MOUNTAINEERING MEDICINE SYMPOSIUM

[Presented by the New York Chapter of the A.M.C. at American Red Cross Headquarters, New York City, on 20 January 1968, and reprinted from Appalachia by kind permission of its Editor].

1. MUSCULAR FITNESS STANDARDS AND PRECONDITIONING FOR MOUNTAINEERING
2. ADVANTAGES OF THE PHYSICALLY ACTIVE AS COMPARED TO SEDENTARY
3. CLOTHING, SHELTER AND COLD HARDINESS
4. HIGH-ALTITUDE PHYSIOLOGY
5. FREEZING, FROSTBITE AND COLD INJURY
6. CHOICE AND RATIONALE OF USE OF ANTIBIOTICS
7. PSYCHOLOGICAL ASPECTS OF MOUNTAINEERING

 

 

Why do we have to talk about preparing to climb mountains, or preparing for any special efforts? One would think that the natural thing to do would be just to get up from a plane ride and do whatever we please. Maybe a hundred or so years ago we could have done something like that, but in the intervening decades our manner of life has changed dramatically. We have become almost 100 per cent sedentary, and even those of us who occasionally wax very athletic are generally not in as good physical condition as even the average person was only a few decades ago. At the same time we have become burdened with tensions. Contrast this with the situation of a person about a hundred years ago, who led a relatively normal life, in a relatively normal countryside, with relatively sufficient exercise and not excessive food.

Chart I suggests what actually has happened to us. We now have become rather mechanized, urbanized and unbalanced individuals. We are overrested, overfed overstimulated, overprotected, underexercised, underreleased and underdisciplined because we are not exposed to the hard discipline of daily confrontation with nature. Now, if you're underexercised and overstimulated, that combination is a rather dangerous one even before you get to face more exercise and more strenuous conditions. If you're underexercised, the lack of physical activity alone, and this is well documented, exposes you to physical disease, which includes cardiovascular disease. You're all aware of the fact that a lot of our coronary patients would never have been in this condition if they had run enough. Eating and overweight are connected with this too. You can eat what you want if you exercise enough. The gastrointestinal and muscular-skeletal systems are linked in this. We confine our talk to this small area.

CHART I: Mechanized, Urbanized, Unbalanced Individual

Over Rested Over Fed Over Stimulated Over Protected Under Exercised Under Released Under Disciplined

 

(documented in 'hypokinetic disease' — kraus, raab — c.c. thomas, publisher)

If we are overstimulated, and most of us are all the time, we are more exposed to being under nervous tension and more open to emotional disease. Anxieties, neuroses, depressions and maladjustments find a very fertile ground in the overstimulated individual. These things together are what we call tension states, and we all know tension headaches, tension backaches, inability to sleep, etc., which are almost everyday companions of the average city dweller.

Now there's another basic thing that is inhibited. Besides being underexercised, we have one basic reflex that is constantly blocked, the so-called fight and flight response. The normal animal response to aggressive stimuli is either to counterattack or to run away. You can see and hear that in a cat. A cat gets very nervous, arches her back, but then either jumps- or runs away, and then the cat relaxes because it has acted out this response. We never do that. We get irritated by the telephone, by people. We don't throw the telephone. It's useless. We can't punch people's noses. It's not permitted.

And so our only responses are the reactions that prepare us for physical action, the increase of adrenal output, the increase in blood pressure, in heartbeat, in respiration, and in muscle tension. All these things are stopped right there, and instead of being used, they accumulate, and in turn are feedbacks to both ends of the disease-producing extremes. All this stress, in turn, has a very deleterious influence on the endocrine balance. There again is a feedback.

 

 

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We all live, whether we are well-conditioned and well-trained or not, in a grey area, where, unless we watch out and counteract the daily effects of steady gnawing overtension and underexercise, we are exposed to diseases which a hundred years ago may not have been quite as often recognized, but certainly were not as frequent as now. The best known of these is coronary disease, or myocardial infarction, as coronary heart disease is usually known. And another that's very well known is backache, that afflicts about 90 per cent of the population in one way or the other, and is, in about 90 per cent of cases, due to just this sort of misfiring.

Now let's compare the active and the sedentary. The weight of the active is low, even if he eats whatever he wants. His blood pressure is relatively low, and his pulse rate is low. You all know that the active's resting pulse is low, and returns after activity to a low rate very quickly. Direct results of neuromuscular tension—headaches, backaches and so forth—are low in the active. His muscle strength and flexibility are high, his breathing capacity better. His adrenaline reserve is high. It means that he is better prepared for any insults, for any emergencies. His resistance to fatigue is high. His emotional stability is greater because he is not constantly irritated. His heart strength and capacity are greater, and ageing comes later—everything else being equal—unless this healthy state is overdone and there is too much work and too much exposure to stress.

Since we all tend to be on the sedentary side, if we just live a normal city life, we must try to get to the active side, that of the trained individual. And a once a year effort is not enough. A one time a year effort if that effort is extreme, is of course completely hopeless, because a once a year maximum activity carries with it all the dangers of exertion and one-time stress, without the training advantages of continued, gradually and sensibly increased stress and strength.

The way to improve this situation, to get from the sedentary to the active side, is by using our muscles properly, that is by trying to get normal exercise. We cannot very often cut out the tension area. We cannot do that with work, normally. We can do it in preparation for a bigger trip . . . trying to get into the pre-trip vacation where we get calmed down, and it is very, very important. Those of you who climb, or participate in sports, where you are a little bit on edge at times, know that if you come from a very strenuous week you are not half as ready to face difficulties or situations as you are when you are reasonably well rested. For instance, it tells immediately when you climb close to your abilities. If you've had a strenuous week, immediately you feel it.

Now we can use a very few simple tests to check the muscular basis for physical fitness, the minimum basis that we should get first. We have a few very simple tests of the ability of our trunk muscles to move our own weight and to work against our own size. The first test consists of a person lying flat on his back, with someone stabilizing his legs, and then sitting up. This tests the strength of your abdominal muscles and your hip flexors to carry your own weight. If you do that, you don't have to be particularly proud, but if you can't do it, and some people can't, you ought to do something about it.

The next test is the same as the preceding one, but with both knees flexed. Now if you can do this test, then you are all right. Again, nothing to be proud about. You should be able to do that many times without much effort. But there are a lot of people who fail this. This test is frequently failed by women, especially if they have had children and haven't done anything for abdominal muscles. All this test means is that your stomach muscles are strong enough to carry your back.

The third tests the strength of your hip flexors. You should be able to keep your legs raised at an angle of about 25° for about ten seconds.

Now, to test the strength of your back muscles, your upper back muscles, put a pillow under your hips and get support by the legs and the lower back, and keep your upper back elevated for ten: seconds. Again a minimum demand.

The fifth test is similar, and tests the strength of the lower leg muscles.

So far we have tested strength, the very minimum your trunk muscles should have, and a lot of people will pass these tests. But a lot of people will not pass this next test. As a matter of fact, many cannot. Those who cannot are particularly subject to back, neck and shoulder aches, tension aches. The sixth test is for flexibility of the back, hamstring, leg muscles and so forth. Statistics show that a large number of people who lack this flexibility are inclined to get muscular aches of the back and legs, sometimes quite severely and unpleasantly.

The sixth test consists of reaching down slowly, trying to touch the floor. Incidentally, it is not to be done violently, and not by somebody who just had some back problems. This is a minimum test to check the flexibility of muscles in the upper back, lower back, the gluta and hamstring muscles. You should be able to do that with ease. Why should you be able to do it with ease? Because if you don't, it shows that these muscle groups have tightened as a result of sitting too long, and generally by sitting under tension. If you sit all relaxed, you usually won't have trouble.

We have three factors that we want to consider when we get into shape muscularly. One is strength. You've seen that in the earlier tests. Two is flexibility. You see it in this test. And three is the ability to relax, which cannot be directly demonstrated in a test but which enters into this test. People who cannot relax are the ones who tighten up and eventually have difficulty in passing this test.

Now a few words about what actually to do. We'll go into detail a little later, but first a few general principles. How do you attempt to get stronger? How do you train for strength? Some studies of this were made by Palmen, a Scandinavian physiologist. He had some healthy young men lift weights until they were completely fatigued, trying to get them strength. And this is what happened.

The first day they could lift 1,600-kilogramme metres. The second day, 1,200. Then less. Then still less. And it took them all of a week to get back to exactly where they were when they began. From then on they started to lift more and more and more. They got stronger and stronger. Their strength approached, but never reached, a maximum, for it continued to increase, but at a decreasing rate. To maintain this strength they had to practice twice a week. If they practised three times a week, their strength continued to increase, but slowly.

Now, what does this mean? Let's say you want to do sit ups, to strengthen your stomach muscles because you feel you can do only one or two. You'd like to do more. And you do as many as you possibly can until you cannot sit up any more. That's fatigue. Then the next day, you won't be able to do quite as many, and you'll have a sore stomach. And the third day you'll probably not be able to do any at all, and have a very sore stomach. Then you'll give up for three or four days, and then you start all over again.

And that is the way very many people try to prepare themselves for exertion. They go right to the maximum. Well, you can do that if you are very young, and if you are willing to go through this painful bit, with a lot of motivation. But otherwise you can't. Otherwise you have to try to work below your maximum. Then try for a steady slow increase. If you were to do sit ups, you can do, let's say, two with ease, five with an effort, and ten is your maximum. Do five for a week. Then do six, and gradually more and more. About the same thing goes for chinning, for push ups, or for weightlifting. We'll talk about that later.

Another basic fact of training which unfortunately is not generally understood, is the fact that it takes a warm up. And I'd like to mention right away that the older you are, the more of a warm up it takes to get the muscles going as strong as they can go. To illustrate. If you can lift about 200 pounds warmed up, you may be able to lift only 150 not warmed up. The average increase from warm up for young people is about 20 per cent. In other words, if you work violently, cold, you will still not get the maximum out of your muscles.

Many people sin against warm up. Let's say somebody who wants to run just goes out and runs as fast as he can. He gets only a fraction out of his running of what he would get if he first warmed up. He should warm up more and longer the older he is. He should also cool off, because if he doesn't, he will remain with another unpleasant effect, namely stiff muscles. The way you build up your individual training session, regardless of how you train your muscles, should always follow this principle- easy, heavy, very heavy—that means you should exert yourself but not fatigue yourself. There is a difference. You should exceed the pleasant easy level, but you should not get to the point where you're prostrate. Then go back to heavy and then down to easy. Now if you know those two principles and observe them, you will avoid a great number of the mistakes that are usually perpetrated when people try to get in shape.

Now what are the best ways to get in shape, generally? One of the best of all conditioners is jogging and running. It primarily takes care, of course, of the lower extremities. It takes care of the trunk muscles too, to a certain point. And it takes care of your cardiovascular system and your lungs. A book has been published recently called Jogging, which can be gotten through the Y.M.C.A. It's a little booklet that gives a very nice description of how you can walk and run and walk and run. In other words, you start in with twenty or thirty steps walking and ten steps slow running, and then gradually increase. This start would be for somebody who is really very sedentary, who has a high pulse rate, and who doesn't function well at all. But then, you can adapt it to your own needs. You may be good enough to start running right away, and put a few sprints in between. Again, the older you are the slower you have to start, and the more you have to cool off. You may have just as many good short sprints, if you want to, but you have to space them later on in time. In other words, it'll take you more time to get there.

Another way to strengthen yourself, if you wish, is by weight- lifting, chinning and push ups. These should only be done if you are able to do the first tests, including several sit ups, with ease. You have to develop a strong firm trunk before you try to put strong extremities on to it. And you should have a flexible back too.

For instance, you can mount the chinning bar, and that's especially important for climbers, or you may have a little lip over the door where you can anchor your fingers and chin yourself. If you cannot chin yourself, and a lot of people can't, you can try to get in the chinning position from a chair and then let yourself down, and gradually work up until you can start with your chin. Everybody knows how to do push ups and most people can. If you can't you can start by first resting on your knees. That is sometimes necessary, especially for the ladies.

If you wish to train with weights, which is a good way of getting strength for the upper extremities, the most important thing is to mix up your lifts. First make five dead lifts, then five military presses, and so forth. Make half a dozen of one, then half a dozen of the next, and so on, with maybe even fewer of each in order to avoid being stiffened up. Now if you are very flexible, by all means go ahead and start lifting ten and ten and ten as you wish, or even more. The reason lifting is usually done by sets of ten is not because nature has built us up through the decimal system, but because this is an easy way to keep track of progress. The best way to start is in a relatively easy way. And unless you want to train for real performance, which most of you probably don't want to, you start working with weights at a medium level rather than higher. The weight work-out should be done about three times a week. If you combine weight- lifting, chinning, push ups and running, you have a reasonably good way to keep yourself in shape all year round.

There still remains the fact that this does not prepare you for the real thing. To prepare for the real thing you should put in as many hikes, as many up-and-down-hill hikes, as many up-and-down-hill runs as you can. If you're that far, use heavy boots, with heavy packs, always gradually increasing until you're really ready for it. There is no substitute for carrying a heavy pack. The only way you can really get strength to carry a heavy pack is to carry it. You know that, if you've ever tried. However, you can work up to it so it doesn't kill you.

Now a last few words about what to do after injuries. This is a matter that always comes up, especially with skiers. Very often you may be released by your surgeon or physician with the statement that you are fine, but you're not fine for climbing or skiing before your injured extremity is as strong and as flexible as the uninjured one. We've used a few simple tests for this and you can use them yourself. Number one, you should be able to make a kneebend on your uninjured leg without using the other one. Now see if you can do the same thing on the injured side. But if you can't, try this simple trick. Pile books alongside a bathroom scale till they are as high as the scale. Stand with one toot on the scale and one on the books. Do a kneebend and read the scale while down. Now reverse the positions of the feet and repeat. You'll often be surprised, especially after knee injuries, to see that you put ten or twenty pounds less on the injured side. If you do that even on one kneebend, what will you do when you've skied a few thousand feet?

Now such a knee, or such an ankle, may be declared perfect by a physician, but it is far from perfect for the skier or for the climber who goes over difficult terrain. It must be strengthened Statistics have shown that the same part tends to be injured again and again. We have had people with second, third and fourth knee injuries, all of the same knee, because it was not adequately strengthened alter injury. Yet, of those who went through a strengthening programme after injury, not one had a recurrence even though, except for two, they all took up skiing again. This shows how important it is to have a good strong recovery after injury. Of course, the same goes for the upper extremities if you want to make good climbs.

Another thing you need in addition to strength, and it can be tested, is flexibility, and that's particularly important for skiers II you have a tight heel cord, and you can test that by pointing your toes upward from the ankle, it will restrict upward movement. You should be able to make this movement on the injured side as well as on the uninjured. If you can't, if the injured side doesn't bend as far as the other side, you should work at it until it does. Otherwise, again, you will have difficulties. I he same thing is true for the long part of the calf muscles. You should be able to stretch it as well on the injured as on the uninjured side.

