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Medical experiences in Peru: resurrected from obscurity
Wilderness and Environmental Medicine. 9, 186-187 (1998)
COMMENTARY
Medical experiences in Peru: resurrected from obscurity Hultgren and Spickard, in their article reprinted in this issue of the journal, provide a fascinating survey of high-altitude medicine in Peru circa 1960. Just as interesting is the paper's style, a combination of travelogue, sociomedical observation, and scientific scrutiny, an engaging and uncommon treat. Had it appeared in a more widely read journal, the article is likely to have had much more influence, and the history of high-altitude medicine would have been different. Much has changed since the 42-year-old Hultgren visited Peru in 1959. One can now travel from San Francisco to Peru in 12 hours, with a nonstop flight between Atlanta and Lima, and for less than it cost 40 years ago! ($689 in today's dollars compared to $675 in 1959 dollars) Peru's population has swelled from 10 to 25 million, and Lima's from 1 to 5 million. Even recent travelers, however, will recognize the same "remarkable contrasts" that Hultgren and Spickard noted between the old and the new, the poverty and the wealth. Health standards have improved considerably, in concert with the higher standard of living, and medical education has advanced dramatically in the last four decades. What has not changed over the ensuing years is the geography of Peru. The high-altitude terrain continues to provoke altitude-related medical problems in both visitors and permanent dwellers. Hultgren and Spickard's excellent description of soroche, or acute mountain sickness, is perhaps the best in English since Barcroft in 1925 [1]. More important, at a time when there still had been no mention of high-altitude pulmonary edema (HAPE) in the English-language medical literature, these authors discussed their review of 44 cases of HAPE seen in 41 individuals at the Chulec General Hospital in La Oroya at an altitude of 3727 m. This hospital was, and still is, the primary medical center for the Cerro de Pasco Corporation, whose workers live at altitudes ranging from 3700 to 4750 m. Most of these episodes were in workers who had just returned from an excursion to sea level, whereas nine were first-time arrivals. Two of 41 died. A better description of HAPE cannot be found. The authors make it quite clear that the Peruvian physicians in La Oroya were well acquainted with HAPE, and they refer to three publications in Peruvian journals regarding HAPE, the first by Hurtado in 1937. In a subsequent
publication by Hultgren and Spickard and two co-authors a year later, in which they discuss HAPE in greater detail [2], they also mention other Peruvian works on the subject, including the thesis of Lizarraga, the most complete work on RAPE at that time [3]. Hultgren and Spickard recognized the expertise of the Peruvians and referred to their work in an attempt to "introduce" it to their English-speaking colleagues. Since this paper appeared 4 months before Houston's publication in the New England Journal [4], Hultgren and Spickard, rather than Houston, should be credited with publishing the first report of HAPE in English; an oversight no doubt due to the relative obscurity of the Stanford Medical Bulletin. In addition, had this article been widely recognized, South American investigators would have received more acclaim; Houston's paper makes no mention of the Peruvian work, although he refers to Hultgren's review of HAPE records in Peru as a personal communication [4]. For an interesting discussion of the historical relationship of Hultgren and Spickard and Houston papers, see the newly published book of West [5]. Not only did these authors render an excellent and careful description of the clinical aspects of HAPE, but they were also the first ones to correctly exclude left ventricular failure as the mechanism. In fact, they suggested that a central blood volume shift due to peripheral vasoconstriction might be important, a theory later confirmed by Indian investigators [6], and also suggested that pulmonary venous constriction might be a factor, a concept that is still prominent [7]. An x-ray of a patient with HAPE that was published in this article was the first in an English-language journal. The authors considered HAPE prime territory for future research, and indeed, the subsequent papers by these authors and their colleagues are classic works on the subject. Another avenue of future research Hultgren and Spickard identified was chronic mountain sickness (CMS), which they nicely described clinically and historically. They considered CMS in the classic or "pure" form, as described by Monge, to be attributable to idiopathic relative hypoventilation rather than secondary to lung or other disease [8]. Hultgren and Spickard also reviewed the Peruvian literature on electrocardiograph
Commentary
changes at high altitude, especially the work of Penaloza, and then made their own original observations. These electrocardiographs were of the highest altitude permanent residents discussed in the world literature (4756 m), and they confirmed that right ventricular hypertrophy was common only at this highest altitude. Their suggestion that the common finding of right-axis deviation :It high altitude might be due to large chest size was provocative; apparently, this idea has still not been carefully evaluated. The authors made observations on the relationship of patent ductus arteriosus and high altitude, described the clinical practice of giving low-flow oxygen to all newborns for 48 hours, and commented on the apparent remarkable lack of hypertension and arteriosclerotic heart disease. Their reference to the problems of burros, sheep, pigs, mules, and horses in the Andes is fascinating. They may have been the first to comment on ruptured pulmonary artery in the horse. All of these were and still are fruitful areas for research. "Medical Experiences in Peru" is an unusually interesting and underappreciated paper. The authors succeeded admirably in their mission of exploring and suggesting areas for future research in high-altitude medicine and also made important original observations. Had the publication been in a different journal, they would have been credited with introducing HAPE to the Englishlanguage literature, this excellent Peruvian work would
187
have received more recognition, and who knows how many young investigators might have been on the next flight to Lima? References 1. Barcroft J. Respiratory Function of the Blood. Part I. Lessons From High Altitude. New York, NY: Cambridge University Press, 1925. 2. Hultgren HN, Spickard WB, Hellriegel K, Houston CS. High altitude pulmonary edema. Medicine. 1961;40:289313.
