PRESIDENTIAL ADDRESS
COLORADO -ENVIRONMENT- MEDICINE - A CONTINUUM S. G. BLOUNT, M.D. Denver
It is my pleasure to have this opportunity to welcome you to Colorado and particularly to Colorado Springs on the occasion of the 90th meeting of the American Clinical and Climatological Association. I will not dwell on the reasons why I am here this morning in this position for they defy logical explanation; suffice it to say that I am profoundly grateful for the distinction and privilege of having been asked to serve as your President. Bill Bean in his Presidential Address of ten years ago cleverly reviewed the gamut of emotions that one experiences from the time of being asked to serve to this very moment of stark reality. As has every President before me I have reviewed many of the addresses of previous incumbents of this office. I took comfort in the great latitude that I might be allowed as to the content of the address or even to the extreme of no address. It is a matter of record that in 1892, Willis E. Ford of Utica, New York, was the President, and he elected not to deliver an address. The meeting was held in Richfield Springs, New York, and Ford enlisted Charles C. Ransom, a local resident and a member of the Association to give simply an address of welcome. This was a tempting solution to the worrisome responibility of the Presidential Address. In fact you might well prefer this to the Presidential Address of William Pepper of Philadelphia, who in 1886 devoted two hours to a discussion of the climatological features of the state of Pennsylvania. However, on further thought I found myself compelled by the precedence of recent years and the insistence of our secretary to offer an address at this time. The first meeting of our Association to be held in Colorado was in Denver in 1890, and Charles Denison of Denver was the President. He gave a welcoming address only but then did contribute the first paper on the program. I would like now to quote from his welcoming address. "We have thought it eminently fit that an Association which is devoted to the subject of climate should once in a while meet in that part of the country blest in a climate fully rich in nature's gifts, is especially blest in a climate which may be favorably contrasted with that of all other sections represented by the abodes of the Association members. We have desired that you would come up here to investigate these claims yourselves, to see the brightness with which the sun shines and feel the expansive influence of breathing the rarefied air. We hope that the 1
2 S. G. BLOUNT times and the skies may be propitious for a successful and happy sojourn for all of you." Possibly as a reaction to this chauvinistic reference to our climate it was only after a sustained effort that the meeting returned to Colorado and to Colorado Springs. An invitation to hold the meeting in Colorado Springs was first extended in 1888 by Dr. Edwin Solly of Colorado Springs, again extended in 1904, and again in 1930. Finally an invitation by Dr. James J. Waring in 1946, was accepted and the first meeting in Colorado Springs was held the following year 1947. I am pleased to relate that the membership apparently enjoyed that meeting for subsequent meetings were held in 1964, 1973, and now again in 1977. The climate and environment of this region have had a powerful influence on the early development of the State of Colorado and during that period (the latter quarter of the 19th century) it also left its mark on the early years of our own Association. This positive influence stemmed directly from the individuals and in our instance the physicians who migrated to Colorado in search of a cure of their tuberculosis, for during these years the climate and environment of Colorado were considered to have a significant curative effect on respiratory diseases and in particular tuberculosis. P. T. Barnum observed that Colorado people are "disappointed" and stated, "Two-thirds of them came here to die, and they can't do it. The wonderful air brings them back from the verge of the tomb." I seriously doubt that all had tuberculosis for many lived long and productive lives dying from other causes. It might also be noted that it was not until 1882 that Robert Koch isolated and cultured
the tubercle bacillus. There have been seven physicians previously elected to the Presidency of this Association from the State of Colorado. I would like at this point to note these physicians and state a few facts about their backgrounds. Charles Denison was a charter member of this Association and President in 1890. He graduated from the University of Vermont in 1869 and then practiced ophthalmology in Hartford, Connecticut, until developing tuberculosis with hemorrhage during Christmas of 1873. He moved to Denver because of his tuberculosis in 1874. He was a great enthusiast of the climate and in the development of Rocky Mountain Health Resorts. He was Professor of Diseases of the Chest and Climatology at the Medical College of the University of Denver. He died on January 10, 1909 of septicemia following cholecystitis. Samuel Edwin Solly was President in 1895. He was born in London on May 5, 1845 and educated at Rugby and St. Thomas Medical College. He contracted tuberculosis and in search of a more favorable climate came to Colorado Springs, in 1875, at the age of 30. He was President of
