{"id":38615,"date":"2017-03-03T18:03:30","date_gmt":"2017-03-03T17:03:30","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=38615"},"modified":"2017-03-06T17:33:09","modified_gmt":"2017-03-06T16:33:09","slug":"jeffrey-aronson-when-i-use-a-word-gout","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2017\/03\/03\/jeffrey-aronson-when-i-use-a-word-gout\/","title":{"rendered":"Jeffrey Aronson: When I use a word . . . Gout"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/jeffrey_aronson.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-32935\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/jeffrey_aronson-223x300.jpg\" alt=\"jeffrey_aronson\" width=\"93\" height=\"125\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/jeffrey_aronson-223x300.jpg 223w, https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/jeffrey_aronson.jpg 446w\" sizes=\"auto, (max-width: 93px) 100vw, 93px\" \/><\/a>Richard Asher once <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/13794725\">commented<\/a>, citing Pel Ebstein fever in Hodgkin\u2019s disease as an example, that some clinical manifestations that are regarded as \u201ctypical\u201d of certain diseases may be in fact rather uncommon or even non-existent. It is several years since I last saw a patient with gout that presented as podagra, affecting the big toe. \u201cIt\u2019s gout, isn\u2019t it, doctor?\u201d He had probably seen cartoons of army colonels with their feet swathed in bandages, or perhaps James Gilray\u2019s famous depiction of the gout demon (picture). I confirmed the diagnosis. \u201cWhat is it exactly?\u201d he asked.<\/p>\n<figure id=\"attachment_38617\" aria-describedby=\"caption-attachment-38617\" style=\"width: 501px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-38617\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2017\/03\/aronson_gout.png\" width=\"501\" height=\"364\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2017\/03\/aronson_gout.png 650w, https:\/\/blogs.bmj.com\/bmj\/files\/2017\/03\/aronson_gout-300x218.png 300w\" sizes=\"auto, (max-width: 501px) 100vw, 501px\" \/><figcaption id=\"caption-attachment-38617\" class=\"wp-caption-text\">The gout demon by James Gilray<\/figcaption><\/figure>\n<p>The IndoEuropean root GHEU meant to pour or gush, like a geyser, or like digestive products pouring through the gut. In Latin guttur was the throat, the passageway down which things are poured, near which you may develop a goitre, and a gutter is something into which things are poured and along which they flow. Gout comes from the Latin gutta, a drop. \u201cAnd on thy blade, and dudgeon, gouts of blood, which was not so before\u201d Macbeth tells the visionary dagger that plagues him.<\/p>\n<p>Gout was supposedly due to a \u201cdefluxion\u201d, literally a flowing down, of certain <a href=\"https:\/\/blogs.bmj.com\/bmj\/2016\/09\/02\/jeffrey-aronson-when-i-use-a-word-humours-and-humour\">humours<\/a>\u00a0in the body, whereby the drops of some noxious substance were deposited in the affected tissues. The falling gout (gutta cadiva in mediaeval Latin) was another name for epilepsy and Covent Garden gout and the ethnophaulism Spanish gout were both euphemisms for syphilis.<\/p>\n<p>In his <em>Herball<\/em> of 1597, Gerard listed \u201cHerba Gerardi, [which] is called in English Herbe Gerard, Aishweed, and Goutwoort, common names for the plant <em>Aegopodium podagraria<\/em>.\u201d In his <em>British Plants<\/em> (1776) William Withering called it goutweed. It was supposedly so efficacious that even carrying it about with you would reduce gouty pains. The Latin name of the genus gives a hint about the possible origin of this supposition. <em>Aegopodium<\/em> comes from the Greek words\u00a0\u03b1\u1f34\u03be (genitive \u03b1\u1f30\u03b3\u03bf\u03c2), a goat, and \u03c0\u03bf\u03cd\u03c2 (genitive \u03c0\u03bf\u03b4\u03bf\u03c2), a foot, and it was so called because its leaves bore a fanciful resemblance to the foot of a goat. So plants in the genus are really goatweeds rather than goutweeds. After it had been used for treating gout, <em>Aegopodium podagraria <\/em>was given its name from the Greek word \u03c0\u03bf\u03b4\u03ac\u03b3\u03c1\u03b1 (from \u03c0\u03bf\u03cd\u03c2 and \u1f04\u03b3\u03c1\u03b1, a way of catching), which originally meant a trap for the feet.