And it is not an accident that it's always the injured extremity that gets hurt skiing. When you go over a little bump and you lean a little forward, this thing tugs you because it's tight, and it may hurt a little bit. You unweight, unconsciously, for a second. The tip of the ski then dips just for a second. That's enough to make you fall, with exactly that same ankle again in jeopardy.

Now one final remark for those of us who are past forty or fifty. Many of us who have passed fifty have found out that we can get in reasonably good shape and do all of the things we've done before, but we do them a little more slowly, and it lakes us a little longer before we are ready to do them. And when we have done them, it takes us a little longer before we are ready to do them again. If you keep that in mind, I think you'll fare well.

Thank you very much.

Applause.

Voice: I'm a bit disturbed when people like football players die at the age of 45 of a heart attack. Now, is there any correlation between strenuous exercise and coronary failure?

Dr. Kraus : I think the football players you've heard of who die of heart attacks when they are older are the ones who have played very intense college football. They are the ones we see, with all sorts of painful backs and knees too. As soon as they get out of college, it's very difficult for them to play football again. And their exercise is mainly having a couple of martinis at lunch. They continue eating as much, or more, than they did before, and these people usually eat very heavily. They are often in a high pressure business, and the combination then affects them in a relatively short time. What actually makes them have a coronary is not the fact that they played football, but the fact that they switched from a very active life to a very sedentary one without adapting themselves. If the same people would continue to take some exercise, let's say run a half hour or hour every day, and cut their diet according to the needs of their physical requirements, they would not be in this danger bracket.

Voice: I'd like to stress one thing that Dr. Kraus has said. It's tragic that many physicians feel that once the X-ray shows that the injury is healed, you're ready to go on the slopes. Those of us who see many ski injuries know that this is untrue. Probably the commonest injury is medial collateral ligament strain, and you've all come off the slope with it at one time or another. You get into a bad habit. To protect it, you walk with the foot flexed and the knee flexed, because you can't get it straight. If you have a doctor who isn't alert to this, you can check this yourself. Walk that way for a week, and I'm sure Dr. Kraus will agree that you'll get a half inch of quadriceps atrophy, which is the circumferential measurement around your thigh. You can measure this yourself, putting a tape measure around your leg about four inches above the patella. I assure you that if you walk that way for two weeks, you'll lose a half an inch muscle mass. As soon as the pain is over, you can rebuild this quickly by sitting, putting weights on your ankle, and extending your leg till fatigue, once a day. And if you've had a serious knee injury, even with cruciate or medical collateral ligament tears, if you will rebuild that muscle to hold 50 per cent of your body weight, in other words, to be able to lift 50' per cent of your body weight, you can do even competitive skiing. Thank you.

Voice: Would you care to comment on the value of swimming and these mechanical gadgets also, like exercycles and so on, for year-round conditioning ?

Dr. Kraus : Swimming comes second to running. In swimming you are using your legs in an entirely different way from the way you're using them when you're running and walking uphill. So, cross-country running is certainly a much closer preparation to what you want to do with your fitness, namely mountain climbing and skiing. However, swimming is certainly good and can do a lot for you, especially for your cardiovascular system and your lung capacity, breathing capacity.

Mechanical gadgets I'm afraid I hate (Laughter). We're surrounded by so many gadgets that even the ones that have a certain limited value should not be part of a programme that tries to prepare us to go to places where there are no gadgets (Laughter and Applause).

Moderator: On that note, thank you very much.

Moderator: Our next speaker will cover the topic of Clothing, Shelter and Cold Hardiness, with particular attention to the protection from cold and the effects of cold. The speaker is Dr. Marlin Kreider, who is a research physiologist with the Army Research Institute of Environmental Medicine in Massachusetts. lie has been doing research on physiological effects of cold, altitude, heat and strenuous muscular activity, and will report on his own and other people's findings in these fields.

 

 

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Cold weather is one of the major challenges of mountaineering, it is the cold together with the reduced oxygen at altitude that forces man to be much more deliberate in all his activities on the mountain. In fact, man's ability to climb mountains and to survive in the cold depends mainly on the deliberateness of his activities ; or, in other words, his behaviour as it relates to the use of his protective equipment for controlling the loss of heat from the body.

A second major group of factors in man's survival in the cold are the biological factors. Knowledge of both these behavioural and biological factors could reduce the incidence of fatal exposure and of frost-bite that occur in mountaineering, and could contribute to the enjoyment and success of mountain climbs.

First of all, I would like to talk to you here today about several methods by which man can reduce the heat loss which occurs, and then go on to the biological factors that are involved. And finally, I would like to talk about exposure and exhaustion, that is how to recognize it and how to treat it.

Heat is constantly produced by the processes of life and activity. And the heat must be lost from the body at the same rate at which it is produced or body temperature will go either up or down. All the factors that can affect body temperature must do it by altering either the heat produced or the heat lost. So I'd like to talk about the methods of heat loss from the human body or any body.

First of all, we'll talk about convection. Air is warmed by the skin and then rises, because warm air is lighter than cold air and cold air will come in to take its place. Clothing prevents the movement of the air, and traps it close to the skin where it warms up and then acts as an insulation against further loss of heat. To give maximum protection against heat loss, clothing must be made with a tight weave, especially the outer garment, which is going to be faced with the wind, and must be closed at the various openings like the neck, the sleeves, the cuffs, and even around the waist, in order to trap the air. Then additional layers give additional protection, and this idea is called the layer principle.

Now since wind increases the convective heat loss, it must be considered also along with the temperature in determining the effective cooling ability of the environment. A factor which does consider both temperature and wind is called the wind-chill.

Let us take as an example of wind-chill a temperature of 32 degrees, which is freezing, and a wind velocity of about 40 miles an hour. The wind-chill here is just a little less than 1,200 calories. But to get the same cooling effect with little or no wind, when one is walking along at three or four miles an hour, a temperature of minus 3, 4 or 5 °F would be necessary. I haven't calculated this exactly from the formula. This difference, then, is about 35 degrees, from 32 to minus 3 or 4. We might say then, in this case, that the cooling effect of a 35-mile-an-hour wind is the difference between 32 and minus 3, which is 35 degrees. But you can't always exchange wind velocity for degrees. It depends on which part of the chart you're on.

Another method of heat loss is conduction. Heat is lost by conduction whenever the body touches another object, such as ice, rock, metal. This occurs commonly when the body is pressed against the ground during rest or especially during sleep. At times of sleep, a foam rubber, or some type of foam pad under the sleeping-bag, even more than an air mattress, gives greatly reduced heat loss. Also, conduction of heat occurs from the hands during normal manipulation when heavy gloves and mittens must be removed. At such times, a thin tight-fitting glove is quite useful. Conduction of heat also takes place from the feet through the boots to a very cold ice or snow. At such times, heavy socks may give considerable insulation if the boot is not too tight.

But for walking in very cold snow and ice, insulated boots are really necessary. The army Korean boot, for example, appears to give about the best kind of protection of any boots that have been tested. And the uninsulated, single layer, leather boot which we use in the summer, gives about the poorest. Incidentally, since I am in the Army, you may be interested in developments there They are developing a new insulated Korean boot of about hall the present weight, and apparently they expect to have one before too long. And they are also testing an insulated, all-purpose, leather mountaineering boot which is much less clumsy than the past army all-purpose mountaineering boot. One thing to keep in mind is that the snow may be much colder than the ambient air for several days following a cold spell, and thus greater foot protection is needed than what one might expect from the ambient temperature.

Heat can also be lost by radiation from the warm human body surface to the ground or to a wall or even to the sky, just as the sun radiates heat to the colder earth. A cover over the radiating surface, such as clothing or a blanket, or even a tent will reduce the radiation of heat. And just a note in passing, the fusilage of a downed plane may offer protection against the wind, but it may also increase greatly the radiative heat loss unless, of course, it is insulated.

Another method of heat loss is through respiration. Heat is Inst through warming and vaporizing the respiratory air, and may amount to as much as 20 per cent of the heat production at very cold temperatures. This loss may also increase in the mountains, due to the increase of respiratory volume.

Another method of heat loss is evaporation. Much heat is lost, in the mountains especially, through evaporation, because one frequently gets clothes wet, either externally from streams or wet rocks and snow, or internally from sweat. The importance of keeping clothing dry is suggested by the fact that in most, if not all, cases of fatal exposure in the mountains, the clothes were quite wet. I'd like to say more about this next point but I'll just move very rapidly over it. It is very important to remove layers of clothing, or to open them at various places such as the cuff, the sleeve and the neck when one begins exercising and producing heat. By the same token, it is very necessary as soon as exercise ceases to close up openings, to put the clothing back on before one has lost much valuable heat, especially when one is in a very cold area.

It would appear that heat loss through already wet clothing may be two to three times greater than through dry clothing, especially if there is some wind. This rate of heat loss is almost as fast as during water immersion. In water immersion, survival is not expected after 30 minutes at 32 degrees, 60 minutes at 40 degrees, three and a half hours at 50 degrees or six hours at 60 degrees. However, much longer survivals have been recorded, especially in cases of channel swimmers and airmen who have come down in water in anti-exposure suits. The clothing that will give the most protection when wet, other than special anti-exposure suits or foam rubber diving suits, is wool.

At this point, I would like to give a very brief warning about the care and protection of the feet. If they have been cold for many hours, or if they are burning or numb, they should be given immediate attention, which would include such things as changing into dry socks. This might be done even in the middle of a climb, if these symptoms appear, or the feet may be warmed, after removing the shoes, by holding them in the bare hands, or even against the bare belly skin of a buddy, if that is the only heat available for warming them. Of course, short periods of very strenuous exercise, if you are not already exercising, would help greatly to warm them. And sometimes loosening tight boots would do the same. But, by all means, when your feet are in this condition, do not just try to forget about them. Do something about them.

Now in addition to these behavioural factors, things which you can do about controlling the temperature, there are a number of biological factors which play a part in maintaining the body temperature in the cold, and I think it is of value to go over these because if you understand these principles, many times you can figure out the thing that is important for you to do. The heat production or metabolism of the body is a very important biological factor. And the major factor that is responsible for heat production is voluntary exercise. A man doing moderately severe work can produce heat at a rate five to ten times faster than he does at rest. Therefore, it is not hard to keep warm during exercise, but it is during times of rest and inactivity. So when forced inactivity occurs, such as at times of accident or exhaustion, a severe exposure frequently follows.

The value of exercise during water immersion may be a different matter. There is some evidence that swimming or thrashing around in very cold water lowers body temperature faster than if you just remain still in the water. And this is especially true for thin individuals.

Any factor that affects the over-all endurance or ability to exercise affects the production of heat. Some of these factors are the level of physical fitness due to prior training, the height of the mountain which you're climbing, and also the amount of acclimatization to altitude which you have. There are several cases of fatal exposure which most of you probably know about-where it would appear that poor physical endurance and the lack of altitude acclimatization were the major contributory factors.

Shivering is another way of producing heat. It has been proved to produce heat up to five times the resting level, but it is not adequate alone, without occasional periods of exercise to maintain the body temperature. Another biological factor that is very important is the nutritional state, and I'm sorry there isn't more time to talk on this. But I would like to say that balanced diet of high caloric content, and consisting of tasty food, would appear to be preferred requirements even at high altitudes for maintaining energy and therefore heat production.

It appears that frequent snacks or bites while on the trail, even as often as every hour during strenuous activity, may help not only to give more energy for activity, but also to produce more heat for the body and at the same time to prevent frost-bite. But, in general, I would say that I know of no foods that are good or bad in the mountains. Perhaps some of our high mountaineering friends would like to comment on this. I can say in passing that if a diet is deficient in total calories, as well as in protein content, a decreased work capacity and heat production will occur after several days. This can easily occur on a mountain.

Another biological factor is circulation. The circulatory response to cold is very important in reducing heat loss. When in contact with a cold environment, the blood vessels in the skin constrict in size, thus greatly reducing the blood flow through the skin. As a result, the heat of the body is maintained internally and is not brought to the surface where it can be lost. As a result, the skin, and the tissues immediately underlying the skin, which might be called the shell, become quite cold. As a result of the vasoconstriction which occurs in the cold, the extremities become much more susceptible to frost-bite. However, if the temperatures of the trunk or core are maintained high by exercise, or by insulating or insulative clothing, the extremities will remain warm in spite of the cold environment.

Many of you will recognize this effect at times when you're out in the mountains or the arctic tundra when you may be pulling a sled or climbing. It may be minus 10 or even minus 20 degrees, and if the wind isn't too strong you may be so warm that you'll be working there without gloves on your hands. This is because the excess heat from the trunk will spill over into the extremities, and therefore warming the trunk will also help to warm the extremities.

Now there are big differences between individuals in the circulation of blood to the skin. This makes some people much more susceptible than others to cold. If one knows that he has this problem, he should be extremely careful when he goes out into the cold. Acclimatization to cold, which is produced by repeated exposure, causes a certain readjustment of the peripheral circulation which allows the skin to remain warmer during a cold exposure, thus giving more protection against frost-bite. If you're exposed or acclimatized to cold by many exposures, you will be able to keep your extremities warmer in a following period of cold exposure.

Another biological factor that is very important is good health. Now many diseases may decrease the amount of available energy, and others certainly decrease the will to force oneself into strenuous activities. For example, a digestive upset one day before a swimming race prevented Florence Chadwick, a channel swimmer, from swimming as fast as usual. And as a result, she had to be pulled out of the water, due to a lower body temperature.

Then also, at times, latent diseases, such as diabetes, may show up under severe stress of cold and altitude, especially in older individuals, and this could produce serious consequences. Drugs are another biological factor. I would say that there is no drug that can be recommended as an antidote against cold, fatigue or altitude, except under very limited conditions, and perhaps then only under direct control of a physician.

Conversely, some drugs will actually increase internal cold by causing vasodilatation. This promotes the flow of blood back into the skin area and into the larger extremities. Or they may act by affecting the temperature control in the brain, or by slowing down metabolism and muscular activity, or by affecting thought processes and therefore behaviour. Alcohol should be avoided in the mountains, because it not only brings more body heat to the surface where it can be lost, but also because altitude has a potentiating effect on the inebriating qualities of alcohol.

Finally, old age tends to decrease the ability to produce heat and at the same time tends to decrease the peripheral circulation during cold exposure.

Body size and fat content are also important factors. Both large body size and a large amount of body fat provide protection from cold. Body fat, especially that directly under the skin, acts as insulation to prevent the loss of heat during exposure to both cold air and cold water. At the same time, with a large body size more time is required for internal heat to reach the surface and be lost. I'm not suggesting though that you put on a lot of weight before you climb mountains.

Now just a few words in closing about exposure and exhaustion. When the internal body temperature cannot be maintained by behavioural and biological factors, deterioration does take place in certain body functions, and thus in performance. The first signs of deterioration due to exposure may show up when the internal temperature falls to between 97 and 95 degrees. Such signs may be violent shivering (or perhaps complete absence of shivering), fatigue, poor co-ordination, stumbling, complaints of severe cold and numbness, poor articulation and disorientation, hallucinations and eventually semi-consciousness. Of course death may follow.