3 the Colorado State Medical Society 1887-88. He was also the founder of the Cragmor Sanatorium in Colorado Springs and also one of the developers of the Antler's Hotel. He was a founder of the National Tuberculosis Association. He died November 18, 1906, on a visit to Asheville, North Carolina. Samuel E. Fisk was born in Northhampton, Massachusetts in 1856, attended Yale College and received his M.D. from Harvard in 1880. While a houseofficer at the Massachusetts General Hospital he developed acute tuberculous pneumonia and came to Colorado in 1882. He succeeded Samuel Solly as President of the Colorado State Medical Society 1888-89. He was Professor of Medicine of the Medical School of the University of Denver and Dean of the School from 1895 to 1899. He was also the major force behind the founding of the medical library of the Medical Society. He was sickly most of his life and returned to Massachusetts to die at the age of 59 in 1915. Henry Sewall was President in 1915. He was from a very old New England family. His ancestor Judge Samuel Sewall was involved in the Salem Witch trials of the 1690's. His grandfather Thomas Sewall also had tuberculosis and was a physician while his father Thomas Sewall, a clergyman, likewise had tuberculosis. Henry Sewall was born in Winchester, Virginia, in 1855 as his father had a parish in this community. He attended Wesleyan in 1871-75 and then went to Johns Hopkins University where he earned a Ph.D. in physiology. He became Professor of Physiology at Michigan where he contracted tuberculosis and because of this moved to Denver. It was Samuel Fisk who persuaded him to come to Denver for his health and following his recovery he went to medical school at the University of Denver. He was also a President of the Colorado Medical Society. He had many scientific accomplishments that time does not permit a discussion of, however, he was a well recognized scientist who lived a full and most productive life before dying at the age of 81 of a heart attack in 1936. Carroll E. Edson was President in 1921. He was born in Massachusetts in 1860, the son of a physician, received an A.B. from Harvard in 1888 and his M.D. from Harvard in 1892. While a houseofficer at the Boston City Hospital he contracted tuberculosis and then came to Colorado for his health in 1894. He was Professor of Therapeutics at the University of Denver School of Medicine 1897-1906 and later Professor of Theory and Practice of Medicine at the University of Colorado School of Medicine. He was President of the Medical Society of the City and County of Denver in 1914. He died in 1930 at the age of 62. Gerald B. Webb was President of our Association in 1930. He was born in Cheltenham England, September 24, 1871. He attended Guys Hospital Medical School and while a student, both he and his wife PRESIDENT'S ADDRESS
4
S. G. BLOUNT
developed tuberculosis and they came to Colorado Springs in 1893. Mrs. Webb died a few years later. He received his M.D. degree from the University of Denver in 1896. He was the founder of the Colorado Foundation and Research in tuberculosis, now the Webb-Waring Institute on our campus at the University of Colorado School of Medicine. He was President of the Colorado State Medical Society 1933-34. He was a man of wide interests and varied talents and apparently recovered from his tuberculosis and died suddenly from coronary artery disease at the age of 78 in 1948. James J. Waring was our President in 1941. He was born in Savannah, Georgia, in 1883 and graduated from Yale College in 1904. He began the study of medicine at Johns Hopkins where he developed tuberculosis and subsequently moved to Colorado. When he recovered his health he entered the University of Colorado School of Medicine and was graduated in 1913. He engaged in private practice of medicine in Denver until 1933 when he became the first full-time Professor of Medicine at the University of Colorado School of Medicine. Many of you here no doubt remember Dr. Waring as a fine gentleman and one of the last of the compleat physicians. Thus, in the first 18 years of the Association there were three Presidents from the State of Colorado which is rather remarkable when one considers the State was in its infancy and that in the year 1900 the population of the State was just in excess of 500,000. It is also of interest to note that on the occasion of the 17th annual meeting in that year 1900, with a total membership of 107, that ten members were from Colorado. I might add that currently there are six members from Colorado of a total membership of 323. All of these men came from the East or Southeast with the exception of Solly and Webb who came from England. All had been afforded the finest of educational backgrounds and without exception, were men of great talent and stature. Finally and most pertinent to this discussion is that all came to Colorado because of tuberculosis and for the salubrious effects of the climate and environment. Although it was the supposedly favorable effects of the local environment that brought people to Colorado these and other early members of our Association were cognizant of the fact that not all effects of the environment were beneficial. As I reviewed the early Transactions of the Association it was noted that there were ten papers presented during the years from 1886 to 1908 on the adverse effects of altitude on the heart and circulation. During the ensuing 69 years there have been no further notations relative to this subject. At this time allow me to refer briefly to a few of these early presentations. The first paper was delivered by Alfred L. Loomis, the first President
PRESIDENT'S ADDRESS
5