<\/p>\n<p>In an article published in the<em> Daily Telegraph<\/em> 100 years ago, on 27 February 1917, titled \u201cThe uric acid question\u201d the anonymous author described the features of the disease and then claimed that Bishop\u2019s Varalettes were the best treatment, ending with the news that a free booklet on the subject was available from its manufacturers, Alfred Bishop Ltd, at 48 Spelman Street, London NE. The article was in fact a disguised advert for the formulation, which was marketed as tablets (picture) and as a liquid in attractive <a href=\"http:\/\/www.worthpoint.com\/worthopedia\/copper-blue-bishops-mineral-water-422630923\">blue glass bottles<\/a>.<\/p>\n<figure id=\"attachment_38621\" aria-describedby=\"caption-attachment-38621\" style=\"width: 401px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-38621 size-full\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2017\/03\/aronson_gout2.png\" width=\"401\" height=\"286\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2017\/03\/aronson_gout2.png 401w, https:\/\/blogs.bmj.com\/bmj\/files\/2017\/03\/aronson_gout2-300x214.png 300w\" sizes=\"auto, (max-width: 401px) 100vw, 401px\" \/><figcaption id=\"caption-attachment-38621\" class=\"wp-caption-text\">An advert for Bishop\u2019s Lithia Varalettes from the <em>Illustrated London News<\/em>, 1920<\/figcaption><\/figure>\n<p>In another article in <em>The Graphic<\/em> in 1907, readers were told, under the headline \u201cBishop\u2019s Varalettes are what you want\u201d, that the medication was useful for acidity, heartburn, or flatulence, and stiff swollen or inflamed joints, and that it would provide \u201ccomplete immunity from gout, rheumatism, rheumatic gout, gouty eczema, gouty indigestion, sciatica, lumbago, and kidney troubles.\u201d A box containing enough treatment for 25 days cost 5 shillings (about \u00a320 at today\u2019s prices) and the treatment was available not only \u201cfrom all chemists and drug stores\u201d in the UK, but also \u201cfrom the leading chemists in any country\u201d and from \u201cdep\u00f4ts\u201d in Paris, Barcelona, Sydney, New York, Cape Town, and Johannesburg.<\/p>\n<p>The<em> Daily Telegraph<\/em> told readers that \u201cBishop&#8217;s Varalettes are purely chemical in their action, and do not contain any of the dangerous medicinal drugs such as colchicum and its derivatives, the salicylates, iodides, mercury, potash, narcotics, and purgatives, which are such preponderating ingredients of other gout remedies.\u201d However, in the BMA publication <a href=\"http:\/\/www.bmj.com\/content\/339\/bmj.b5415\"><em>Secret Remedies<\/em><\/a> (1909), Bishop\u2019s Gout Varalettes were described as containing \u201clithium citrate and a small quantity of what appeared to be piperazine, together with the usual effervescing basis consisting of sodium bicarbonate and tartaric acid.\u201d Presumably lithium citrate acted by being converted to the highly soluble salt <a href=\"https:\/\/blogs.bmj.com\/bmj\/2017\/01\/20\/jeffrey-aronson-when-i-use-a-word-discovering-lithium\">lithium urate<\/a>. I imagine that the use of this remedy, if effective, led to not a few cases of acute lithium toxicity.<\/p>\n<p>I don\u2019t know the origin of \u201cvaralette\u201d. It does not seem helpful to know that \u201cvara\u201d in Latin denoted a branched structure and that \u201cvaral\u201d means a clothesline in both Spanish and Portuguese.<\/p>\n<p>I didn\u2019t give my patient all these details, but explained that he had a kind of inflammation in the joint and described the treatment. He thought about it for a moment. \u201cYou mean, like it\u2019s inflammable and caught fire?\u201d \u201cSort of.\u201d \u201cBut I haven\u2019t put it anywhere near a fire.\u201d<\/p>\n<p><strong>Acknowledgement:<\/strong> Thanks to Desmond Devitt for drawing my attention to the 1917 article in the<em>\u00a0Daily Telegraph<\/em>.<\/p>\n<p><em><strong>Jeffrey Aronson<\/strong> is a clinical pharmacologist, working in the Centre for Evidence Based Medicine in Oxford&#8217;s Nuffield Department of Primary Care Health Sciences. He is also president emeritus of the British Pharmacological Society.<\/em><\/p>\n<p><strong>Competing interests:<\/strong> None declared.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Richard Asher once commented, citing Pel Ebstein fever in Hodgkin\u2019s disease as an example, that some clinical manifestations that are regarded as \u201ctypical\u201d of certain diseases may be in fact [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2017\/03\/03\/jeffrey-aronson-when-i-use-a-word-gout\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":38622,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5762],"tags":[],"class_list":["post-38615","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-jeff-aronsons-words"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Jeffrey Aronson: When I use a word . . . 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