Avraham Z. Cooper, MD 🩺 Profile picture
Jul 1, 2019 13 tweets 7 min read Read on X
1/
Many think that Van Gogh was "dig toxic" and that it impacted his vision and painting. Was that really true? This #tweetorial explores whether the great artist was actually toxic on digitalis.

#medtwitter #FOAMed #meded #medicalhumanities Image
2/
First, we need to understand a couple of things:
▪️What ailed Van Gogh?
▪️How can digitalis affect vision?
3/
Many diagnoses have been applied to Van Gogh, from lead poisoning to porphyria.

Most historians believe his depression, mania, and convulsive episodes indicate:
⭐️Schizoaffective disorder
⭐️Epilepsy
Both of which were made worse by absinthe.

ajp.psychiatryonline.org/doi/full/10.11…
4/
After episodes of psychosis and self-harm (see: the famous ear-cutting incident) Van Gogh was admitted to the Saint-Remy asylum from 1889-1890. He was cared for by a Dr. Gachet and it is here that he may have been treated with digitalis.

Dr. Gachet 👇 Image
5/
In the 19th century digitalis was used medically for many indications, from epilepsy to cough.

Visual changes are known side effects of digitialis, including yellow discoloration of vision (aka xanthopsia) and blurred halos around points of light.

binged.it/2WKsO5Z Image
6/
So how might digitalis have affected Van Gogh’s art? Art historians have pointed to his “Yellow Period” which coincided with his prolonged hospitalization at Saint-Remy...

jamanetwork.com/journals/jama/… Image
7/
...As well as the famous halos in “Starry Night”, which he is thought to have painted from his window in the asylum. Image
8/
So, what is the evidence that Van Gogh even received digitalis? It's all circumstantial:

➡️Digitalis was commonly prescribed at the time for his ailments
➡️He featured the digitalis plant in portraits of his physician, Dr. Gachet (red arrows below)

bit.ly/2X94fuM Image
9/
And there's actually ✅ evidence *against* the dig toxic theory...
10/
✅ Analysis of Van Gogh's color palette over time revealed a gradual transition to predominantly yellow (rather than a sudden change that would be expected from a drug toxicity).

bit.ly/2ZNYxAl Image
11/
✅ Van Gogh rarely painted during his acute episodes, the times at which, if he was receiving digitalis, his serum drug levels should have been highest.

ncbi.nlm.nih.gov/pmc/articles/P…
12/
✅ And Dr. Gachet is reported to have tested Van Gogh's vision, including color perception, and found it be normal.

ncbi.nlm.nih.gov/pmc/articles/P…
13/
To sum up, was Van Gogh really dig toxic as is commonly supposed?

While it is very possible he received digitalis for epilepsy and his mood disorder, the evidence suggests he simply liked the color yellow.

What do you think?

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More from @AvrahamCooperMD

Mar 3
1/THREAD

How could eating black licorice cause life-threatening hypokalemia?

Why in the world could specifically eating this food cause serum potassium levels to dangerously drop?

#medtwitter #tweetorial Image
2/
Let's first review what black licorice is actually made from.

Black licorice is a sweetener found in candy, tea, sweet drinks, and even beer.

It's extracted from the root of the legume Glycyrrhiza glabra plant.

licorice.com/blogs/news/wha…
Image
3/
Thousands of years ago, ancient Egyptians drank licorice as a sweet drink, and archaeologists found licorice in King Tut's tomb.

Alexander the Great and Napoleon both chewed on black licorice root during battle for its soothing properties.

klepperandklepper.com/knowledge-base…
Image
Read 16 tweets
Sep 24, 2023
1/
Why can multiple sclerosis symptoms worsen with heat exposure, something known as the Uhthoff phenomenon?

This question is especially relevant in the era of record-breaking heat waves and climate change.

#tweetorial #medtwitter Image
2/
In 1890, Wilhelm Uhthoff noted multiple sclerosis (MS) patients having a “marked deterioration of visual acuity during exercise" or after a hot bath, which ⬆️ body temperature.