of our Association, at the third meeting in 1886. It was entitled, "The Effects of High Altitudes on Cardiac Disease". He presented six case histories illustrating the deleterious effects of patients going to altitudes from four to six thousand feet. It is doubtful that the altitude was of significance but his thoughts are of interest. I quote, "the ventricular dilatation which unquestionably was the cause of the sudden development of the distressing symptoms, seemed to be directly due to the effects on the cardiac circulation of the changes from a low to a high altitude". He believed the dilatation to be the result of, "an abnormal degree of blood pressure," which "if the resulting power of the cardiac walls is greatly impaired may produce cardiac dilatation". (This prior to Riva Rocci's development of the sphygmomonometer, 1899.) In 1888 Dr. Frank Donaldson of the University of Maryland offered a paper entitled, "On the Causes of Cardiac Failure in High Altitudes". He concluded "the chief and immediate cause of dyspnea and cardiac failure may, I think be traced to the diminished pressure on the heart walls and their consequent dilatation". His explanation was that the Ba pressure 760 mmHg. at sea level presses against the interior of the lungs and pushes them against the heart and great blood vessels and the inside of the chest walls. He stated that at an altitude of 10,000 feet the pressure on the heart would only be 494 mmHg; actually the altitude of Leadville is 10,150 feet and its barmometric pressure 525 mmHg. He then noted, "now the arterial pressure and therefore, the intracardiac pressure would be the same as if at sea level when the pressure on the heart walls was 760 mm and the result would be a stretching and dilatation of the heart walls-especially of the right side -and this is precisely what is found in many of those who go onto high altitudes for their health or for other reasons and what we found in experiments upon animals". Two years later in 1890 Dr. Donaldson gave another paper on the same subject and came to the same conclusion. Henry Sewall presented a paper at the Annual meeting of the Association in 1902 entitled, "Altitude in Fact and Fancy". This paper discussed the effect of altitude on the course of pulmonary tuberculosis, and he stressed the point that many patients with tuberculosis do not do well at altitude. During the discussion he did state relative to the heart "that the characteristic effect of high altitude upon the circulation is an overloading, with a tendency to strain, of the right side of the heart". Although there is some truth in this statement, his thoughts as to the pathophysiology were at variance with our current understanding. Earlier Charles Denison had appreciated the fact that patients with respiratory diseases other than tuberculosis, namely emphysema, do not tolerate higher altitudes. His presentation at the meeting in Denver in 1890 tells of a man with emphysema from Warren, Massachu-
6 S. G. BLOUNT setts, who came to Denver for his health. "The young man went to Idaho Springs as advised but returned at once stating he could not stand it. This confirmed my diagnosis as to emphysema in his case and as to the advisability of his going East. From his home he writes me July 1, 1855, 'You would be surprised to see me since my return; the swelling has all gone from my face and feet. My strength is coming back to me. I harness and take care of the horse, run a lawn mower and do much outdoor work'." The last reference to the heart and circulation and altitude was by Josiah N. Hall, a Denver physician, who presented to the Association in 1908 a paper entitled, "Cardiac Danger in High Altitude". This paper discussed the potential danger of patients with known heart disease who exercise vigorously at high altitude. Of great interest is his report concerning a patient without known heart disease who ascended abruptly to high altitude and I quote, "One patient had been a hunter and trapper in the Rocky Mountains until 50 years of age when he purchased a ranch in the Arkansas Valley at an elevation of only 3,000 to 4,000 feet. Seven years later some friends visited him from the East, and he took them up Long's Peak, over 14,000 feet in altitude. He suffered greatly from palpitations and dyspnea, but his grit being better than his judgment, he continued until he dropped from exhaustion and dyspnea. When he started he was a hale-looking ranchman of 57 years, with no suggestion of heart disease." This case historyis of interest for it may well represent one of the earliest reports of an individual with high altitude pulmonary edema, a fascinating entity that currently holds great concern for our group. While ascending abruptly to such an altitude does result in changes in cardiovascular function they are not of serious consequence and never result in the failure of a normal heart. There were no further papers related to the deleterious effects of altitude on the lungs, heart and circulation and this may well reflect the general trend that was developing relative to the interests of the members of the Climatological Association as it was called at that time. There was a definite decrease in interest in climate and environment as related to the treatment of respiratory diseases as it became increasingly apparent that other factors were of greater importance. This is reflected in the changing of the name of the Association in 1914, to the American Climatological and Clinical Association following the suggestion by Dr. Charles L. Minor of Asheville, North Carolina in his Presidential address of the previous year. Stewart Wolf in his Presidential Address of last year also referred to the growing dissatisfaction of some of the members at that time over the narrow focus of interest by the Association and also quoted from Henry Sewall's Presidential Address.