Both fatigue and lack of oxygen may modify some of these signs and perhaps confuse them. But the appearance of only two or three of these signs should be good reason to make a very careful examination of the individual and possibly to initiate drastic action for rewarming and rest. If the symptoms are due lo cooling, the individual must be removed from the cooling environment soon, or death can follow in less than two hours.

Now there is some reason to believe that once one has reached (he point where he shows most of these symptoms, he should no longer be encouraged to exercise to keep warm, that is even if he could. Rather he should be carried in a horizontal position, to prevent development of low blood-pressure, and he should be kept inactive in order to prevent undue stimulation of the heart, which may fail when excited at a lower than normal body temperature. Of course, he will need as much protection from the cold as possible when he becomes inactive like this.

Occasionally, one may come upon an individual who has suffered exposure. How do you recognize it? The first impression may be that he is dead. Respiration and heart rate may not be detectable, and the reflexors may not function. The skin may be very white or may be very red in spots, and the flesh may be as hard as frozen turkey in a deep freeze. Yet it is possible that such an individual may still be alive and that he can be brought back by proper treatment. When the exposure has taken place in severely cold water and the individual is unconscious (and even if his face is down in the water) if the rescue occurs rapidly, perhaps within half an hour of the first exposure, recovery in some cases may be possible.

And finally, in concluding I would say concerning this matter, when cooling is fast, as in such cases of water immersion, it appears that rapid rewarming is the preferred method, that is immersion in warm water. On the other hand, when cooling is slow, over many hours, slow rewarming in a mildly warm room, over many hours, seems to be the preferred method. Various types of supportive medical treatment might be beneficial to recovery, especially for the latter type.

Thank you very much.

Voice: Would you say that large doses of vitamin C or any other vitamins would have beneficial effects?

Dr. Kreider: The studies that I know of, which involve particularly the testing of vitamin C, seem to have shown that only if one is deficient in vitamin C will it have any benefit. As for other vitamins, I would think that as long as you have good vitamin balance, and are getting the proper foods containing good vitamins, I don't think they would have any benefit. If however, you are on the mountain for many days, or weeks, and probably not getting good food, then I would think vitamins would be of considerable value.

Voice: Could you comment on people purposely in cold water, how you can detect when they are approaching dangerous levels? Say, in mountaineering, when they are uncoordinated or complain, or it comes on slowly enough to detect, can you give any warning signals for somebody immersed and doing something in cold water, as to when he should come out?

And the second part of the question, could you speculate on why it seems that when people are in cold water and they come out, they may then faint dead away, but do not seem to in the cold water? This has been an experience at an Outward Bound camp in cold water. How can it be prevented?

Dr. Kreider: I'm not familiar enough with people in cold water from my own practical experience. Perhaps somebody else would know more about this than myself.

Moderator : Dr. Silverstein, I think, has a comment.

Dr. Silverstein: I'm not quite certain why this occurs, and whether or not it has to do with change in blood-pressure. There is another factor, though, that occurs. Many times people who have been immersed in cold water for quite a length of time and are brought out and re warmed have a continuing drop of their rectal temperature for a period of ten or fifteen minutes. This is called the afterdrop. And this is due to the fact that we start rewarming all this peripheral tissue, which is now very cold and swollen and hard. When the blood starts going through there and gets back to the heart, it makes the heart much cooler, and death quite frequently has taken place after the person has been rescued, and after rewarming has been initiated.

Voice: I wanted to say two things: One is about the clothing that you wear. Mountaineers know this very well, especially expeditionary mountaineers, but getting clothing wet, as you've pointed out, is a fast way to freeze. And one of the best ways to avoid getting clothing wet is to have clothing which you can open up in one way or another. For instance, there are down pants that zip all the way up to your hip, so you can walk along with the pants open all the way to the hip, especially when you're packing along, and then when it gets cold and you stop working, you can zip the pants all the way down. And the same goes for parkas and for various other items of clothing. I did want to ask why it is that wool clothing, even when it's wet, will keep you warm.

Dr. Silverstein: I'm not a physical chemist or physicist, but I have been told it has to do with the way the water evaporates from wool, that it evaporates where the heat is in the inner layer, and the water which is in the outer layer doesn't get back to this inner layer, so that you have greater warming qualities right at the skin. I think this is the explanation.

Moderator : Thank you very, very much.

Our next speaker will consider a topic of great interest and increasing significance, High-altitude Physiology, and particularly Pulmonary Edema. Our speaker is Dr. Charles Houston, a gentleman mountaineer who has climbed extensively in the Himalayas and in the Western Hemisphere. Dr. Houston is now professor in, and Chairman of, the Department of Community Medicine at the University of Vermont.

 

 

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It is very interesting that while a man transported from sea level very rapidly to high altitude is dead in a few minutes, yet people can live at 25,000 feet for days and days, although they would pass out in a matter of minutes if they went directly to sea level.

Parenthetically, it's really quite impressive that bird without any acclimatization at all can fly from sea level to 35,000 feet, and apparently fly around quite happily for long periods of time without trouble. Now there's a clue here that we dont know about but I don't think it's appropriate to discuss this morning.

I'm' not going to discuss physics or physiology m any detail, because I've written all of this down elsewhere for those of you who care to read it, but basically the problem of altitude is due to the fact that air has weight. The blanket of air which wraps the earth is about 60,000 feet thick. It is dense at the bottom, near the earth, and rare at higher altitude. This is very obvious, almost a truism. Because of this, the air close to earth is rich in all components, and the higher you go the thinner and poorer it is Oxygen makes up about the same percentage of air, 21 per cent at low altitudes as it does at high altitudes. However, the partial pressure of oxygen, that is the amount of the total pressure that s available to the body for breathing, decreases as the total barometric pressure decreases. Again a truism. As you go high m the air, the amount of oxygen that's available to you decreases, and you become short of oxygen, and it is to combat this that the body acclimatizes.

The only thing of interest, in what I'm sure is a rather old story to most of you, is that recently there have been observations and questions about what altitude really is. I pointed out some years ago that barometric pressure fluctuates with weather, as we all know, and that a town like Aspen, where I then lived, which is 8,000 feet above sea level, may actually have an effective altitude as low as 6,500 or 7,000 feet, when the barometric pressure is high, while there's good weather, and as high as 9,000 or even 9,500 feet, when the barometric pressure is low and there is bad weather. Some people have said that this is why people who live in towns like Aspen are so kooky some of the time, because they/re a little bit more anoxic on some 'days than they are on other days.

This is a real fact, and it's something that you must bear in mind when you talk about climbing a certain number of feet into the air. Recently, Terris Moore has gone further and pointed out something that may be even more significant. Because the earth is flattened at the poles, or may be it's more appropriate to say it has an equatorial bulge, the blanket of air is actually thinner at high latitudes than it is near the equator. And because the air is cold near the poles, the cold dense air tends to settle out and therefore, in very brief and much simplified terms, if you climb 16,000 measured feet, that is actual linear feet above sea level, in Alaska, you may be in a physiologic environment that is many thousand feet higher than the same number of measured feet above sea level at the equator. So when you talk about climbing, you have to be rather specific. Did you climb 16,000 measured feet, or did you climb to an altitude of 16,000 feet effective altitude, as measured in terms of barometric pressure?

I don't want to belabour this point, but it's quite clear that physiologists have been guilty, as I shall be guilty as I talk further, of not being precise in what they've been talking about. They talk in terms of the effect of altitude on people, when they ought to talk in terms of pressure altitude, or effective altitude, or physiologic altitude. If we're talking about where we've been on the earth, then we can quite properly say we went 16,000 feet up, The point of this is that a natural mountain of 14,000 feet in Panama may be considerably lower, and much less of a triumph to I ! mountaineer, than a 14,000 foot peak in the high latitudes, near cither the North or South Pole.

The changes that make it possible for man to live at high altitudes or to survive for any length of time are quite elaborate. I won't go into them except more or less to list them. There mi the fairly obvious ones. One of the first things that the body does is to breathe more, deeper and faster. This has the obvious benefit of making the air deep in the lungs approach the ambient air, that is the environmental air, more closely. We're a rather inefficient breathing machine in some ways, and there's quite a difference in the content of oxygen between the air that we breathe in this nice, clean city and the air that we actually have down deep in our lungs. If we can ventilate more, eliminate more carbon dioxide, we'll get better oxygenation where it counts, that is where it's in contact with blood. The overbreathmg that the body does automatically is the first step in acclimatization. You pay a price for this, quite a serious price it can be, because you're losing carbon dioxide as well as taking in oxygen.

Loss of carbon dioxide has to be paid for in some way and this is paid for by losing base in the kidneys, so the kidneys begin to work overtime, base is extruded, and we can continue the overbreathing. Now a good many other changes take place and some of what I've told you is probably not completely true. It s a very rough first approximation, and not one that I think would satisfy many physiologists, but it's a reasonably close approximation and from a practical point of view, it's enough for the average lay man.

More capillaries open up, that is more of the tiny blood vessels that feed oxygen and food to the muscles, and this distributes more efficiently to the tissues what little oxygen there is at high altitudes As Dr. Kreider points out, it also makes you more susceptible to cold, because it distributes more blood to areas that are exposed. We do get an increase in red blood cells. Haemoglobin is made. This enables the blood to carry more oxygen per unit of blood. This is a pretty good change but it s not really quite as effective a change as one would like to think. It's a convenient and comfortable thing to measure. You can say that the red cells increase, the haemoglobin increases (you can measure it) and we've come to regard this as one of the most important changes whereas in reality it's one of the lesser important changes that take place.

But John Pappenheimer at Harvard, who is well known to many of us, a skier and climber as well as an eminent physiologist has done some very interesting work with goats, demonstrating that the spinal fluid has much more of an effect on many body functions than was previously recognized. There has recently been another drastic revolution in the palace of the sacrosanct physiologists, who are now beginning to feel that maybe the Sal fluid is the most important determinant of acclimatization, and that the kidney may be taking a back seat.

I don't think this is the time and place to go into that, but there are some very major changes taking place in our thinking. We also know that electrolytes, that is salts, potassium and sodium fluoride and so forth, shift quite markedly, and I'm going to come back to this when I talk about fluid distribution in pulmonary edema. There are minor changes that probably are not important, but so wonderful and intricate is the mechanism that preserves our functioning that there are probably many changes we're going to identify in the next decade that we don't even suspect at the present time.

Some of the thermostats, so to speak, or feedback mechanisms fail when we ask them to do more than they're capable of doing. Then we've got mountain sickness, and I suspect that most of you have had symptoms of mountain sickness at one time or another. It does occur at altitudes generally above six or seven thousand feet, if you go up too rapidly. It's not very common to see mountain sickness on Mt. Washington, although I suppose it could be produced there.

It's interesting to read old-fashioned descriptions of mountain sickness. A hundred or two hundred years ago people did go to thirteen or fourteen thousand feet and described fantastic experiences. You don't hear these stories today. Whether this means that more people are going and have exposed the humbugs who have reported these tales, or whether we're a healthier race of people, which is quite possible, or whether the psychological effect has been eased and it's no longer rare and unusual to go to 14,000 feet, I don't know, but we don't hear much about mountain sickness until we get up or go very rapidly up above six, eight nine or ten thousand feet.

The symptoms, of course, are quite well known. The most severe one is headache, very severe headache, sometimes not responsive to any of our usual medicines, but quite often responsive to aspirin. Nausea and vomiting are very common. In acute mountain sickness nosebleed is not uncommon. Palpitation of the heart, disorders of sleep, major changes in personality, all of these things occur in acute mountain sickness. It's a most unpleasant syndrome, headache, nausea, vomiting, either sleeplessness or too much sleep, shortness of breath, palpitation of I he heart. Pain is very uncommon. Collapse is rare. It does happen, but it's not terribly common. And then, of course, there is pulmonary edema, which I'll mention later.

Treatment of the symptoms is not terribly effective, and the best treatment, obviously, is to go down, and nobody wants to do that. Oxygen, if you have oxygen, does give remarkable relief. And here you come into one of these funny little things that nature does to us. Oxygen is one of the things that are necessary to life that we can't store in the body. You use it up as fast as you take it in, so that the oxygen that you're breathing now is used within minutes, and you can't get along for more than five or six minutes without oxygen.

At the same time, we do know from practical experience that if you're at a high altitude and you're having a bad time from mountain sickness, pretty much like a hangover, if you can get a few whiffs of oxygen every hour or so, it'll make you feel better for the entire hour. I don't know why, but it's the truth. It has the same beneficial effects on a bad hangover. Generally speaking, oxygen is more available in climates where you can have a hangover than it is in the mountains, but I think many expeditions are carrying oxygen now, not as a climbing aid, but to protect against pulmonary edema, and occasionally you might be able to bootleg a little bit of it if you were having severe mountain sickness.

But prevention is, of course, the best thing of all, and I've given you in this paper a very rough schedule of ascent which will enable you to acclimatize and probably avoid the acute symptoms. You can go to six or seven thousand feet in one day without any trouble. Most people can then go from seven to ten thousand feet the next day without much trouble, and roughly one to two thousand feet more in each of the next three or four days without getting symptoms.

When you get up around fourteen or fifteen thousand feet you have to limit yourselves to about 500 feet a day, or else you will have trouble. When you go above 18,000 feet you can just about make 500 feet a day. As Mallory said, you're like a sick man walking in a dream. I'm delighted to give way to Willi Unsoeld and Dave Dingman, who know much more about this than I do. We have some real experts on high altitude. As soon as I saw ' that Willi was here, I almost turned tail and ran.

Also, if you're going above fourteen or fifteen thousand feet, it's possible to go down a couple of thousand feet and spend the night just to get a breath of that big, rich, fat, juicy air lower down. It makes quite a lot of difference in your acclimatization. A lot of other preventives that have been used from time to time, ammonium chloride, potassium chloride-I won't list them all-have almost no effect.

It has been shown in theory and been tested, and I believe it to be really true, that a diet that is pure carbohydrate gives you about a 2,000 foot benefit in ceiling when you get up around twelve, fourteen or sixteen thousand feet. There again you have to pay a price, because if your diet is pure carbohydrate you'll lose muscle mass and you'll lose, heat and you'll lose weight and strength more rapidly than if you eat a mixed diet. So if you need the extra altitude, pure carbohydrates will help, but you'll have to pay for it in another way.

Now perhaps the only thing in what I'm saying that's really new, and may be it isn't new to some of you, is that we do have a drug which has real specific promise for prevention of altitude sickness. The most promising is Diamox. It acts by lowering the conversion of carbon dioxide to bicarbonates, through inhibiting carbonic anhydrose, an enzyme that promotes this conversion. It seems to enable the body to overbreathe and pay a smaller price for doing so.