3. Lizarraga L. Edema agudo de pulmon. Ann Fac Med (Lima). 1955;36:244. 4. Houston CS. Acute pulmonary edema of high altitude. N Engl J Med. 1960;263:478-480. 5. West J. High Life: A History of High Altitude Physiology and Medicine. New York, NY: Oxford University Press; 1998. 6. Roy SB, Guleria JS, Khanna PK, Manchanda SC, Pande IN, Subba PS. Haemodynamic studies in high altitude pulmonary oedema. Br Heart J. 1969;31:52-58. 7. Hackett PH, Roach RC, Hartig GS, Greene ER, Levine BD. The effect of vasodilators on pulmonary hemodynamics in high altitude pulmonary edema: A comparison. Inti J Sport Med. 1992;13:S68-S70. 8. Monge CM. Chronic mountain sickness. Physiol Rev. 1943;23:166-184.
Peter H. Hackett, MD Grand Junction, CO
COMMENTARY
Medical experiences in Peru: resurrected from obscurity Hultgren and Spickard, in their article reprinted in this issue of the journal, provide a fascinating survey of high-altitude medicine in Peru circa 1960. Just as interesting is the paper's style, a combination of travelogue, sociomedical observation, and scientific scrutiny, an engaging and uncommon treat. Had it appeared in a more widely read journal, the article is likely to have had much more influence, and the history of high-altitude medicine would have been different. Much has changed since the 42-year-old Hultgren visited Peru in 1959. One can now travel from San Francisco to Peru in 12 hours, with a nonstop flight between Atlanta and Lima, and for less than it cost 40 years ago! ($689 in today's dollars compared to $675 in 1959 dollars) Peru's population has swelled from 10 to 25 million, and Lima's from 1 to 5 million. Even recent travelers, however, will recognize the same "remarkable contrasts" that Hultgren and Spickard noted between the old and the new, the poverty and the wealth. Health standards have improved considerably, in concert with the higher standard of living, and medical education has advanced dramatically in the last four decades. What has not changed over the ensuing years is the geography of Peru. The high-altitude terrain continues to provoke altitude-related medical problems in both visitors and permanent dwellers. Hultgren and Spickard's excellent description of soroche, or acute mountain sickness, is perhaps the best in English since Barcroft in 1925 [1]. More important, at a time when there still had been no mention of high-altitude pulmonary edema (HAPE) in the English-language medical literature, these authors discussed their review of 44 cases of HAPE seen in 41 individuals at the Chulec General Hospital in La Oroya at an altitude of 3727 m. This hospital was, and still is, the primary medical center for the Cerro de Pasco Corporation, whose workers live at altitudes ranging from 3700 to 4750 m. Most of these episodes were in workers who had just returned from an excursion to sea level, whereas nine were first-time arrivals. Two of 41 died. A better description of HAPE cannot be found. The authors make it quite clear that the Peruvian physicians in La Oroya were well acquainted with HAPE, and they refer to three publications in Peruvian journals regarding HAPE, the first by Hurtado in 1937. In a subsequent
publication by Hultgren and Spickard and two co-authors a year later, in which they discuss HAPE in greater detail [2], they also mention other Peruvian works on the subject, including the thesis of Lizarraga, the most complete work on RAPE at that time [3]. Hultgren and Spickard recognized the expertise of the Peruvians and referred to their work in an attempt to "introduce" it to their English-speaking colleagues. Since this paper appeared 4 months before Houston's publication in the New England Journal [4], Hultgren and Spickard, rather than Houston, should be credited with publishing the first report of HAPE in English; an oversight no doubt due to the relative obscurity of the Stanford Medical Bulletin. In addition, had this article been widely recognized, South American investigators would have received more acclaim; Houston's paper makes no mention of