or political or military leaders, while the ordinary members of society were the “plebeians.” In the modern era, however, gout has become a disease of the common man, the “plebeian.” With the widespread use of appliances and transportation modes, sedentary lifestyle has become a rampantly common public health problem. The mass production and consumption of calorie-dense instant food items has contributed to escalating prevalence of obesity. Across the globe, the incidence of gout is rising along with increased prevalence of obesity, metabolic syndrome, and sedentary lifestyle.⁷

Reflecting on the history of medicine can yield important lessons to the modern practitioner. At the time Franklin wrote this dialogue, knowledge accumulated over the millennia on the association between gout and an opulent lifestyle was already available to him.^23-26 But credit must be given to Franklin for his self-reflection and astute and prescient observations, particularly his lamentations on his sedentary lifestyle, a problem that has grown exponentially in the intervening 240 years.^12,26 Yogi Berra famously said, “You can observe a lot by just watching”, perhaps that is all Franklin did. Common sense observations have remained an important aspect of humanity’s scientific endeavor all the way from antiquity to the modern era. Some of these observations turn out to be true, later verified by science, and some turn out to be false. For example, Hippocrates observed 2400 years ago “a woman does not take the gout unless her menses be stopped.” This turned to be an accurate fact, later validated by science, since gout is uncommon among premenopausal women. But then “common sense” can be deceiving, since he also observed “a youth does not get gout before sexual intercourse,”²⁷ which is yet to be validated by science.

Over the millennia and across several civilizations, theories about various humors of body and speculations on how imbalances among these humors contribute to disease have been very popular.²⁸ The humoral theory describes four body fluids: phlegm, blood, gall (black bile), and choler (yellow bile). The body remains healthy when these humors are in equilibrium, and imbalance of the humors results in diseases.^28,29 Gout may be one entity where one could argue the humoral theory may have turned out to be somewhat true, since it is caused by an increase in serum urate level,¹⁴ perhaps an imbalance of a humor? In the modern scientific era several additional risk factors for hyperuricemia and gout have been established including congestive heart failure, renal impairment, renal transplantation, use of certain medications (e.g., diuretics and cyclosporine).^30,31

Gout became somewhat of a “status symbol” from the Middle Ages to the early modern era, and having gout was perceived as evidence “one has arrived successfully in life.”^25,27 One could make a cynical argument that Franklin was flaunting his higher socio-economic status by publicizing his experience with gout. The more considerate (if not more convincing) argument could be he was only displaying humility, one of the 13 virtues advocated by him, by admitting his failings and inadequacies. The rich and elite over the millennia often suffered immensely from gout, and the “remedies” available to them were ineffective. Elaborate contraptions and furniture, such as ornate chairs and stools,²⁵ were designed to cope with gout. Or worse, often the touted remedies were alcoholic beverages,³² which could only have contributed to worsening of gout. The inexpensive and very effective anti-inflammatory medications that are readily available today even to the poorest of the global population, the plebeians, were not available even to the elitest of the patricians until recently. Although not among the virtues listed by Benjamin Franklin, reflecting on the history of gout would certainly oblige us to practice yet another important virtue: gratitude.