The Severe Gout of Emperor Charles V
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《新英格兰医药杂志》
To the Editor: Ordi et al. (Aug. 3 issue)1 confirm that the Holy Roman Emperor Charles V suffered from what physicians had long suspected was severe tophaceous gout.2 Lead poisoning may also have contributed to the decline and fall of this emperor.3 Saturnine gout results from exposure to lead through the addition of lead sugar (acetate) to wine to sweeten it and from the leaching of lead from glazes on amphora or from pewter drinking vessels.
Voracious consumption of wine (and lead) addled not only the Romans, but also the bibulous, podagrous English aristocrats of the 18th century,4 who were immortalized by Hogarth's caricatures. Ordi and colleagues tell us that Charles V liked to drink large quantities of beer and wine and that he even ordered a specially designed four-handled drinking mug. It would be fascinating to know the material from which his chalice was made. Even more interesting would be an analysis of the final phalanx of the emperor's fifth finger for lead content.
Richard T.L. Couper, F.R.A.C.P.
University of Adelaide
Adelaide 5006, Australia
richard.couper@adelaide.edu.au
References
Ordi J, Alonso PL, de Zulueta J, et al. The severe gout of Holy Roman Emperor Charles V. N Engl J Med 2006;355:516-520.
Boonen A, van der Linden SJ. Case number 33: about being a famous European and suffering from gout.... Ann Rheum Dis 2005;64:528-528.
Nriagu JO. Saturnine gout among Roman aristocrats: did lead poisoning contribute to the fall of the Empire? N Engl J Med 1983;308:660-663.
Ball GV. Two epidemics of gout. Bull Hist Med 1971;45:401-408.
The authors reply: Dr. Couper suggests the interesting possibility of lead poisoning as a cause of Emperor Charles V's gout,1 a condition that has been reported to have afflicted other historic figures.2 Chronic lead poisoning impairs urate excretion, leading to hyperuricemia,3,4 and the composition of the crystals in the joints is similar to that of crystals caused by common gout. Nevertheless, we used scanning electron microscopy to further analyze the bone and soft tissues surrounding the tophi from Charles V and found no traces of lead. It would be interesting to know whether the emperor's specially designed mug or other vessels contained lead, but we have no record of their current whereabouts. The negative results of our recent analysis and the historical records regarding the emperor's gluttony suggest that his condition was most likely related to his dietary habits.
Pedro L. Fernández, M.D.
Pedro L. Alonso, M.D.
Hospital Clínic d'Investigacions Biomèdiques August Pi i Sunyer
08036 Barcelona, Spain
References
Boonen A, van der Linden SJ. Case number 33: about being a famous European and suffering from gout.... Ann Rheum Dis 2005;64:528-528.
Nriagu JO. Saturnine gout among Roman aristocrats: did lead poisoning contribute to the fall of the Empire? N Engl J Med 1983;308:660-663.
Lin JL, Huang PT. Body lead stores and urate excretion in men with chronic renal disease. J Rheumatol 1994;21:705-709.
Shadick NA, Kim R, Weiss S, Liang MH, Sparrow D, Hu H. Effect of low level lead exposure on hyperuricemia and gout among middle aged and elderly men: the Normative Aging Study. J Rheumatol 2000;27:1708-1712.
Voracious consumption of wine (and lead) addled not only the Romans, but also the bibulous, podagrous English aristocrats of the 18th century,4 who were immortalized by Hogarth's caricatures. Ordi and colleagues tell us that Charles V liked to drink large quantities of beer and wine and that he even ordered a specially designed four-handled drinking mug. It would be fascinating to know the material from which his chalice was made. Even more interesting would be an analysis of the final phalanx of the emperor's fifth finger for lead content.
Richard T.L. Couper, F.R.A.C.P.
University of Adelaide
Adelaide 5006, Australia
richard.couper@adelaide.edu.au
References
Ordi J, Alonso PL, de Zulueta J, et al. The severe gout of Holy Roman Emperor Charles V. N Engl J Med 2006;355:516-520.
Boonen A, van der Linden SJ. Case number 33: about being a famous European and suffering from gout.... Ann Rheum Dis 2005;64:528-528.
Nriagu JO. Saturnine gout among Roman aristocrats: did lead poisoning contribute to the fall of the Empire? N Engl J Med 1983;308:660-663.
Ball GV. Two epidemics of gout. Bull Hist Med 1971;45:401-408.
The authors reply: Dr. Couper suggests the interesting possibility of lead poisoning as a cause of Emperor Charles V's gout,1 a condition that has been reported to have afflicted other historic figures.2 Chronic lead poisoning impairs urate excretion, leading to hyperuricemia,3,4 and the composition of the crystals in the joints is similar to that of crystals caused by common gout. Nevertheless, we used scanning electron microscopy to further analyze the bone and soft tissues surrounding the tophi from Charles V and found no traces of lead. It would be interesting to know whether the emperor's specially designed mug or other vessels contained lead, but we have no record of their current whereabouts. The negative results of our recent analysis and the historical records regarding the emperor's gluttony suggest that his condition was most likely related to his dietary habits.
Pedro L. Fernández, M.D.
Pedro L. Alonso, M.D.
Hospital Clínic d'Investigacions Biomèdiques August Pi i Sunyer
08036 Barcelona, Spain
References
Boonen A, van der Linden SJ. Case number 33: about being a famous European and suffering from gout.... Ann Rheum Dis 2005;64:528-528.
Nriagu JO. Saturnine gout among Roman aristocrats: did lead poisoning contribute to the fall of the Empire? N Engl J Med 1983;308:660-663.
Lin JL, Huang PT. Body lead stores and urate excretion in men with chronic renal disease. J Rheumatol 1994;21:705-709.
Shadick NA, Kim R, Weiss S, Liang MH, Sparrow D, Hu H. Effect of low level lead exposure on hyperuricemia and gout among middle aged and elderly men: the Normative Aging Study. J Rheumatol 2000;27:1708-1712.