There have been a good many exciting studies done and I think the evidence is rather convincing. If you take Diamox for one or two days before going high rapidly, and then for a day after you get there, the headache, the nausea and the vomiting are greatly decreased and actually may not occur. In tests on experimental subjects, those who did not take the drug but who were only on a placebo, that is a pretend drug, a sugar pill, were violently sick, vomiting all over the place, and those who were taking Diamox were holding basins for them. You can't take Diamox for very long before you go up, and you can't take it for very long when you ‘re up there, because it loses its effect. It’s only a two or three days' shot, but it gets you through the first symptoms, if you have to go up very rapidly. Now you also pay a bit of a price for Diamox. Sometimes it's rather an uncomfortable one. You have to urinate a good deal more frequently, and if you're snowbound at 17,500 feet, as some of us were last summer, this is a fairly stiff price to pay.

Some of the more enterprising investigators discovered you can tell whether you re taking a sugar pill or Diamox, because Diamox makes beer taste awful. The sugar pill doesn't influence beer at all. Also Diamox causes some tingling sensations in your fingers and feet which are unpleasant but not particularly significant. But Diamox does look like one of the best things that we’ve got to prevent the acute symptoms of mountain sickness. If you take it a couple of days before you go up and if you have go up last, you can acclimatize. So far as we know it does not change pulmonary edema much, but I don't think I can say anything very strong about this because we simply don't know.

The patient usually gives a story of having gone up to five, six, seven or eight thousand feet very rapidly. Then he climbed 2,000 feet the next day without adequate time to acclimatize, worked hard, began to get very tired, very short of breath and began to cough. The shortness of breath gets worse, the cough gets worse, then sputum comes out. Temperature may be high or low or normal. Pulse may not indicate anything. But you can hear the bubbling in the chest. Unless something is done about it this can proceed quite rapidly, and in a matter of six, eight or ten hours end in death.

Now the treatment is the obvious one. You get on a horse and go down just as fast as you can, if you've got a horse. If you haven't got a horse, you get people to help you down before you're incapacitated. If there is reason to suspect pulmonary edema, from the symptoms that I've described, a person should get down to a lower altitude as rapidly as possible and as soon as possible. You can go down three or four thousand feet and I he difference is dramatic. Then you can often come back up again, a couple of days or a week later, and go right on up without any further symptoms.

Pulmonary edema, once it has occurred, tends to recur in the same person. But here again acclimatization can protect him. Pulmonary edema seems to affect young people rather than old people. (That's one of the few advantages I know of to getting older.) And it does seem to be aggravated by exertion. Strenuous exertion makes a difference. We think it was one of the major I K tons that enabled the Chinese to overrun the Indians in 1962. The Indians had hundreds of cases of pulmonary edema while lighting in Ladakh, because they were flying people up from valleys, from 500 feet of altitude, up to 14,000 feet in a matter of a few hours.

Treatment is not terribly effective except for descent. If you're lucky enough to have it, breathing oxygen is a great benefit. Going down is, of course, the most important thing. Whether or not digitalis helps is debatable. I'm personally convinced that digitalis does help, and I think no expedition should go above 12,000 or 14,000 feet without carrying digitalis and instructions for using it.

The diuretics, such as diuril, may or may not help. We don't know the answer to this, there is some reason to believe that anything that encourages loss of fluid to the kidneys does help. Now here's the very anomalous situation in which you want to lose fluid, but at the same time you must be sure that the body

Thrombophlebitis is a disease that has been a problem in mountaineering expeditions. A definition is in order here, since most people are not really dealing with thrombophlebitis. It's a hyphenated word, or it's a combination of two words, ‘thrombo', which means thrombosis or clotting, and ' phlebitis', which means inflammation of a vein. It can happen anywhere in the body where you have veins, but the most dangerous place is in the lower extremities, in the deep veins of the calves and the thighs. The reason it is dangerous in these locations is that these seem to be the only locations in the body where clots break off and travel to the lungs to form fatal pulmonary emboli. I will limit my remarks more or less to the treatment of deep thrombophlebitis. Superficial thrombophlebitis causes a local redness and a hard¬ness of the superficial veins, and is the sort of thing for which an intravenous injection of a drug is given. It does not seem to embolize to the lungs, so we might as well forget about it as far as therapy goes.

Consider a clot in a vein just above a valve. Now clots tend to form in areas where you have sludging and stasis of blood. We'll go into this a little later, but this happens in the legs and usually in the vein just distal to a valve, because you get a little bit of stasis of the blood in there, and a little bit of sludging, and this is aggravated by cold, inactivity and other factors. But this is what the clots look like in the deep veins of the legs if you open them up at autopsy.

Now I can't really explain how these clots happen without going into a little of the more exciting and recent explanations that have come from the laboratory about why thrombosis happens in general. Charlie warned me about getting too deep into some of these explanations, but I think that this is interesting material, and it will make the whole subject more understandable to you.

Now the charges on the vessel wall and the charges of the particulate matter in the blood stream, in other words, the sludge c ells, are the same in the normal state. Like electrical charges (hey repel each other, and this is why in the normal situation you do not have thrombosis. What has been proven in recent research is that injury or other factors that affect the vein wall aid to change the charge on the vessel wall. This may be a very incidental trauma, or something that the mountaineer or person in the field does not even remember in his daily knocking around. Anyway, with that change of electrical charge on the vessel wall you get an attraction of the particulate matter to the area of entry on the intima of the vessel and clumping of blood

Redness or blueness is due to venous obstruction. This is most marked usually when the legs are pendent.

Leg pain when coughing. The reason for this is that when you cough you increase the pressure in the vascular system. This wave of pressure travels down the veins into the lower extremities, and many people have pressure, or have a sudden pain with coughing, at the site of thrombophlebitis.

Pain on pressing the calf. Pressure between the heads of the gastrocnemius muscle is a very important way to identify thrombo¬phlebitis. Usually a patient with acute thrombophlebitis will have exquisite pain on pressure straight in on the calf below and behind the knee, between the heads of the gastrocnemius muscle.

Flexing the foot. This puts a stretch on the deep vein, also between the heads of the gastrocnemius muscle, and this is usually a positive test for thrombophlebitis, called Homan's sign.

Blood pressure cuff. Most of you won't have a blood pressure cuff with you, but many expeditions will, for either scientific or medical reasons. A person who has thrombophlebitis will not be able to stand the pain caused by putting a blood pressure cuff on like this and pumping up the cuff to 180 millimetres mercury. The way to do it is first to put it on the affected leg. Don’t tell the person what you're going to do, but just watch his facial expression. If he has this condition it will be obvious that he is in exquisite pain. Then repeat it on the other leg, and there will be a marked difference in his ability to tolerate this on the two extremities.

The treatment of thrombophlebitis is a controversial thing among physicians and universities throughout the world. I have an idea about how it ought to be treated in the field. I don't want to get into the best way to treat it in the hospital, because I'm sure I hat many of us could argue all day about that. But there are four major things to do.

1. Wrap the limb with an ace bandage, and this cuts down the stasis. In other words, it gives an outside pressure to the limb, which increases the velocity of blood flow in the vein. This knocks out one of the predisposing factors, stasis of the blood in the vein.

Anticoagulation. Now this is where the controversy comes in. There are three major ways to anticoagulate a person. One is oral medicine. A second is with heparin, and the third, a newer method, is with dextran, a medicine which is given intravenously, t he first two drugs, heparin, and the oral anti-coagulants actually comes in, and the dextran molecule ties on to the negative charge at the site of injury on the vessel wall. This neutralizes the charge on the vessel wall, so that the particulate matter in the blood stream is not attracted and no thrombosis occurs. This is the theory on the way dextran works.

Now why treat thrombophlebitis? We haven't even talked about thromboembolism, but this is the whole key to why we treat thrombophlebitis so vigorously. Thrombophlebitis is not a fatal disease, but thromboembolism to the lungs is. The usual site of thrombophlebitis is in the calf of the lower extremity.

If a thrombus there breaks off, or commonly a piece of it breaks off, it can travel to the lungs. It goes via the femoral veins into the common channel in the abdomen, the vena cava, and into the right side of the heart, from which it is pumped through the pulmonary arteries into the lungs, in which it travels until it meets a pulmonary artery which is so small that it can't go any further. This causes massive infarct of the lung, and if it's big enough, instant collapse and death. So this is why it's important to bear in mind that thrombophlebitis is a very serious entity. Are there any questions about thrombophlebitis?

Voice: Do you give the dextran continuously?

DR. DINGMAN: NO. I'm glad you asked that. I forgot to mention that. You don't give it continuously. The dextran molecule stays in the circulation practically eighteen hours before it is cleared. You give it over a four-hour period. The reason for that is that dextran was originally used as plasma expander. Anything that rapidly expands the blood volume at high altitudes is not to be taken lightly, because of the problem Dr. Houston mentioned, pulmonary edema. But if it's given over a four-hour period it only raises the blood volume 1 per cent and therefore i safe. Also, with an 18-hour duration in the blood stream, plus a four-hour administration time, you get essentially 22- to 24- hour coverage if one unit is given per day. And that's all you need, 300 c.c. to 500 c.c. per day.

Voice: Did you say thromboembolism to the lungs is fatal ?

DR. DINGMAN: That's true. VOICE: Why?

DR. DINGMAN: Because it causes massive reflex changes in the heart, and the heart ceases to function as a pump and often goes into fibrillation, and the organism just does not circulate blood.

Voin;: There appears to be in the medical literature certain evalonce that ' The Pill', which may be taken by female climbers, has provided a predisposition to thrombophlebitis. Would you agree that it might be a good idea to discontinue its use while climbing?

DR. DINGMAN: It depends on what that individual thinks is the greater danger. It's quite true that thrombophlebitis was a rare disease in young people who were healthy, prior to the advent of the pill for contraceptive use. And since their wide¬spread use it is much more commonly seen. So I think that it is a predisposing factor. That's my personal view about that.

VOICE: IS thrombophlebitis more aggravated at higher altitudes?

DR. DINGMAN: IS thrombophlebitis more aggravated at higher altitudes? The predisposing factors that we mentioned are present at higher altitudes. I've left out a lot of other predis¬posing factors, like debilitating diseases, and previous operations. I've just picked the things that happen to you when you're in the mountains. Then also, anything that happens to you at high altitude that makes you sick creates a much more serious situation because of underlying hypoxia, underlying debilitation, underlying lowered ability to fight any situation. And if you throw off a clot to the lung, that area of lung is unavailable for use in oxygenating your body, and at lower oxygen tension this is certainly aggravated.
VOICE: (Inaudible).

DR. DINGMAN : Would people with family tendency toward varicose veins have higher incidence of thrombophlebitis?
I would not say so, but I would say people who have varicose veins are, because this leads to stasis, which is one of the pre¬disposing factors. People that have that would do well to wear supportive hose at all times, and especially when they're in the mountains.

VOICE: (Inaudible).

DR. DINGMAN: Yes. What is the difference between symptoms of thrombophlebitis and loss of fluids and electrolytes? Loss of potassium or calcium can give you cramps. The cramps that you get with loss of potassium and loss of other electrolytes don't tend to be localized just to one area. You often get parathesias in the hands, the fingers, claw type tetany in the fingers, as well as cramps in the legs. And thrombophlebitis in an upper extremity is almost unheard of. So usually if it's on a dehydration basis you have many more generalized symptoms.

VOICE: DO you recommend use of the low molecular weight form of dextran?

DR. DINGMAN: No, sir. I do not, at this time, advocate the use of low molecular weight dextran for this problem. I mean, it's all right to use, but it has been relatively unobtainable until just recently, and there's pretty good clinical evidence that the clinical weight dextran, the 70,000 molecular weight form, is just as good in most cases of thrombosis. I have seen several allergies supposedly due to dextran, but since dextran is not a protein, and therefore should not be an allergic, it is probably not an allergy to the dextran molecule itself. It's probably an allergy to an impurity in the dextran which is left over from the bacteria that changed mannose into dextran.
Now the second part of my subject, the one that was assigned to me, is immunology, and I'm going to limit this to immuniza¬tions and a few comments about problems in expeditionary health as far as the intake of certain organisms is concerned.

Every time we have a war we learn a great deal about what is required to keep our combat people healthy, if they need to have world-wide mobility. The outline map of the world and accompanying recommendations are just what we do with our combat crews in B-52's that are on alert to go anywhere in the world. The areas are outlined and marked by a letter—R stands for routine immunization, T for typhus and routine, CT for cholera and typhus plus routine, PCT for yellow fever, cholera and typhus plus routine, etc.
The recommended frequencies of immunization are also shown in the table. These are more often than many people will recom¬mend, but people who go on expeditions are essential to the efforts of a very expensive project, just as the people who fly a big bomber are. If one person gets sick, it's disastrous for the whole expedition.
There is a moderate amount of controversy about infectious hepatitis. There is no active immunization, but it is a very debilitating problem. Willi Unsoeld can tell you how he almost died from it when he got back from the expedition. There is no active immunization for this disease, but passive immunization can be given by gamma globulin if it's given just prior to beginning travel. In our case we gave it on the airplane after we took off I mm San Francisco. How long this gives immunization is really not known, but it's at least six weeks. If you get a moderately good dose, for an average male 7 c.c., it’s probably longer than six weeks, and you may have some immunity, or at least altera¬tion of the severity of the disease, for up to four months. It is

DR. DINGMAN: The question was is the millipore filter effective as the sole treatment of water? I would say no.

VOICE : Is halo effective against viruses?

DR. DINGMAN: Some people believe that if it's used in the water long enough, it will be effective against hepatitis. Charlie, what do you feel about that?

DR. CHARLES HOUSTON: I don't think you can be sure that it does. If you want to be triply sure, boil, filter and haloglobuline.

VOICE : Then stay home.

DR. DINGMAN: These health problems are largely when you're passing through an area, It's really a very small period of time, because you leave home, travel through an area of danger, and then you're on the food that you're carrying on your back. We found a great increase in all sorts of problems when people returned to Kathmandu. There was a great release of tension, and a large round of parties. Then everyone immediately got sick.

VOICE: Where did Willi Unsoeld get hepatitis?

DR. DINGMAN: Willi, where'd you get hepatitis?

WILLI UNSOELD : Got it while in hospital.

DR. DINGMAN: This is very likely the case, really. Nobody knows. Any case of hepatitis is almost impossible to track down. I might also mention that Willi was the only one who didn't have gamma globulin.

WILLI UNSOELD : That's not so.

DR. DINGMAN : I'm sorry. Did you have it prior to the . . .

WILLI UNSOELD: Let me say a word on that. Just a word on the use of gamma globulin. I had had gamma globulin six months prior to coming down with the disease, to the day. In fact, the health nurse felt very guilty because she had missed me on two appointments to give me my booster, and so she blamed herself. But it was useless, I would have come down with it anyway. There seems to be a definite connection between severe injury, some sort of physical trauma, and the disposition to come down with the hepatitis. I refer to Ambassador Reichauer, who was stabbed in Japan, and then contracted hepatitis while in Hawaii. I think it just lowers the general body resistance to the disease, and so you're much more apt to come down with it.

DR. HOUSTON: Dave, do you want to comment on the timing of gamma globulin and other injections?

WILLI UNSOELD: I could speak for the Peace Corps on this, because they've had a lot of experience. They started out the Inst group in the fall with a dose of gamma globulin, just when they went out of the country. They gave another six months later and then they terminated the treatment. So they went .the final year with no gamma globulin injection. At the termina¬tion procedure, at the end of the second year, there were three cases that came down within, I think, a week. DR. HOUSTON: I didn't mean ...