PRESIDENT'S
ADDRESS
7
However, some members of the Association continued to believe strongly that vital information could still be learned from the effects of environment on the body and they deplored the tendency of many members to advocate a more widespread interest. Thus, Henry Sewall, in his Presidential address of the following year 1915, made the following remarks. "A year ago it was formerly decided that the best interests of our organization demanded an extension of its scope to embrace practically all conceivable disorders of the human frame. Like pampered children we reject half-eaten our piece of bread and butter to grab the cake and candy left within our reach." He went on to say, "Has the scope of legitimate activity laid down by our founders so narrowed that we have no longer sufficient standing room within it, or rather has the intellectual curiosity and energy of this generation retrograded, and do we fail to grasp the opportunities spread before us?" Along similar lines Dr. Carroll E. Edson of Denver in his Presidential Address of 1921 remarks as follows. "Climatology is not a field to be neglected or one of narrow interest. Indeed the last six years have seen its boundaries enormously extended. We are no longer confined by latitudes and longitudes. We have added a third dimension to our realm, and now know no limits in space to what our Association may not soar. The paramount importance of aviation in war and its growing usefulness in commerce has necessitated an intensive study of the physiologic effects of higher altitude such as we little dreamed of ten years ago." Dr. Edson further urged the establishment of laboratories for clinical research as to the effects of altitude. He stated, "one should be at sea level and the other in a high arid inland region. Such research work could be done in a laboratory of our own, or if not so feasible, by aid of our funds in connection with some already established foundation for medical or physiological research." Thus, it would seem appropriate that currently some members of the Association and in particular residents of Colorado should have heeded the advice of their illustrious predecessors. It was Dr. James J. Waring, the President of our Association in 1941, who was largely instrumental in my decision to come to the University of Colorado School of Medicine. Although one dislikes to break with tradition in contrast to all of the earlier Presidents from Colorado, I do not have tuberculosis as best I know although I will admit that the climate did have a favorable influence on my decision to come to Colorado. My interest in the effect of altitude (hypoxia) on the heart and in particular the pulmonary circulation was kindled shortly after arrival in Colorado in 1950 when an acquaintance inquired as to whether I knew why one of his yearling steers had developed heart failure and died while pastured in South Park at an elevation of 10,000 feet.
8
S. G. BLOUNT
This was my first introduction to Brisket disease of cattle and was the initiation of my interest in the effect of hypoxia on the pulmonary circulation, an interest that has developed and continued unabated to the present. While this is not the appropriate time to discuss in any detail the problems involved, it may be said that the research interests of our division of Cardiology have since that time been involved with the effect of hypoxia upon the pulmonary circulation. This lead to the development of a high altitude laboratory in 1960, located in St. Vincent's Hospital in Leadville, Colorado, at an altitude of 10,150 feet. Through this brief address I have recalled to mind that the climate and environment of Colorado was a powerful and beneficial influence in the early development of this State and at the same time exercised a positive effect on the growth of our Association during its early years. The changing interest in climate and environment as medical knowledge advanced and new problems arose has been referred to, and I have indicated that a healthy concern as to the influence of the environment upon mankind continues within our Association. Finally it is hoped that this sustained interest would greatly please the founders of our Association.