the Peruvian work, although he refers to Hultgren's review of HAPE records in Peru as a personal communication [4]. For an interesting discussion of the historical relationship of Hultgren and Spickard and Houston papers, see the newly published book of West [5]. Not only did these authors render an excellent and careful description of the clinical aspects of HAPE, but they were also the first ones to correctly exclude left ventricular failure as the mechanism. In fact, they suggested that a central blood volume shift due to peripheral vasoconstriction might be important, a theory later confirmed by Indian investigators [6], and also suggested that pulmonary venous constriction might be a factor, a concept that is still prominent [7]. An x-ray of a patient with HAPE that was published in this article was the first in an English-language journal. The authors considered HAPE prime territory for future research, and indeed, the subsequent papers by these authors and their colleagues are classic works on the subject. Another avenue of future research Hultgren and Spickard identified was chronic mountain sickness (CMS), which they nicely described clinically and historically. They considered CMS in the classic or "pure" form, as described by Monge, to be attributable to idiopathic relative hypoventilation rather than secondary to lung or other disease [8]. Hultgren and Spickard also reviewed the Peruvian literature on electrocardiograph
Commentary
changes at high altitude, especially the work of Penaloza, and then made their own original observations. These electrocardiographs were of the highest altitude permanent residents discussed in the world literature (4756 m), and they confirmed that right ventricular hypertrophy was common only at this highest altitude. Their suggestion that the common finding of right-axis deviation :It high altitude might be due to large chest size was provocative; apparently, this idea has still not been carefully evaluated. The authors made observations on the relationship of patent ductus arteriosus and high altitude, described the clinical practice of giving low-flow oxygen to all newborns for 48 hours, and commented on the apparent remarkable lack of hypertension and arteriosclerotic heart disease. Their reference to the problems of burros, sheep, pigs, mules, and horses in the Andes is fascinating. They may have been the first to comment on ruptured pulmonary artery in the horse. All of these were and still are fruitful areas for research. "Medical Experiences in Peru" is an unusually interesting and underappreciated paper. The authors succeeded admirably in their mission of exploring and suggesting areas for future research in high-altitude medicine and also made important original observations. Had the publication been in a different journal, they would have been credited with introducing HAPE to the Englishlanguage literature, this excellent Peruvian work would
187
have received more recognition, and who knows how many young investigators might have been on the next flight to Lima? References 1. Barcroft J. Respiratory Function of the Blood. Part I. Lessons From High Altitude. New York, NY: Cambridge University Press, 1925. 2. Hultgren HN, Spickard WB, Hellriegel K, Houston CS. High altitude pulmonary edema. Medicine. 1961;40:289313.
3. Lizarraga L. Edema agudo de pulmon. Ann Fac Med (Lima). 1955;36:244. 4. Houston CS. Acute pulmonary edema of high altitude. N Engl J Med. 1960;263:478-480. 5. West J. High Life: A History of High Altitude Physiology and Medicine. New York, NY: Oxford University Press; 1998. 6. Roy SB, Guleria JS, Khanna PK, Manchanda SC, Pande IN, Subba PS. Haemodynamic studies in high altitude pulmonary oedema. Br Heart J. 1969;31:52-58. 7. Hackett PH, Roach RC, Hartig GS, Greene ER, Levine BD. The effect of vasodilators on pulmonary hemodynamics in high altitude pulmonary edema: A comparison. Inti J Sport Med. 1992;13:S68-S70. 8. Monge CM. Chronic mountain sickness. Physiol Rev. 1943;23:166-184.
Peter H. Hackett, MD Grand Junction, CO