MODERATOR: I think Dr. Houston means if you have gamma globulin in conjunction with immunization you get into problems. Why don't you get up and mention that Charles?

DR. HOUSTON: Just happen to have a few slides in my pocket.
Some evidence has been coming up lately to indicate that if you do take gamma globulin you interfere quite significantly with the development of antibodies when you give agents that inspire active immunity. So that if your doctor outlines a fancy schedule of typhoid, cholera (I don't agree with you about plague and a few of the others), and then puts the gamma globulin too close to any of them, you will almost certainly neutralize the effect of the shots. So, as you said, gamma globulin probably should be the last shot given as you get on the airplane and several weeks, if possible, after you’ve had your other injections. Is that right?

VOICE: I think you should say something about yellow fever and smallpox.

VOICE: Why don't you say something about it? VOICE- There is some evidence, particularly from the British, who have sent people all over the world for years, that you should have at least two weeks between your smallpox vaccination and yellow fever immunization. If you put them closer together there is a real chance that encephalitis, or rather severe brain inflammation, can occur.

MODERATOR: I think well take one more question, Di. Sifverstin?

 

DR. SILVERSTEIN: Since we're adding complications of vaccina¬tion, I think we can complicate even more. If you or anyone in your family has a rash at the time that you're revaccinated, it is possible for the smallpox virus to spread to the rash area. A person about to be vaccinated is seldom asked if he, his wife, or his child has a skin rash. Vaccination is something that ought to be done well ahead of the time that you're going on an expedi¬tion so that when the time comes to go if anyone m your family does have a skin problem, there won't be this temptation to be vaccinated anyway I think this is something that is frequently overlooked. There are a small number of children in the United States every year who die of complications, of vaccination. So vaccination is something that you can think about and take care of with no harm.

MODERATOR : Thank you. This will end the morning session.

IMMUNIZATIONS FOR SPECIFIC AREAS

AREA R: Smallpox, Typhoid-Paratyphoid, Tetanus-Diphtheria, Oral Poliovirus Vaccine, Influenza and Plague.

AREA T: Those for Area R plus Typhus.

AREA CT: Those for Area R plus Cholera and Typhus.

AREA Y: Those for Area R plus Yellow Fever.

AREA YCT: Those for Area R plus Yellow Fever, Cholera and Typhus.

Recommended Immunizations for Optimum Protection for Persons doing World-wide Travel, Expeditions:

VACCINE

 

A Highly Debilitating Disease of World-wide Distribution.

No Active Immunization but Passive Immunity Is Afforded for at least 6 Weeks and Probably Longer (Up to 4 Months) by Gamma Globulin.

Dose for Average Male Is 7 c.c. Given First Prior to Beginning Travel.

Consult Local Public Health Department for Availability of Scrum.

MODERATOR : The first talk of the afternoon session on Freezing, Frostbite and Cold Injury will be delivered by Dr. Charles Huggins, of the Harvard Medical School who is chief of the group which is investigating low temperature phenomena.

 

 

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FROSTBITE and cold injury were one of the foremost problems of primitive man. Successful methods for dealing with these conditions were essential for survival of the human race. The upright posture, with head, feet, and hands at different tem¬peratures, and the relative lack of body hair, make man unusually susceptible to cold injury.

Frostbite with loss of tissue is not common in civilian practice. At the Massachusetts General Hospital only one to four patients are seen each year with true frostbite. The majority of these patients also suffer from alcoholism, cerebral vascular disease, mental retardation, or other conditions that dull the patients' senses, and delay or prevent immediate treatment.

Accidental cold injury, however, is a major problem both in mountaineering and in Arctic warfare. Man can either survive under low temperature conditions, or he can fight against nature or other men, but to do both simultaneously is frequently impossible.

The degree of success with which mountaineers, or foot soldiers, prevent frostbite and freezing injury is largely related to their state of training, and discipline. The military importance of cold injury was brought out dramatically during World War II when frostbite was relatively common among American troops, relatively uncommon among British soldiers, and in the German and Russian Armies, where frostbite was an offense punishable by death, virtually no cases of the disease were seen.

The relatively high incidence among American troops was contributed to by the fashion of wearing shoes that fit snuggly. British Army Quartermasters, on the other hand, fitted their men for boots in such a way that the uppers of the shoes came together, and thus could not be laced more tightly by the man than when he was fitted by the Quartermaster.

In Korea during the winter of 1950-51, there were many cases of serious cold injury. A good friend of mine who was a medical officer there in the fall of 1951 went to the Division Surgeon's office, thinking that it would be well to make plans for treatment of additional patients with cold injury. He was told, 'Here, read this and was handed a piece of paper which read somewhat as follows:

' To all Officers and Men in the First Marine Division,
Subject: Frostbite, Various References:
1. There will be no frostbite.

Signed:
/s/ Major General USMC'

There were very few cases that winter. This anecdote illustrates the fact that frostbite is primarily a disciplinary disease. Well trained people, well equipped with knowledge of the problems very seldom get frostbite. The inexperienced person poorly pre¬pared and unaware of the problems is the one who gets serious frostbite.

Cold injuries can be divided into two broad categories, sub- freezing and freezing. The former is commonly referred to as trenchfoot, or immersion foot. This injury is normally related to prolonged exposure to cold and dampness at temperatures above the freezing point, but it can also be seen in tropical climates. Although there is still controversy about the mechanisms ol injury, this type of pathology is primarily due to wetness, rather than temperature per se.

True frostbite implies ice formation in parts of the body usually extremities, at temperatures below the freezing point of tissues (-0-6 °Q. Classically this injury has been divided into four degrees. Although these categories are useful for com¬parative purposes, they represent a retrospective diagnosis. Super¬ficial or deep frostbite, depending on whether or not tissues are lost, is the most helpful forward looking classification.

Freezing kills cells, not by mechanical damage from ice crystals, but rather by biochemical injury related to increased concentra¬tions of salts that develop as pure water is deposited in ice. Crystallization of water in tissues with corresponding increase in solute concentration begins at the freezing point and progresses until -40 °C. Toxic concentrations of salts are not reached until a hand, foot, or ear reaches temperatures below - 3 °C (26-6 °F).

The concept of a critical subfreezing temperature explains the fact that tissues can freeze—as in ' frostnip '—and be thawed with no permanent tissue damage. The solute concentrating action of freezing has been known for years. This principle is used commercially to concentrate orange juice, or desalinate sea-water. Recognition of the biological effects of concentrated solutes, how¬ever, only dates back to papers by Lovelock in 1953.

If one keeps in mind the fact that tissues must be frozen below 3 °C (26-6 °F) to be damaged by freezing alone, many of the principles for prevention of frostbite become clear.

Preservation of living cells by freezing at temperatures below 3 °C is practised widely with glycerol-treated bull semen, and human blood for transfusion. Success with these techniques, however, requires pretreatment of the cells with cryophylactic agents such as glycerol, or dimethylsulfoxide. To date, however, there is no satisfactory method for getting these chemical com¬pounds into or out of human extremities. Unfortunately, this otherwise attractive approach to prevention of frostbite is not feasible. The problem of frostbite thereby reduces itself to its prevention.

Frozen extremities can be damaged above the critical tissue temperature of - 3 °C if flexed forcibly. If this happens, blood vessels are disrupted and incapable of normal function after thaw¬ing. Tissues distal to the damaged vessels are deprived of normal nutrition and die. To illustrate this point, consider a wooden pencil placed in the freezer. If the pencil is removed from the freezer it will re warm and be none the worse for wear. If, however, you flex the frozen pencil it will break, and be ruined permanently. Mechanical flexing of frozen extremities can convert superficial frostbite to deep frostbite with permanent loss of tissue.

Prevention of frostbite requires a balance between heat loss from the extremity and heat gain from the circulation to prevent lowering tissue temperature below - 3 °C. Any factor that reduces the normal blood flow is potentially dangerous. Obvious factors that decrease circulation are constricting footgear, tight elastic in stocking tops, and fractures or other injuries to the extremities. Less obvious, but very important, reduction of blood flow can also occur when blood vessels constrict as part of the bodies normal response to prevent central core cooling, or from the vasoconstricting action of tobacco. Keep warm and avoid tobacco.

Alcohol and/or hallucinogenic drugs like marihuana, although they do not cause vasoconstriction by themselves, reduce aware¬ness, permit general body cooling, and lower the temperature of blood flowing into the extremities.

Heat loss from extremities can take place by direct conduction to the environment. Air, being a very poor conductor of heat, is not a major factor in heat loss, unless the air is moving rapidly. The wind chill factor of 1° per mile per hour is important to remember, particularly with snowmobiles operated on clear wind¬less nights.

Heat loss by direct conduction to metal, however, occurs extremely rapidly. Anyone who has touched the tip of his tongue to a brass doorknob in winter appreciates the speed with which tissues can freeze. Extreme care should be used when operating cameras, guns and surveying instruments in cold weather condi¬tions, or at high altitude. Parts of this equipment that must be handled should be covered with adhesive tape, if possible, before going into the cold. Otherwise, light silk gloves provide good insulation and permit delicate manipulations of metal devices.

Evaporative cooling of extremities is a major mechanism for heat loss. Perspiration should be avoided particularly under windy conditions. As a rule, multiple layers of outer clothing are preferable to multiple layers of insulated underwear since you must, of necessity, undress to remove the latter.

Particular care should be taken to avoid spilling gasoline, alcohol, or ether on hands or clothing. When volatile chemical solvents evaporate local cooling is intense.

Radiational cooling from light coloured clothing is relatively unimportant when balanced against necessity to be seen if rescue may be required, or if camouflage in a snow environment is essential.

HEAT LOSS MUST EQUAL HEAT GAIN—otherwise frost¬bite may result.

Treatment of frostbite requires early recognition that it has occurred. If a frozen part at -2 °C can be thawed immediately no permanent damage will result. The sensation of coldness is serious. Of much greater significance, however, is a change from coldness either to no sensation or worse, warmth. These changes in sensation are the early warning sign of superficial frostbite. If unrecognized, the change to deep frostbite will occur at a rate dependent on the rate of heat loss. When frostbite can occur keep thinking, 6 ears, hands, feet . . . ears, hands, feetWherever possible, a formal regular 4 Buddy System' should be instituted, in which members of the party are paired, and made responsible for the others safety.

If frostbite has occurred the patient must be taken to an area where the frozen part can be thawed, and remain protected. Freezing, thawing and refreezing is many times more likely to result in permanent loss of tissue than one cycle of freezing and thawing alone.
Bradford Washburn, in his excellent article 'Frostbite', has pointed out the danger of rewarming on the trail. 'Contrary to general belief, a strong patient can walk a long way on frozen feet without further injury to them—and by so doing not only get himself down to a better site for recovery but also save his companions the difficult (and sometimes dangerous) task of dragging or carrying him down after thawing has rendered it impossible for him to walk at all.

Massage is absolutely contra-indicated in the treatment of frostbite since trauma to frozen tissue like the broken pencil can cause irreparable damage.

Rapid rewarming in a vigorously stirred pan of water, or whirlpool bath is the most important method of treatment. Water temperature should not exceed 44 °C (112 °F). If the accuracy of the thermometer is suspect, use a lower temperature and test the water temperature with the skin of your elbow. Simple thermo¬metry of this type may be more accurate than any readily available thermometer.

Anticoagulants like heparin, and low molecular weight Dextran, can be very helpful, but only under direct medical supervision at a definitive treatment facility.

Long-term management of patients with severe frostbite requires ultraconservatism with prevention of infection, and maceration. Amputation of dead tissue should not be done except in cases of invasive infection.

Awareness, preparation, discipline and the attitude 'there will be no frostbite' are essential for success in dealing with this normally preventable injury.

VOICE : In connection with what you said a moment ago, isn't it true that the dextrans are useful only if you can inject them very close to the time of the injury, like within seventy-two hours cither before or after?

DR. HUGGINS : That is correct. Actually, I would prefer to start it even before rewarming, if possible. Unfortunately, unless one is highly organized there usually tends to be a bit of confusion at that time. It would be well to try to be organized for this, and clearly the time to do it is beforehand.

VOICE: What are the relative merits and hazards of splinting versus frostbite?

DR. HUGGINS : This is a tough one. Obviously you must splint fractures. Try to keep the patient's foot as warm as you can, and get him to a place where he can be handled definitively.

VOICE: Where an extremity has been subjected to frostbite, is there a permanent disability or is it only temporary?

DR. HUGGINS: In general, an extremity that's had a major episode of freezing is usually sensitive, and it may be sensitive forever. Another long term effect in frostbitten hands is thinning of the pad of the fingers. You can frequently make this diagnosis years after a serious frostbite, just by looking at the extremity.

VOICE : Would you comment, please, on rapid or slower re¬warming?

DR. HUGGINS: Well, I think all the controlled experimental studies that I know of, and the experience of Dr. Mills in Anchorage, who has probably had more clinical experience with this sort of thing than anybody else, indicate that rapid rewarming is considerably more painful than slow rewarming, but ultimate preservation of tissue tends to be better with rapid rewarming than with slow rewarming. Slow warming arose out of general con¬servatism, that one ought not rock the boat. It must be emphasized that water for rapid warming must not exceed 44 °C, which is the same as 111 °F.

VOICE : Is there any way that you can precondition an extremity by increasing the circulation?

DR. HUGGINS: That's an interesting thought. I know of no way. Maybe somebody else does.

VOICE: It was suggested a little earlier at lunch that you might get some benefit out of walking around with a snowball in your hand.

DR. HUGGINS : I would be inclined to think that move of little value, unless you wanted to throw the snowball.

DR. KREIDER: I mentioned this morning in my lecture that apparently one of the benefits of repeated exposure to cold is a warmer peripheral area or warmer extremities. I think this is about the only real physiological acclimatization a man shows to cold. If you had your hands exposed quite a bit for a period of days and days to the cold, your hands would be warmer during any successive cold exposure than if you had not had this previous exposure to the cold. Do you disagree with this?

DR. HUGGINS: I've had no personal experience. I'm interested by that. I have seen patients that have had their hands repeatedly immersed in cold water, serving drinks from an ice bucket, develop vascular phenomena in their hands, but this is a selected group of patients. (Laughter)

VOICE: I have a question for you and for some of the people who have been on expeditions. What would be the expedition equivalent of rapid rewarming? How do you achieve it? Or what's the closest thing to achieving it that you can get?

DR. HUGGINS: I'll have to leave this question to the experts. Bradford Washburn, though, worked out a beautiful little device from a gasoline can. But, as he pointed out, to rewarm on the trail is very hazardous. One ought to be very circumspect about rewarming unless it's possible to be absolutely certain that the extremity will not freeze again, otherwise you may do the patient more harm than good.

Willi?