COLORADO -ENVIRONMENT- MEDICINE - A CONTINUUM S. G. BLOUNT, M.D. Denver
It is my pleasure to have this opportunity to welcome you to Colorado and particularly to Colorado Springs on the occasion of the 90th meeting of the American Clinical and Climatological Association. I will not dwell on the reasons why I am here this morning in this position for they defy logical explanation; suffice it to say that I am profoundly grateful for the distinction and privilege of having been asked to serve as your President. Bill Bean in his Presidential Address of ten years ago cleverly reviewed the gamut of emotions that one experiences from the time of being asked to serve to this very moment of stark reality. As has every President before me I have reviewed many of the addresses of previous incumbents of this office. I took comfort in the great latitude that I might be allowed as to the content of the address or even to the extreme of no address. It is a matter of record that in 1892, Willis E. Ford of Utica, New York, was the President, and he elected not to deliver an address. The meeting was held in Richfield Springs, New York, and Ford enlisted Charles C. Ransom, a local resident and a member of the Association to give simply an address of welcome. This was a tempting solution to the worrisome responibility of the Presidential Address. In fact you might well prefer this to the Presidential Address of William Pepper of Philadelphia, who in 1886 devoted two hours to a discussion of the climatological features of the state of Pennsylvania. However, on further thought I found myself compelled by the precedence of recent years and the insistence of our secretary to offer an address at this time. The first meeting of our Association to be held in Colorado was in Denver in 1890, and Charles Denison of Denver was the President. He gave a welcoming address only but then did contribute the first paper on the program. I would like now to quote from his welcoming address. "We have thought it eminently fit that an Association which is devoted to the subject of climate should once in a while meet in that part of the country blest in a climate fully rich in nature's gifts, is especially blest in a climate which may be favorably contrasted with that of all other sections represented by the abodes of the Association members. We have desired that you would come up here to investigate these claims yourselves, to see the brightness with which the sun shines and feel the expansive influence of breathing the rarefied air. We hope that the 1
2 S. G. BLOUNT times and the skies may be propitious for a successful and happy sojourn for all of you." Possibly as a reaction to this chauvinistic reference to our climate it was only after a sustained effort that the meeting returned to Colorado and to Colorado Springs. An invitation to hold the meeting in Colorado Springs was first extended in 1888 by Dr. Edwin Solly of Colorado Springs, again extended in 1904, and again in 1930. Finally an invitation by Dr. James J. Waring in 1946, was accepted and the first meeting in Colorado Springs was held the following year 1947. I am pleased to relate that the membership apparently enjoyed that meeting for subsequent meetings were held in 1964, 1973, and now again in 1977. The climate and environment of this region have had a powerful influence on the early development of the State of Colorado and during that period (the latter quarter of the 19th century) it also left its mark on the early years of our own Association. This positive influence stemmed directly from the individuals and in our instance the physicians who migrated to Colorado in search of a cure of their tuberculosis, for during these years the climate and environment of Colorado were considered to have a significant curative effect on respiratory diseases and in particular tuberculosis. P. T. Barnum observed that Colorado people are "disappointed" and stated, "Two-thirds of them came here to die, and they can't do it. The wonderful air brings them back from the verge of the tomb." I seriously doubt that all had tuberculosis for many lived long and productive lives dying from other causes. It might also be noted that it was not until 1882 that Robert Koch isolated and cultured
the tubercle bacillus. There have been seven physicians previously elected to the Presidency of this Association from the State of Colorado. I would like at this point to note these physicians and state a few facts about their backgrounds. Charles Denison was a charter member of this Association and President in 1890. He graduated from the University of Vermont in 1869 and then practiced ophthalmology in Hartford, Connecticut, until developing tuberculosis with hemorrhage during Christmas of 1873. He moved to Denver because of his tuberculosis in 1874. He was a great enthusiast of the climate and in the development of Rocky Mountain Health Resorts. He was Professor of Diseases of the Chest and Climatology at the Medical College of the University of Denver. He died on January 10, 1909 of septicemia following cholecystitis. Samuel Edwin Solly was President in 1895. He was born in London on May 5, 1845 and educated at Rugby and St. Thomas Medical College. He contracted tuberculosis and in search of a more favorable climate came to Colorado Springs, in 1875, at the age of 30. He was President of
