Avraham Z. Cooper, MD 🩺 Profile picture
Sep 24, 2019 14 tweets 8 min read Read on X
1/
Were ancient Romans chronically lead poisoned and did this contribute to the decline of ancient Rome?

This #medhistory #tweetorial explores these questions as well as the pathophysiology of Saturnine gout!

CC: @tony_breu @AdamRodmanMD @virenkaul @ETSshow @DrStevenTChen Image
2/
The hypothesis that ancient Romans may have been chronically lead poisoned was first explored in @NEJM in 1983 due to the observation that Roman aristocrats and rulers had notably high rates of gout.

bit.ly/2mnp1du Image
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Chronic lead exposure predisposes to gout by poisoning the proximal renal tubule's ability to excrete uric acid, ? via interference with the function of the URAT1 transporter, raising serum uric acid levels.

urlzs.com/AuMQN
Image source: goutpal.com Image
4/
The resultant gout has been called "Saturnine" gout, in reference to Saturn, the alchemical name for lead, as well as the Roman festival of Saturnalia, where much wine was drunk (which, we will see, is relevant to our initial question)

Pic source: illuminatiwatcher.com Image
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So if the Roman aristocracy had high rates of gout, is there any evidence that it was "Saturnine" in nature, or due to high lead levels?
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Examination of lead levels in the skeletons of ancient Romans did reveal very high lead levels (though comparable to those in Medieval Britain)!

urlzs.com/M29gF

Adapted from: Poweredbyosteons.com Image
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Romans sweetened their wine with a syrup called sapa, which was produced by boiling grapes in leaden pots. The heat leached the lead from the pots into the sapa, which was then consumed. This is thought to be the main source of Roman lead exposure.

urlzs.com/7pacp Image
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The lead content in ancient Roman sapa was actually extraordinarily high, almost 800X higher than that tested in the water supply of Flint, MI!

urlzs.com/7pacp Image
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Other potential sources of Roman lead exposure were lead-infused make up products and lead pipes of aqueducts, leading to elevated lead levels in the general water supply. Roman tap water had about 100X more lead than the surrounding natural springs.

urlzs.com/M29gF Image
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So, were ancient Romans, especially the aristocratic and leadership class (who drank a lot of wine), chronically lead poisoned? The evidence suggests yes.

Did this contribute to high gout rates? Possibly.
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Chronic lead poisoning is also associated with infertility and after the reign of Augustus the Roman birth rate and population began to decline steeply, especially after 150 AD.

🧐 This was particularly pronounced amongst the aristocracy.

urlzs.com/Umtbk Image
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Can we draw a connection between a chronically lead-poisoned populace, low birth rates, population decline, and the decline and fall of the Roman Empire? What do you think?
13/
To sum up what we've learned:

▶️ Ancient Romans had high blood lead levels
▶️ This may have been due to significant sapa (syrup) consumption and leaden aqueduct pipes
▶️ It also may have contributed to high gout rates amongst the Roman aristocracy
14/
And a lingering question:

▶️ Did lead poisoning contribute to infertility and Roman population/social decline?

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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…
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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…
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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
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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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