1 patient lost vision just by walking vigorously in Uhthoff's clinic.

pubmed.ncbi.nlm.nih.gov/20375511/

Image
Image
3/
The Uhthoff phenomenon is now recognized as exceedingly common in MS.

Up to 80% of patients experience ⬆️ neurological symptoms w/ even small body temp increases. These can include diminished physical (eg gait) and cognitive (eg mental fog) function.

journals.sagepub.com/doi/abs/10.117…
Image
Read 15 tweets
Jun 25, 2023
1/THREAD
Has it ever occurred to you that Graves' disease presents a conundrum?

Graves' involves an autoimmune antibody that ACTIVATES a receptor, which is relatively unique in the landscape of human disease.

Let's unpack this fascinating mechanism.
#medtwitter #tweetorial
2/
Graves’ disease was first described by English physician Caleb Parry in 1786, when he noted an association between thyroid enlargement, tachyarrythmias, and exopthalmos in 8 patients.

Parry’s son posthumously published his description in 1825.

https://t.co/sklIBMwyzDlitfl.com/graves-disease/


3/
In 1835, 10 years after publication of Parry's description, Irish surgeon Robert Graves described a patient w/ thyromegaly + exophthalmos.

Although clearly not the first description, Trousseau proposed the name Graves' disease in 1862 and it stuck.

https://t.co/D3DY4WwF7dlitfl.com/graves-disease/


Read 18 tweets
Apr 23, 2023
1/THREAD
Ever wonder why amphotericin B can cause severe infusion reactions, including chills/rigors + hypotension?

These infusion reactions are so awful that it carries the nickname "amphoterrible".

Why does this happen? The answer is mind-blowing.

#medtwitter #tweetorial Image
2/
First let's review amphotericin B's history.

In 1953, analysis of a fermentation broth from Venezuelan soil found 2 antifungal compounds: amphotericin A and B.

B had a broader antifungal activity spectrum and so underwent further drug development.

pubmed.ncbi.nlm.nih.gov/33261213/ Image
3/
Amphotericin B (AmB) contains a hydrophobic polyene "tail" and a hydrophilic amine "head".

This amphipathic profile allows AmB to bind ergosterol in fungal membranes, which is thought to cause ion-leaking pores to form, killing the fungus.

pubmed.ncbi.nlm.nih.gov/33261213/ Image
Read 19 tweets
Mar 5, 2023
1/THREAD
Ever wonder why fluoroquinolones increase the risk of tendon rupture?

It seems so random that a whole class of antibiotics could cause tendon injuries, but the risk is real.

#medtwitter #tweetorial
2/
Fluoroquinolones inhibit bacterial function by blocking topoisomerase activity.

They first emerged as an antibiotic class in the 1960s, as byproducts of antimalarial quinine development.

Nalidixic acid = the first quinolone discovered.

pubmed.ncbi.nlm.nih.gov/14056431/
3/
The first report of fluoroquinolone-associated tendinopathy occurred in 1983.

2 renal transplant patients received norfloxacin and subsequently developed achilles tenosynovisitis.

Their symptoms spontaneously resolved w/ cessation of the norfloxacin.

pubmed.ncbi.nlm.nih.gov/6223241/
Read 16 tweets
Jan 22, 2023
A short 🧵 on my 3️⃣-prong approach to rounding with resident teams in the MICU…

I emphasize 3️⃣ themes to the residents and fellows:

1️⃣ Clinical care
2️⃣ Education
3️⃣ Development

#MedTwitter #MedEd
1️⃣ Clinical care

I ask teams to focus on efficiency, ⬆️ time for teaching/ discussion

⏳⬇️ transitions b/w patients by alerting next RN
⏳Enter orders on rounds, w/ clearly defined roles as to who will do that
⏳Present from memory (if possible), focusing on critical issues
2️⃣ Education

🧠I ❤️ to teach but avoid overwhelming residents by teaching high yield points on 2-3 patients max. I supplement w/ PM chalk talks after lunch and notes are done

🧠 I also ask each learner to share one learning point from rounds, and do so myself as well
Read 5 tweets

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