3 the Colorado State Medical Society 1887-88. He was also the founder of the Cragmor Sanatorium in Colorado Springs and also one of the developers of the Antler's Hotel. He was a founder of the National Tuberculosis Association. He died November 18, 1906, on a visit to Asheville, North Carolina. Samuel E. Fisk was born in Northhampton, Massachusetts in 1856, attended Yale College and received his M.D. from Harvard in 1880. While a houseofficer at the Massachusetts General Hospital he developed acute tuberculous pneumonia and came to Colorado in 1882. He succeeded Samuel Solly as President of the Colorado State Medical Society 1888-89. He was Professor of Medicine of the Medical School of the University of Denver and Dean of the School from 1895 to 1899. He was also the major force behind the founding of the medical library of the Medical Society. He was sickly most of his life and returned to Massachusetts to die at the age of 59 in 1915. Henry Sewall was President in 1915. He was from a very old New England family. His ancestor Judge Samuel Sewall was involved in the Salem Witch trials of the 1690's. His grandfather Thomas Sewall also had tuberculosis and was a physician while his father Thomas Sewall, a clergyman, likewise had tuberculosis. Henry Sewall was born in Winchester, Virginia, in 1855 as his father had a parish in this community. He attended Wesleyan in 1871-75 and then went to Johns Hopkins University where he earned a Ph.D. in physiology. He became Professor of Physiology at Michigan where he contracted tuberculosis and because of this moved to Denver. It was Samuel Fisk who persuaded him to come to Denver for his health and following his recovery he went to medical school at the University of Denver. He was also a President of the Colorado Medical Society. He had many scientific accomplishments that time does not permit a discussion of, however, he was a well recognized scientist who lived a full and most productive life before dying at the age of 81 of a heart attack in 1936. Carroll E. Edson was President in 1921. He was born in Massachusetts in 1860, the son of a physician, received an A.B. from Harvard in 1888 and his M.D. from Harvard in 1892. While a houseofficer at the Boston City Hospital he contracted tuberculosis and then came to Colorado for his health in 1894. He was Professor of Therapeutics at the University of Denver School of Medicine 1897-1906 and later Professor of Theory and Practice of Medicine at the University of Colorado School of Medicine. He was President of the Medical Society of the City and County of Denver in 1914. He died in 1930 at the age of 62. Gerald B. Webb was President of our Association in 1930. He was born in Cheltenham England, September 24, 1871. He attended Guys Hospital Medical School and while a student, both he and his wife PRESIDENT'S ADDRESS
4
S. G. BLOUNT
developed tuberculosis and they came to Colorado Springs in 1893. Mrs. Webb died a few years later. He received his M.D. degree from the University of Denver in 1896. He was the founder of the Colorado Foundation and Research in tuberculosis, now the Webb-Waring Institute on our campus at the University of Colorado School of Medicine. He was President of the Colorado State Medical Society 1933-34. He was a man of wide interests and varied talents and apparently recovered from his tuberculosis and died suddenly from coronary artery disease at the age of 78 in 1948. James J. Waring was our President in 1941. He was born in Savannah, Georgia, in 1883 and graduated from Yale College in 1904. He began the study of medicine at Johns Hopkins where he developed tuberculosis and subsequently moved to Colorado. When he recovered his health he entered the University of Colorado School of Medicine and was graduated in 1913. He engaged in private practice of medicine in Denver until 1933 when he became the first full-time Professor of Medicine at the University of Colorado School of Medicine. Many of you here no doubt remember Dr. Waring as a fine gentleman and one of the last of the compleat physicians. Thus, in the first 18 years of the Association there were three Presidents from the State of Colorado which is rather remarkable when one considers the State was in its infancy and that in the year 1900 the population of the State was just in excess of 500,000. It is also of interest to note that on the occasion of the 17th annual meeting in that year 1900, with a total membership of 107, that ten members were from Colorado. I might add that currently there are six members from Colorado of a total membership of 323. All of these men came from the East or Southeast with the exception of Solly and Webb who came from England. All had been afforded the finest of educational backgrounds and without exception, were men of great talent and stature. Finally and most pertinent to this discussion is that all came to Colorado because of tuberculosis and for the salubrious effects of the climate and environment. Although it was the supposedly favorable effects of the local environment that brought people to Colorado these and other early members of our Association were cognizant of the fact that not all effects of the environment were beneficial. As I reviewed the early Transactions of the Association it was noted that there were ten papers presented during the years from 1886 to 1908 on the adverse effects of altitude on the heart and circulation. During the ensuing 69 years there have been no further notations relative to this subject. At this time allow me to refer briefly to a few of these early presentations. The first paper was delivered by Alfred L. Loomis, the first President
PRESIDENT'S ADDRESS
5