WILLI UNSOELD : The question of whether or not to rewarm fast is a very vexed one, because you know you're rewarming slowly all the way down the mountain. It's not the old situation in Alaska where you're so solidly frozen that you could walk for two or three days without thawing. So that there's your dilemma. Do you stop at the nearest camp and boil up a big pot of tea and plunge into the pot in order to rewarm rapidly and then macerate the foot on the subsequent days that you walk on it?

The only case in point that I know is of Barry Bishop and me, and to my recollection we played it oppositely. I plunged my feet into the pot of tea and rapidly thawed them out, I guess. Barry Bishop didn't. The next day was a painful day for me, and somewhat less so for Barry. He lost ten toes and I lost nine. {Laughter)

I got to drink the tea too. (Laughter)

DR. HUGGINS : This is a very important point that you raise, and I certainly think that there is no answer to it. The other common situation is where a person is rescued by police and transported in a warm police cruiser to the hospital five or ten miles away. The extremity is almost rewarmed. You're damned if you do, and damned if you don't.

DR. MCDADE: When you are in the mountains you often have to compromise. You must recognize this, and remember that your best judgement is the only judgement that counts. I think the evidence indicates that if you can rapidly rewarm under ideal conditions you add materially to the final salvage of tissue. But this is terribly painful, and takes a big dose of demarol and a big dose of morphine and lots of guts. Now if you are going to try this in a gasoline can in the mountains you have got problems. You would want the water to be about 112°, maybe 114° Fahren¬heit, but remember that muscle tissue coagulates and is destroyed at 117°, so you would need a thermometer. And remember it is liable to be superheated on the bottom, near the fire, so be careful of that or you will cook this fellow. If you thaw a foot it will be soft and boggy, and you will have a litter patient. Walking on that foot, every step you take would be destroying tissue.

 

 

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THE material I am to discuss today concerns the use of anti¬biotics on mountaineering expeditions where a physician is not available. I would like to centre attention upon the common, but not life-threatening, medical problems which may arise during the course of a mountaineering expedition. These problems can become serious if neglected, yet they can be treated by intelligent and informed lay members of an expedition. The situations of which I speak are in contrast to those discussed earlier in this symposium, which generally force an expedition to evacuate the sick individual as quickly as possible.

The best time to start this consideration of what to do about medical problems in the mountains is before you leave. Before you go on any mountaineering expedition you should have a complete physical examination, and that includes a chest X-ray, complete blood count, and urinalysis. During your visit to your doctor you should have your immunizations brought up to date. Everyone should have a tetanus booster before departing on an expedition. In addition, you ought to visit your dentist and have your teeth checked. Dental caries can lead to dental abscesses, and these can be sources of very serious infections, difficult to treat in the mountains, yet easy to prevent.

You ought to be sure that you have no ‘minor' infections such as athlete's foot, a fungus infection between the toes, which causes itching and cracked skin. You may have picked it up in the gym last winter. This can be a portal of entry for serious bacterial infections of the foot.

Superficial fungal infections can be problems which are espe¬cially severe under Arctic conditions. Many of the boots that are used in cold climates work on the vapour seal principle, so while your nose is freezing in the cold blue air, your feet are sloshing around in the warm, damp environment within your boots. By the end of a day of wearing vapour barrier boots, you'll find that your socks are literally wringing wet. This was a real problem during the Korean war, when many GI's developed fungal infec¬tions of their feet while their upper extremities were freezing. Frequent changes of socks and the use of a fungistatic powder (like Desenex) can prevent this.

There are a few other procedural items that I would like to review. First, I think that one of your group ought to be responsible for the medical problems of the expedition. In other words, he should see that all of the preparations about which we have been talking (vaccinations, etc.) are satisfactorily completed, and that a physical examination has been done—not 'yeah, I'll get it next week', but that it has been done.

Second, I think it would be very useful to have on hand the excellent little book called Medicine for Mountaineering. It is published by the Mountaineers, Seattle, Washington, and has an abundance of useful information. It is small enough to carry with you.

Third, all members of your group should have a good grasp of any medical problems particular to one member of your expedi¬tion. I think it would be well for you to sit down before you go, and talk with one another about any such individual problems as reactions to insect bites, asthma, food allergies, etc. There may be a particular medicine which an expedition member needs for his own health. For instance, he may have asthma and require an atomizer. Don't rely on him alone to bring along the thing he needs for his own health. It may well be that his supply gets lost, or he neglects something that's very important for him. His problem then becomes your problem. These very necessary sup¬plies should be scattered among other members of the expedition as well. I should add that when you are preparing a medical kit, it's just as well to divide it into two or three small kits. In this way, when you pull Joe out of the crevasse that wasn't suspected, and his pack doesn't come out with him, you won't look into the hole and say ⁴ Well, we won t get sick anyway.'

Fourth, and most important, long before departure you should find out if any one of you is allergic to any of the particular medicines that you think you are going to use. Now, you can ask someone, and this happens all the time in the hospital, ' Are you allergic to any drugs or medicines?', and they say ‘no '. But later, when you are about to give them penicillin, they say ‘Oh, Doc, I forgot to tell you but last time I got penicillin I broke out in a rash.' So the important thing to do is go right down the list of drugs that you are planning to take along. Are you allergic to penicillin?' 'Are you allergic to any of the pain killers?' 'Are you allergic to tetracycline?' Ask all these things individually. It takes about five minutes to do this, and you come away with a really complete answer. If someone says, ' I'm not sure—I don't think so' have him go see a doctor and get a definitive answer, and if you are still not sure, then don't use the drug.

Fifth, each expedition member ought to have a small packet which contains routine medical supplies such as salt tablets, bandaids, tape, foot powder, aspirin, sleeping pills, insect repellent, and sun and skin creams. If an individual has these in his own pack, he'll use them ; if he has to ask someone else for them each day he may not do so. If you have ever seen someone with badly sunburned lips who is not able to eat effectively, you realize that his personal problem is a community problem, and that it probably could have been prevented.

Once your expedition medical kit is assembled, it's a good idea to get a mountaineering physician friend to talk with your whole group, not you alone, but to all the members of the expedition. Find out if your programme of medical therapy is a sound one, and if the things you are planning to do make good sense.

Finally, it's very important that all drugs in the medical kits be well labelled, and that the dosages and methods of administration are written down and readily available. You, the fellow who is going to take care of all these people, may become the patient, and when you think about that your whole attitude about the situation changes.

I have prepared a table of drugs and medicines suitable for four people on about a month-long expedition. Almost all the drugs on this list are intended for oral use, because I feel that the layman does better with oral therapy. This table can be found at the end of this article.

What are the infectious disease entities that you ought to be prepared to treat? They are simple things that we see all the time, and they come up in the mountains as well. One is a sore throat. At high altitudes, the most frequent cause of a sore throat and a dry cough is dehydration, and the constant irritation to the mucous membranes from breathing cold dry air. This type of cough is well treated by increasing fluid intake, which is something we've emphasized all day, and by taking some throat lozenges and some elixir of terpin hydrate. (All of the medicines are on the list which appears at the end of this article.)

In the 15 January 1968 issue of Life magazine, you may have noticed that a Portland, Oregon pediatrician recommends a mix¬ture of gin, honey and lemon juice for a sore throat. It sounds like a very pleasant combination, but if you find yourself upside down in the mountains, you'll know that it was a little too much cough medicine that caused the problem.

A sore throat accompanied by fever is probably due neither to dehydration nor to just cold air. There should not be enlargement of the lymph glands, and there should not be pus in the throat. This combination of fever, lymph gland enlargement and thick, yellow exudate in the throat can be caused by either a viral or a bacterial illness. The most frequent bacterial offender is the streptococcus. That's a ⁴ strep ' throat.

The most astute physician, with all deference to everyone here, cannot distinguish a viral pharyngitis with fever, lymph node enlargement, and pus in the throat from a ‘strep' throat more than half of the time. He relies on the bacteriology lab to give him a definitive answer. In the mountains you don't have a bacteriology lab, and so for this reason I recommend that if you have this constellation of symptoms you start conservatively with symptomatic therapy: lots of hot tea, soup or lemonade, salt water or aspirin gargles, and two aspirin tablets every 6-8 hours. If your patient is not getting better after 24-36 hours of sympto¬matic treatment, then I suggest you add penicillin to the above regimen. The doses of oral penicillin for a bacterial sore throat are indicated in the table. This treatment is cheap and very simple, and should be continued for ten days. If your patient is allergic to penicillin, I have indicated an alternative medicine. Use erythromycin four times a day for the same period.

What does a ‘strep' throat look like? There are generally white patches of mucus on the tonsils (the areas on the side of the throat). There is reddening and inflammation in the back of the throat. (If you are not sure if the patient's throat is red, compare it with the throat of a healthy member of the party.) And there will probably be enlargement and tenderness of the lymph glands, which can be felt below the angle of the jaw. Fever, as noted before, is almost certainly an accompanying sign. This is a straightforward problem that you can treat in the mountains and achieve an excellent result in almost all cases.

Two other things ought to be said right here. First of all, oral penicillin is inactivated to some degree by stomach acid. So when you give this medicine, it ought to be given either half an hour before or two hours after the patient eats. These are the times when gastric acid is lowest. Second, when your patient is feeling better after you have started penicillin therapy, either because your medicine made him better or because he was going to get better anyway, he is not going to want to continue to take his medicine. But the ten-day course is important if you are to prevent a relapse. Under these circumstances, you are going to have to keep after him if you are the expedition doctor.

The next infection I want to talk about is an ear infection. This may announce itself by an earache, or by draining of pus from the ear. This can be a complication of an untreated throat infection, and is not only debilitating, but can be the start of a bacterial meningitis. The most common organisms in adults are streptococci, staphylococci and pneumococci, and since some strains of staphylococci, as you've all heard, are not sensitive to penicil¬lin, the drug I've suggested here is one of the newer, semi-synthetic penicillins, cloxacillin.

Unfortunately, some of these new drugs are expensive, and cloxacillin turns out to be very expensive. For example, a ten-day course of cloxacillin therapy for one person will cost between $40 and $50. However, there are enough uses for this drug to justify including it in the table. If your patient is allergic to cloxacillin, use erythromycin. Again the dose and method of administration are indicated in the table. Cloxacillin, as in the case of penicillin, should be administered half an hour before or two hours after meals

Sinusitis is a frequent problem in the mountains, and a frequent accompaniment of either an ear infection or a sore throat. In the vast majority of patients, acute inflammation of the nasal sinuses is caused by a bacterial infection brought on by blockage of the sinus passages following a common cold, or an allergy. Sinusitis is manifested by local pain, sometimes by swelling of the soft tissues of the face, and by headache and fever. The headache is usually worse in the morning when you wake up. This is because the pus has failed to drain. When you are in an upright position during the day, the pus will drain. The initial treatment for this consists of symptomatic therapy : adequate decongestants, such as neosynephrine spray, an antihistamine such as pyraben- zamine, and aspirin for fever and headache. Should the patient fail to improve, or worsen following 24-48 hours of symptomatic therapy, I would start an antibiotic.

The antibiotic I choose under these circumstances is again cloxacillin, because staphylococcus can be the offender in the nasal passages. The dose is indicated in the table. The drug of second choice would be erythromycin. In my experience many people have an inflammation of the sinuses and a lot of watery discharge during the course of an expedition, and I think an antihistamine and/or a decongestant, something like Grnade, is a good way to prevent the whole cycle of irritation, congestion, infection from building up.

Conjunctivitis is an inflammation of the membranes of the eye. This disease can be recognized when your eyelids tend to stick together in the morning, and your eyes become red and inflamed. I realize that some people have this problem without having conjunctivitis, but I have never been able to carry enough bottles of the causative beverage in my pack. Snow-blindness may also mimic the picture of conjunctivitis, but I will not discuss this problem here except to say that the pain with snow-blindness is usually much more severe, and the discharge is usually not puru¬lent. A good treatment for conjunctivitis is Neosporin eye oint¬ment. Place the ointment into the corner of the eye four times a day. Since conjunctivitis is a communicable disease, and since a shared towel is a good way to spread this disease among all the members of the expedition, I suggest that you take some precau-tions in this respect.

Cellulitis is an inflammation of the skin. Bacteria seep between the cells in the skin, and an area of reddening, swelling and tenderness develops. Cellulitis can be caused by a direct injury, or can be secondary to something such as an insect bite. There may be red streaking up the arm or leg, and there may be swelling and tenderness of the lymph nodes, either in the armpit or in the groin. Fever may accompany cellulitis. Whatever the cause of the cellulitis, the wound area should be cleaned at the time of injury with soap and water, and if there are splinters or gravel in the wound they should be removed.

Despite good local therapy, active infection may develop, and this should be treated with rest, elevation, warm soaks, and an antibiotic. Staphylococcus, which is normally found among the bacteria of the skin, is one of the most frequent causes of superficial pus-forming infections in man.

Over 50 per cent of the serious staphylococcal infections of deep tissues arise from the skin. When penicillin was first introduced in the 1940s, this normal staphylococcal flora was almost uniformly sensitive to penicillin. Over the ensuing years of widespread antibiotic use, between 15 per cent and 20 per cent of non- hospitalized people have been found to carry penicillin resistant staphylococci. It is this high incidence of penicillin resistant staphylococci in the general population that prompted me to recommend cloxacillin as the antibiotic of choice for cellulitis. Let me emphasize that antibiotic therapy is an adjunct to good local care, e.g. warm soaks, rest and elevation of the limb.

Despite the best treatment of the cellulitis, an abscess or ' boil' may develop. This is the body's way of walling off an infection. The bacteria and pus form a cavity in an area of dead skin. The surface may look red, shiny and raised, and the skin may feel warmer than the surrounding area. The raised area will be tense, and slightly rubbery. As the 4 boil' comes to a head a whitish area may develop in its centre.

In addition to the treatment outlined, a boil which comes to a head as described should be drained surgically. Again, this is something a well-prepared layman can do in the field with a scalpel and a small curved hemostat (surgical clamp). The area to be incised should be washed with a surgical soap, such as Phisohex, and then anesthetized with a freezing spray like ethylchloride. (An injected anesthetic would merely spread the infection.) Then the abscess can be incised with one stroke of the scalpel and the pus will pour out. When you have opened the abscess you should insert the hemostat and open it once or twice within the pocket of the wound. You will get a little bit of bleeding, but this spreading motion with the hemostat will insure that all the pus pockets are well drained. The area should be washed again, the abscess pocket packed with iodoform gauze, and the warm soaks continued. The iodoform gauze is used to allow continued drainage of pus from the abscess pocket and can be removed after a few days. The patient should be kept on the proper antibiotic, cloxacillin, or as a second choice erythromycin, for a full 10-14 days.

Finally, I will say a word or two about pneumonia. Pneu¬monia is an infection of the lungs, frequently caused by bacteria. Pneumonia may occur in young, healthy adults following some kind of trauma. For instance, a fall into a crevasse may cause bruised or broken ribs making breathing painful. The patient is then wary of taking a deep breath or coughing because of pain. This may cause pulmonary secretions to pool in the lungs, creating a good site for pneumonia formation. Similarly, I have seen pneumonia develop following a near drowning in a river crossing. The man involved aspirated some of his own saliva, and sub¬sequently he developed pneumonia. Penicillin would be the drug of choice for pneumonia, and I have indicated oral penicillin in the table. Erythromycin would be the alternative drug of choice.

Gastro-enteritis and diarrheal illness is a broad topic which cannot be covered adequately here. The spectrum of infectious agents which may be encountered will depend upon the country, the water, the presence or absence of animals carrying parasites, etc. Each area will have unique problems in this respect and public health authorities should be consulted before visiting each area so that vaccinations and drugs are appropriate for the diseases most likely to be found in a particular locale.

In my experience many adults are constipated when they change to a mountain diet. Hence the onset of diarrhea after a few days in the mountains should not be accepted as a 4 normal' response to a new diet. If everyone on the expedition comes down with a sudden and severe bout of vomiting and diarrhea it is obvious that a common agent is the source of the problem. The greatest single danger from such episodes of vomiting and diarrhea is dehydration. This can be especially serious at high altitudes where adequate fluid intake is already a problem. For this reason I suggest that you treat the person with a diarrheal illness with large volumes of soups or bouillon, making sure you put a teaspoon of salt in each quart. Try to replace the amount of fluid that your patient is losing. This may amount to as much as 3-4 quarts of fluid daily. You can estimate the adequacy of fluid replacement by keeping track of the patient's urine output. A good urine output (one quart or more each 24 hours), generally signifies a good state of hydration. If your patient has a lower volume of urine output, I would increase his fluid intake.

In addition to fluid replacement I suggest that you treat the person with severe diarrhea with Lomotil, 2 tablets four times daily until his diarrhea abates.

Care should be taken to have the person with a diarrheal illness keep as clean as possible and common sense tells you that he should not be involved in cooking for the expedition. In addition, some detective work on your part can sort out the problem.

If everyone suddenly develops a diarrheal illness it is more than likely that it was caused by something they ate. Principal offenders are items containing mayonnaise, spoiled milk products, and poorly refrigerated meats, in addition to contaminated water in areas where this is a problem. You will do well to treat the fluid losses as I have indicated and avoid using the food which was the possible offender.

In closing, I want to make a few additional general comments. Keep an accurate daily record of the therapeutic endeavours you make on behalf of your companions. This means having a pencil and paper in the medical kit. This record will be particularly useful if the patient does not improve and requires additional medical attention. Such facts as temperature and general condition should also be recorded. Finally, remember the medical problems we have been discussing are not emergencies. The most important thing you can do is to use common sense in arriving at a decision as to the proper course of action. Take your time, talk to your patient, who is also your friend. Find out what is bothering him, and how long it has been present. Take an adequate history, and then in your mind review the possible causes of the symptoms. Common problems occur commonly. Look for the obvious first. Then make a decision as to what to do. When in real doubt, don't do anything unless the situation is desperate. In the vast majority of cases what you do is going to work out well. You will be dealing with young, healthy people. If you are careful in what you do, your treatment is going to work. Time is generally on your side.

MODERATOR: We have time for just a few questions. The gentleman in the back. Yes, sir?

VOICE: YOU have written in footnotes to the table that an antibiotic should not be stored and carried over until next year, but how about for the next two or three months? Particularly that $40 worth of cloxacillin, which is apparently a multi-purpose drug; might we keep that three or four months?

DR. SILVERSTEIN: Yes, sir. The cloxacillin actually will be stable for over a year, assuming that you store it in a medicine chest and in a reasonably dry place. It stays in the pharmacy much longer than that, but since you are going to be taking these drugs to use if you need them, and since they may be involved in maintaining an expensive expedition in the field, it makes sense to have fresh antibiotics. So, despite the fact that the antibiotic is good for at least a year, I think it is good economy to throw it away.

VOICE: Will you comment on the effect on drugs of excessive heat in summer, or of extreme cold in the winter?

DR. SILVERSTEIN: Freezing temperatures will have no effect that I know of. I think that if the medicine kit is put in the middle of your rucksack, it will not get very warm. I do not know precisely at what temperature each of the drugs mentioned will become unstable. If you are going to the Sahara, perhaps this is important, but by and large I do not think it will be a crucial factor.

VOICE: What is the danger of using unwashed cups and silver¬ware in the mountains?

DR. SILVERSTEIN: I'm smiling because in the mountains I'm as guilty of that as everyone else. I can tell you that I lived in a tent in British Columbia one summer. The tent door overlooked a lovely stream. We dammed up the stream, and at night we would throw the pots out into the stream, and they would slosh around in the pool behind the dam. We called this the washing machine. We all survived very well. Many expeditions I know of have done similar things in areas where water is not a problem. Of course, if the water is polluted, then further precautions are indicated. In addition, any patient with a diarrheal illness obviously ought to be kept away from cooking equipment. In areas like the Himalayas—Willi, will you tell us what you did with your pots?

WILLI UNSOELD : We gave them to the Sherpas.

VOICE: What would you do for someone who gets appendicitis?

DR. SILVERSTEIN : That is a good question. First, of course you must determine that he has appendicitis. Assuming that you have a patient with an acute abdominal problem and no obvious source of injury, all your efforts should be devoted to getting him out of the mountains and to a definitive treatment centre as quickly as possible. Care for such an individual while evacuation is in progress might include:

1. Tetracycline—250 mg. intramuscularly four times daily.
2. Nothing by mouth if evacuation will be possible in 24 to 48 hours. If evacuation will not take place until after 48 hours I would treat the patient with frequent small sips of lukewarm water, with a tablespoon of salt in each quart. This is one of those situations that must be ‘played by ear'.
3. Move the patient in a jacknife position, and maintain him in this position while resting if possible. This means that pus and infection will drain to the lowest part of the abdomen.

BASIC DRUGS FOR MOUNTAINEERING EXPEDITIONS *

DRUG
Penicillin V-K 250 mg. tabs
Cloxacillin 250 mg. tabs
Neosporin eye ointment
Elixir terpin2 hydrate with codein
Ornade spansules
apply topically every 2-4 hours as needed
2 tabs 4 x daily diarrhea
1 lozenge 6-8 times sore throat daily
pack abscess to insure good drainage
Pyrabenzamine Lontabs 100 mg.
Neosynephrine nasal spray 0-5%
Lomotil 2*5 mg. tabs.
Cepacol lozenges
surgical soap for wounds Scalpel with a no. 10 blade and one small curved hemostat.
Second choice antibiotic if patient allergic to penicillin, cloxacillin
Iodoform 1/4 inch gauze
Erythromycin 250 mg. tabs
Erythromycin eye drops 0*5 %
Phisohex soap
DOSE
1 tab 4 X daily
2 tab 4 X daily
2-4 tab 4 X daily 2 tab 4 x daily 4 tab 4 X daily 1 drop in eye 4 X daily
1 tsp. every 2-4 hrs.
1 capsule every 12 hrs. 1 tab every 12 hrs.
1 tab 4 X daily
2 tab 4 x daily
1 tab 4 X daily
2 tab 4 X daily
1 drop in eye 4 x daily
DISEASE OR SYMPTOM
sore throat pneumonia
ear infection sinus infection cellulitis eye infection
cough
nasal congestion
insect bites allergies
nasal congestion nasal congestion
sore throat ear infection sinus infection cellulitis, pneu¬monia
eye infection
AMOUNT 160 tabs 200 tabs
2—1 6z. tubes
2—4 oz. bottles
30 caps.
30 tabs
2— 2 oz. spray vials
60 tabs
3— boxes 24 loz/box
1 roll
3 oz.
or neosporin 200 tabs
2—1 oz. bottles

DRUG DOSB AMOUNT
Optional drugs—not for routine use
Tetracycline 250 mg. 250 mg. intramuscular- Bacterial ente- 20-40 vials vialsly 4 x daily ritis, penetrating
wound of the abdomen, ap¬pendicitis
Sterile water for dissolving tetracycline, and syringes for administration.
Ampicillin 500 mg 1 tab 4 X daily bacterial or ame- 80 tabs
tabs bic enteritis

you avoid this decision and don't do something, you may actually aid and abet the death of your good buddy. So I think we have to face the fact that if we go into expedition conditions and do not have with us a trained physician, then we should be prepared to do a little more rigorous first aid than we normally would do in the usual circumstances. Be prepared on this. Think about it, talk to your physician before you go, and be alert to the things that you should know.

When confronted with an emergency, inspect the whole patient. Then think in terms of calories and intake and output. Ask him if he's got to void. Ask him if he's got to pass urine. Some¬times these fellows, particularly if you give them a little narcotic, may not be thinking of this, and you've got to do their thinking. Keep good notes so that the guys who are going to come and bail you out have some idea of the sequence.

If you've given drugs, tell them this. I think the prophylaxis has been mentioned. I would like to stress, particularly if you're going in with pack animals, that a simple fall on the trail means that you're in cow dung or buffalo or horse dung that is loaded with tetanus spores. Be sure that in any of those areas everybody has had tetanus shots. And, when you're getting these patients on the litters, remember to watch for the little personality changes which show that the patient has begun to lose body heat more than you anticipated. He becomes irascible. He's quarrelsome. He may fumble reaching for the cup. This is a guy you've got to warm up.

It's nice to warm him, to rewarm him, in a hot tub, but there aren't any hot tubs in the mountains. Here you've got to get him out of the wind. You've got to share body heat. You may have to place sleeping bags around him and somebody get in with him. If you give him warm liquids, this can be dangerous, as has been mentioned. Remember secondary chill. You've all come in from ice skating or skiing, felt perfectly warm, had a cup of hot tea, and then suddenly begun to feel real chilly. This is because you've suddenly released all that cold blood in your skin, and it's coming back into your inner body areas. Then you get that secondary slump and you get a shiver response. Don't fight shivering. This is nature's way of telling you how to warm up. But again, think of your patient. Anticipate his problems. You may lose him from exposure if you're not thinking of these things then, rather than of just blood loss, which might scare you, or of the fractured arm.

I think one of the things that gets the usual lay person most disturbed is bleeding. It's rather frightening. It's messy. Some of your buddies may faint. Somebody has got to be calm and collected, and that's you. Now the first thing you can do is to stick your finger on the bleeding and that will stop almost all of it. Keep your first aid as simple as you can. If you know pressure points, that is fine. But if you don't practice them all the time, you'll be stumbling around looking for them, and the blood will be running away. Just press on what is bleeding whatever you have handy. Use a glove, a relatively clean handkerchief, or just your hand, and you will soon have it under control. I dare say you will stop over 98 per cent of the bleeding this way.

I've been in medicine of one form or another since 1949, and in surgery most of that time, and I think just twice in my personal experience have I put on tourniquets. Both of these involved high velocity missile wounds, high up in the leg, and the tourniquets were merely a short-time effort, until other things could be done. With an injury under average conditions I think the chance of your needing to put on a tourniquet is most remote.

You can identify venous bleeding, which is a dark slow flow. It may seem quite vigorous to you, but it won't be the pulsating, driving, spurting, usually bright red blood that you'll see from an arterial injury. If you see this slower flow you can relax right away. If you do see spurting, you'll have to be more vigorous with your dressing, more vigorous with your pressure, and more consistent with maintaining that pressure, but it will still stop. Remember that most bleeding will stop within ten minutes. If you put pressure on it don't peek at it all the time. A clot is forming, and if you're pulling it apart, the bleeding is going to start all over again. So maybe you should admire the view, and talk very knowingly for fifteen minutes about your past experience and you think the patient will live, and then you can peek.

One thing we might say here is that many first aid kits have three or four little four by four pads in a nice little package. If you really get some bleeding these are almost useless. It's like trying to scrub up Main Street with a toothbrush. You really need some equipment, and when you put your first aid kit together for an expedition get several of these packages of four by fours, because you'll really need a handful of these to control good bleeding and to stop up some of that bleeding, until you get it under control. You may want eight or ten of these together as a pressure pad when you put the dressing on.

If you happen to know where the pressure points are it helps. For instance, if you're treating a bad gash on the arm, and you're trying to clean it up, every time you let go it'll bleed some more.

You're going to have someone press the brachial artery against the humerus—you know you've got the muscle mass in front, the biceps and the triceps behind, and right in the middle the bone, and you just jam your thumb on it, and you've got the artery stopped. You can try this pressure point and feel your pulse or your buddy's pulse disappear. You can hang onto that while you're cleaning the wound up. Then put your tight dressing on and release the pressure point. Use of a pressure point is nice, but you don't really have to remember where it is if you remember to press hard on the spot that you were originally treating.

Soap and water is the best treatment. If you're going to put any antiseptic on it, I would urge you to use something like phisohex or zephiran. It's not tinted, because you may have to make a decision to use some of the drugs that you just heard about. If you smear things all up with red paint like mercurochrome or merthiolate, you've hidden the first cardinal symptom of an infec¬tion, redness. It's hidden under all your red paint. So paint it up with clear zephiran and kill the bugs just as well. It won't look as pretty, but you won't hide anything.

There have recently come out some very effective tapes with which you can actually close a surgical incision. You might look into this. It sticks even when things are a little bit damp. I might add that on the mountains, and when it's cold, adhesive tape is pretty lousy. I can remember a couple of years ago when we were up Russell and had 13 days of blizzard. Carter's tent went down, and another one started to go. Somebody called for adhesive tape, and I got a great big roll. Then there were some nasty words about where the blankety-blank McDade got that cheap tape. But, when it's cold and frigid tape is lousy and it won t stick. So, while you're doing something, you might well put that roll of tape in your armpit and warm it up, if you're going to use adhesive tape.

Blood loss shock is, well, there's just a limit to that red stuff you know. That's why we have blood banks, and they're hard to come by in the mountains. These are the things to look for when things are desperate. The patient will be restless. He'll be pale, and if you don't know whether he's pale or not, look at your own fingernails against his. Compare his lips against your buddy's lips. Look in the conjunctival sac, and look in your buddy's first. If these things are sort of pale, you know he's getting a little washed out.

He will sweat, and this is dangerous in a cold environment, because it will lead to heat loss. He'll faint if he's sitting up, and this is very ominous, because young people who get to that point really don't have much blood left. The pulse will be very thready. He'll want to make some more blood, and he'll want to make some fluid to get in that vascular system, so he'll be thirsty. Now, if you're on a mountain it may be very well to give him something for that thirst, and if you do, put a quarter of a teaspoonful of salt in a glass of water for him, or in a cup of water, to help replace some of the saline material he has lost.

If you're going to get him off a ski slope, or off Mount Washington, and take him to Conway or maybe to Littleton, we get that guy full of hot salt solution and if my anaesthetist gets it in his lap he's going to be unhappy. So if you have a case like this and can get him to a doctor quickly, you don't give him anything to drink, but if it's going to take you a week to get this guy out, hopefully alive, then you do want to supply that fluid. He will eventually pick some of it up, because he'll pull it from his tissues to fill up his vascular space, and then have to replace some.