of our Association, at the third meeting in 1886. It was entitled, "The Effects of High Altitudes on Cardiac Disease". He presented six case histories illustrating the deleterious effects of patients going to altitudes from four to six thousand feet. It is doubtful that the altitude was of significance but his thoughts are of interest. I quote, "the ventricular dilatation which unquestionably was the cause of the sudden development of the distressing symptoms, seemed to be directly due to the effects on the cardiac circulation of the changes from a low to a high altitude". He believed the dilatation to be the result of, "an abnormal degree of blood pressure," which "if the resulting power of the cardiac walls is greatly impaired may produce cardiac dilatation". (This prior to Riva Rocci's development of the sphygmomonometer, 1899.) In 1888 Dr. Frank Donaldson of the University of Maryland offered a paper entitled, "On the Causes of Cardiac Failure in High Altitudes". He concluded "the chief and immediate cause of dyspnea and cardiac failure may, I think be traced to the diminished pressure on the heart walls and their consequent dilatation". His explanation was that the Ba pressure 760 mmHg. at sea level presses against the interior of the lungs and pushes them against the heart and great blood vessels and the inside of the chest walls. He stated that at an altitude of 10,000 feet the pressure on the heart would only be 494 mmHg; actually the altitude of Leadville is 10,150 feet and its barmometric pressure 525 mmHg. He then noted, "now the arterial pressure and therefore, the intracardiac pressure would be the same as if at sea level when the pressure on the heart walls was 760 mm and the result would be a stretching and dilatation of the heart walls-especially of the right side -and this is precisely what is found in many of those who go onto high altitudes for their health or for other reasons and what we found in experiments upon animals". Two years later in 1890 Dr. Donaldson gave another paper on the same subject and came to the same conclusion. Henry Sewall presented a paper at the Annual meeting of the Association in 1902 entitled, "Altitude in Fact and Fancy". This paper discussed the effect of altitude on the course of pulmonary tuberculosis, and he stressed the point that many patients with tuberculosis do not do well at altitude. During the discussion he did state relative to the heart "that the characteristic effect of high altitude upon the circulation is an overloading, with a tendency to strain, of the right side of the heart". Although there is some truth in this statement, his thoughts as to the pathophysiology were at variance with our current understanding. Earlier Charles Denison had appreciated the fact that patients with respiratory diseases other than tuberculosis, namely emphysema, do not tolerate higher altitudes. His presentation at the meeting in Denver in 1890 tells of a man with emphysema from Warren, Massachu-
6 S. G. BLOUNT setts, who came to Denver for his health. "The young man went to Idaho Springs as advised but returned at once stating he could not stand it. This confirmed my diagnosis as to emphysema in his case and as to the advisability of his going East. From his home he writes me July 1, 1855, 'You would be surprised to see me since my return; the swelling has all gone from my face and feet. My strength is coming back to me. I harness and take care of the horse, run a lawn mower and do much outdoor work'." The last reference to the heart and circulation and altitude was by Josiah N. Hall, a Denver physician, who presented to the Association in 1908 a paper entitled, "Cardiac Danger in High Altitude". This paper discussed the potential danger of patients with known heart disease who exercise vigorously at high altitude. Of great interest is his report concerning a patient without known heart disease who ascended abruptly to high altitude and I quote, "One patient had been a hunter and trapper in the Rocky Mountains until 50 years of age when he purchased a ranch in the Arkansas Valley at an elevation of only 3,000 to 4,000 feet. Seven years later some friends visited him from the East, and he took them up Long's Peak, over 14,000 feet in altitude. He suffered greatly from palpitations and dyspnea, but his grit being better than his judgment, he continued until he dropped from exhaustion and dyspnea. When he started he was a hale-looking ranchman of 57 years, with no suggestion of heart disease." This case historyis of interest for it may well represent one of the earliest reports of an individual with high altitude pulmonary edema, a fascinating entity that currently holds great concern for our group. While ascending abruptly to such an altitude does result in changes in cardiovascular function they are not of serious consequence and never result in the failure of a normal heart. There were no further papers related to the deleterious effects of altitude on the lungs, heart and circulation and this may well reflect the general trend that was developing relative to the interests of the members of the Climatological Association as it was called at that time. There was a definite decrease in interest in climate and environment as related to the treatment of respiratory diseases as it became increasingly apparent that other factors were of greater importance. This is reflected in the changing of the name of the Association in 1914, to the American Climatological and Clinical Association following the suggestion by Dr. Charles L. Minor of Asheville, North Carolina in his Presidential address of the previous year. Stewart Wolf in his Presidential Address of last year also referred to the growing dissatisfaction of some of the members at that time over the narrow focus of interest by the Association and also quoted from Henry Sewall's Presidential Address.
PRESIDENT'S
ADDRESS
7
However, some members of the Association continued to believe strongly that vital information could still be learned from the effects of environment on the body and they deplored the tendency of many members to advocate a more widespread interest. Thus, Henry Sewall, in his Presidential address of the following year 1915, made the following remarks. "A year ago it was formerly decided that the best interests of our organization demanded an extension of its scope to embrace practically all conceivable disorders of the human frame. Like pampered children we reject half-eaten our piece of bread and butter to grab the cake and candy left within our reach." He went on to say, "Has the scope of legitimate activity laid down by our founders so narrowed that we have no longer sufficient standing room within it, or rather has the intellectual curiosity and energy of this generation retrograded, and do we fail to grasp the opportunities spread before us?" Along similar lines Dr. Carroll E. Edson of Denver in his Presidential Address of 1921 remarks as follows. "Climatology is not a field to be neglected or one of narrow interest. Indeed the last six years have seen its boundaries enormously extended. We are no longer confined by latitudes and longitudes. We have added a third dimension to our realm, and now know no limits in space to what our Association may not soar. The paramount importance of aviation in war and its growing usefulness in commerce has necessitated an intensive study of the physiologic effects of higher altitude such as we little dreamed of ten years ago." Dr. Edson further urged the establishment of laboratories for clinical research as to the effects of altitude. He stated, "one should be at sea level and the other in a high arid inland region. Such research work could be done in a laboratory of our own, or if not so feasible, by aid of our funds in connection with some already established foundation for medical or physiological research." Thus, it would seem appropriate that currently some members of the Association and in particular residents of Colorado should have heeded the advice of their illustrious predecessors. It was Dr. James J. Waring, the President of our Association in 1941, who was largely instrumental in my decision to come to the University of Colorado School of Medicine. Although one dislikes to break with tradition in contrast to all of the earlier Presidents from Colorado, I do not have tuberculosis as best I know although I will admit that the climate did have a favorable influence on my decision to come to Colorado. My interest in the effect of altitude (hypoxia) on the heart and in particular the pulmonary circulation was kindled shortly after arrival in Colorado in 1950 when an acquaintance inquired as to whether I knew why one of his yearling steers had developed heart failure and died while pastured in South Park at an elevation of 10,000 feet.
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S. G. BLOUNT
This was my first introduction to Brisket disease of cattle and was the initiation of my interest in the effect of hypoxia on the pulmonary circulation, an interest that has developed and continued unabated to the present. While this is not the appropriate time to discuss in any detail the problems involved, it may be said that the research interests of our division of Cardiology have since that time been involved with the effect of hypoxia upon the pulmonary circulation. This lead to the development of a high altitude laboratory in 1960, located in St. Vincent's Hospital in Leadville, Colorado, at an altitude of 10,150 feet. Through this brief address I have recalled to mind that the climate and environment of Colorado was a powerful and beneficial influence in the early development of this State and at the same time exercised a positive effect on the growth of our Association during its early years. The changing interest in climate and environment as medical knowledge advanced and new problems arose has been referred to, and I have indicated that a healthy concern as to the influence of the environment upon mankind continues within our Association. Finally it is hoped that this sustained interest would greatly please the founders of our Association.