The ones that will be sneaky for you are the cases of internal or hidden blood loss, and anybody that's taken a bad fall on a rope, slipped in a crevasse, or just tumbled, rfiay very well get a ruptured spleen or the liver may be torn. Here you may have all of the symptoms I mentioned appear without any blood on the surface. So you must think of this. The key is usually pain in the shoulder. If he's really gotten most of his blow around the side or the ribs, and he starts complaining up here, and he gets pale and restless, you may want to be thinking of internal bleeding.

There's another reason for getting some of these cases out. Suppose you have a man with a fractured femur. This is a major injury. He'll lose a quart of blood into his thigh with a fractured femur. That's a big bone, and if you put one in a hydraulic press, it'll take a ton of pressure to break it. So if he hits anything hard enough to break that femur, he's put a lot of injury into soft tissue.

Fractures and dislocations. I'll just mention a few things briefly. Put a splint on right away. Accident reports are replete with cases of people being hauled off mountains by some heroes who picked them up like sacks of potatoes, their broken limbs flapping around, and this is where you get your fat emboli. You can prevent these by adequate splinting, and again it doesn't matter what you call the splint. The main thing is to splint the joint just above and the joint just below the fracture. Then you'll have it under control

When you put someone in a litter and have denied him motion with a splint or the litter, if the environment is cold you must instruct him to shiver, if he doesn't shiver by himself, and some people don't. A good brisk shiver will produce almost as much heat as walking around briskly, and if it's very cold you may want him to do isometric exercises with the uninjured part. This will help preserve his heat. If you're waiting for some sort of convey-ance remember these people are dressed for their ambient tem¬perature. They're pretty good in the outside air without wind on them, but they're conducting to the surface. Get something beneath them. Better put your extra parka beneath them, onto the snow.

Plastic splints are excellent, but don't forget your standard techniques, because if you get plastic splints in the cold they may split. We saw them splitting at 14° below zero and 30° below zero on Mount Washington last week, along the seam. If they begin to tear you've got nothing, and you have to go back to your tried and true. Don't forget you can always splint the upper extremity to the chest, with the arm flexed at the elbow, and the fractured leg to the good leg. If you have time and it won't hurt somebody's hand, put a pair of gloves between the knees and the ankles, where the bony prominences are, and you can carry someone out very well in this fashion.

Dislocations are injuries out of joint, where the joint is in an unusually abnormal position, and doesn't move well. With an arm dislocation, you can get a cold hand, numbness and tingling. The main thing you have to do for this is to pull the arm out in line, with your left foot in the patient's left armpit if this is a left arm dislocation ; with your right foot in his right armpit if it is a right arm dislocation. You may chip a fracture in doing this, so if you have a narcotic along give him a dose of it, and then you just lean on that foot and pull for about fifteen minutes before you think of anything. Gradually you'll overcome his muscle spasm, and you'll feel a give and it'll roll back with quite a little pop. You'll be very happy. (Laughter)

This is the type of thing you may have to do to preserve the nerves and circulation of the hand. You won't do this on a ski slope, nor on Mount Washington, but you may have to do this on a remote mountain.

For fractures of the foreleg, I think that a Thomas splint and traction are very good. If you're on a ski slope, this is one thing, but those of you who have ever carried somebody off a rough terrain know this is a very different thing, and difficult. We've even seen a man sprain his opposite ankle in the litter trying to brace himself against the jolts coming down the ledges. It's rough going, and one thing you must do is give his opposite foot adequate purchase. You may have to put rocks in there, perish the thought, but you have to give him a firm purchase for his good foot, so he can brace himself in that litter.

Another thing, in some mountaineering journals you can find a beautiful description of a traction type splint made with ice axes. How the-heck can you get off the mountain when you have all of your ice axes tied up?

Here's where you use the other leg. Don't expend your equip¬ment for something of this sort. Then when you get the patient in that litter, remember these few things. If he wants something to drink, put it to his lips. If you want to keep him warm, warm the cup up, but don't give it to him before you have checked the temperature. And don't give him a hot metal cup, because if you do you're going to blister his lips and you'll have a more uncomfortable situation than when you started. Remember that a blanket that's slopped over his face will get frost on it, and he actually can get frost burn, so check him periodically.

Remember his body temperature. You yourself, standing around or walking, are going to be much more comfortable, because you can move about. You must continually consider his body temperature. Keep him warm. Help, him to do exercises. Give him calories. Put a chocolate bar to him. If you're going to have to sleep at night at some low temperature, and you take 800 large calories of protein, you'll do much better sleeping warm that night than if you don't have anything.

Fractures of the neck. You know that all of these are very, very dangerous. You also know that the best possible splint on the outside is a blanket roll around the neck. But the whole key is never, never, never flex the neck, or you're going to kill him. The guy at the head of that patient, when you move him, has got to move the whole body up to get the roll in. And you don't want a roll too big because he settles down, and too big a roll will flex his neck. See how big that hump is in the back of your own neck. It's about as much as your fist, no more than that. Here's where you can kill somebody though well-intentioned.

"With a fractured back, don't worry about whether he's face down or face up. Keep him in line, and get him on something firm. Move him with lots of help. You start flipping him back and forth and you will break something that hasn't already been damaged.

 

Head injuries. These are real booby traps. Generally speaking, the person who has been out less than fifteen or twenty minutes will not get in much trouble. On the other hand, if you come to my hospital and the cop tells me you were knocked out on a ski patrol and says you were out for a minute or two, you'll stay overnight. And if you don't like it, you can sign yourself out on a nice little medical release. Pass the buck. This is the guy that you see in the newspaper that's found dead in the jail in the morning. Assailants have rolled somebody and the police threw him in the clink, because they thought he was drunk, and he's got a subdural hematoma and he dies.

Suppose you bruise your arm. You get a bump there. The skin swells up over the bump by the blood clot, but there s no damage. Now a concussion, when you get knocked out, is just a bruise of the brain, and when you get a bruise you get blood that comes out and leaves a black and blue mark. If you do this with your arm, there's no harm. But if this happens under a rigid skull that can't give, and the only way the blood clot can get room is to push on the brain, you literally get knocked out again by your own blood clot, and this is what kills you.

This is what you have to watch for. Keep notes on these patients. Watch to see if both pupils are equal. The pupil on the side of the injury will dilate. See if they are alert. Do they know who the President is ? Don't ask them ball-players. They may hate baseball. But maybe they'll know and be able to count backwards by twos. If they vomit, they won't spill oyer their vest like a drunk and make a mess. It's projectile vomiting—a couple of feet. Very dramatic! You won't miss this.

If they get drowsy and start going back to sleep, you cant keep them awake. Just get these people off the mountain. Heres where you want the helicopter to come in. They need a surgeon who can do trephining for them, and you really have to get burr holes in there and get that clot out. Bleeding from the ear and bleeding from the nose are symptoms, but remember that lots of head lacerations will bleed and get in the ear. Don't panic with that. Incidentally, it's very easy to stop scalp lacerations because the skull is a nice firm place to press on, and you can actually tie the hair over in a square knot and let it clot and it s all fixed.

These people may get very restless while you're carrying them out, dangerously so, thrashing about and even hurting themselves Nembutal capsules given rectally, two of them with some holes punched in them, will calm them enough so that you can handle them in a difficult area.

Chest injuries can present serious problems, many fractured ribs on one side, possibly a rib tearing a lung, possibly bleeding. Always transport them on the side of the injury. First, the pressure of the body splints that rib. Secondly, if bleeding into the tracheal-bronchial tree (windpipe) occurs, you want the injured side down.

Suppose you have a patient with a broken rib, and it's bleeding into the lung and the trachea, and it's running out of his mouth. Now if you flip him over so the injured lung is on top, you get bleeding from that lung down its bronchus with spill over into the other lung. Now you've got two bad lungs. So you've got two reasons to keep that patient on the side of his injury. He won't like it at first, but if he has thrashed around all night, that's the way you'll find him in the morning. You can save him a lot of pain by getting him into that position.

To lessen pain and the chance of further injury, strap the injured side just below the nipple line from the nipple line to the shoulder blade with a tape about 2" wide. Have him take a big breath and then let it all out just before you put on the tape. This will limit movement of the whole chest.

The unconscious patient always requires more care. Think of his bodily needs. Move him more carefully because he can't complain about where he's hurting.

Lightning can be a cause of injury. These people will be severely burned. We had two cases this summer and I learned something. They'll have such massive contraction that they'll hardly be able to move, and will have terrific muscular pain. They will need some narcotics to get any rest.

They can be knocked out. They can have cardiac arrest. Here is where you should try to see the film ‘The Pulse of Life'. You should learn how to do closed chest cardiac massage. You may not get them back without a defibrillator, but a certain number of them you can get back with a short episode of good closed chest cardiac massage.

Here is a picture of a boy who was lying about 30 feet from the top of Mount Lafayette. He had dissipated lightning hit him from ground contact, and he was lying on his side in a sleeping bag. You can see these burns on the side of his chest. He is knocked out, and his buddy had shock therapy, just as if he had had schizophrenia and had just had a couple of shocks for it. He'd run off at the lightning, and was really confused for a day or two.

I saw the patient about four months later, and his blood vessels were nicely coagulated all the way out. The lightning just followed his blood vessels as it would have the waterpipes in your house. You might be interested to see what it did to the rock. It blew it right up, and you can see the fractures there.

I think this next slide will show you what not to do for frost-bite. You heard not to do what this fellow did. He rubbed his toe vigorously. Notice the haemorrhaging and blood there, and that haemorrhage means damaged tissue underneath.

Now this fellow did not rub his feet. He rewarmed them slowly. He didn't put them in the Bunsen burner, and he did a little bit better.

Here is a picture of frost-bite several stages later. I put this on to show you the demarcation between the frost-bitten tissue and that not frost-bitten. It isn't always a sharp demarcation, but this can get to be a very rigid band around something like a toe. On the way out, if you notice it, and you should, you should split this, because as this skin dries it'll cut off circulation to the toe. This can be done with just a little nick with any sterile instrument.

And here we are in the end stage, pretty well healed up, and you see this nice delicate pink tissue here. Nothing was cut off. He lost a toenail, which you see.

In a mountain tent in a bad storm I think there are only two main dangers. First is asphyxiation as the snow gets up on your tent. The body heat and the cooking heat can actually freeze snow on top of the tent and you can actually get breathless before you realize it, particularly if everybody is tired out from shoveling. The second is bed sores, jokingly, but you lie down enough so that you really can get sore, and phlebitis does become a danger. You should move your feet vigorously in bed, every hour. Pull your knees up and down, pump your feet up and down. Your blood is probably thicker, and you may have trouble getting fuel, or be down on fluid, and you may be hoping the next day will be a better day. You haven't eaten well, and you've got sludged blood so to speak. You've got a real set-up for phlebitis. So be active in your sleeping bag!

Review your first aid before you go on an expedition. Go over what you've got for dressings. Ace bandages are generally much better for the casual band wrapper, because they add pressure and they conform, so you don't have to do those fancy reverses, and get all mixed up and tied up like a kitten with grandma's yarn.

When all of this is said and done, what are you going to do with that patient if you find him down in the tail of the slope where he landed when he slipped and the rope broke? If he's conscious, ask him where he is hurt. He can tell you where he hurts, but ask him several times, because if he's got a big bump on his head and it's bleeding and he sees the blood, he thinks—he's thinking ahead. He may have a minor fracture in his wrist. He may have a bad gash some place else, and you haven't looked under his clothing because the weather's bad.

MODERATOR: Fine, very good, we'll have a few questions and then go on to our final paper. Are there any questions for Dr. McDade?

VOICE : Would you give an antibiotic in the case of any injury?

DR. MCDADE: Well, they talk about the golden ten hours or eight hours. Antibiotics have stretched this of course. If you're high in the mountains, then you're on snow and ice. I usually don't use antibiotics with an injury there because it's a very, very clean environment. If you're going in or coming out on some of these dirty trails, then by all means I would hit them and hit them hard. Where is our antibiotic specialist down there? How do you feel about that?

DR. SILVERSTEIN: I'M SORRY.

DR. MCDADE : The question was about prophylactic antibiotics with injuries. I mentioned that with ice and snow I really would not give them, but on the trail coming out with dirt or dung around, I probably would.

DR. SILVERSTEIN: I think also if you had a compound fracture it's rather important to use antibiotics as a prophylaxis then. Otherwise I would use antibiotics as a prophylaxis only if it's going to be a significant period of time till you can get expert help. I think the best rule is that if in 24 hours you're going to get to a doctor, then don't mess up what might be reasonable bacteriology with antibiotics, so that he can understand what's going on.

If it will take longer to get help, then I think tetracycline and lots of sun would be a good combination.

DR. MCDADE : With that compound fracture, I'd say too that I would wipe off that bone with zepharin on a sterile pad. And if it's going to take several days getting out, put the bone back under the skin where it belongs. Then just stabilize the fracture, not pulling as in traction, just so it doesn't wobble when you carry him.

VOICE : What would you do for someone who has taken a bad fall in low temperature?

MR. ROSENTHAL: What was the question?

DR. MCDADE : The problem is that we have somebody who's taken a real, windmill tumbling fail down a steep slope, and m a very cold temperature. I think the obvious thing is that when you get to him you automatically start artificial respiration if its needed If he bleeds, you control this. If the man is conscious, you ask him where it hurts, and if he isn't hurt maybe he can get up on his own, because if he hasn't hit anything hard he may not have really gotten anything more than a shaking up.

If he is not conscious then it behoves you to check him, but you can do this. You can check each major bone area by a little side pressure and direct in line pressure to see if things give or not. Check the collar-bones quickly. Check along the rib area quickly, the pelvis and the legs. If there's an obvious fracture you re going to splint it in some way, perhaps just wrapping it to himsell, before you move him. Then from that point you're going to have to find out how best to transport him. Is that all?

VOICE : I was thinking about back injuries also. DR. MCDADE: YOU just have to move him as carefully as you can, preferably in line, but you're going to make it just as rigid as you can with whatever you have, maybe a ski pole, maybe a tent pole.

MODERATOR: Are there more questions?

VOICE : What would you do for a person in the Green Mountains with a badly fractured ankle?

DR. MCDADE : I think I would get that patient comfortable and to shelter. I think you should splint the injury. If he or she has injuries like one of those ankles I just showed you, or if I had it and you found me there, please straighten my ankle out, because I'd like the orthopaedist to be able to do an immediate closed, or open, reduction on it when I got down to town. Then you'd go for help and carry him out in orderly fashion. One of our district foresters broke his ankle in Greenleaf several years ago, and George Hamilton and I went up with some others for him. We found him sitting comfortably splinted on the front porch. It was after supper. We had a nice meal, and then we elevated his foot and got him comfortable and we all went to sleep. We carried him out the next morning. You don't go hauling these people on the trails in the middle of the night. They transport well, and with a good splint they'll hold over very nicely.

MODERATOR: We thank you very much.

Our next speaker is Dr. Willi Unsoeld whose topic will be Psychological Aspects of Mountaineering. Willi has a background in sociology and psychology and has climbed extensively in the United States, the Karakoram and the Himalaya, including a first ascent of the West Ridge of Mount Everest. He is executive Vice- President of Outward Bound.

 

 

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I WANT to admit to being a complete impostor on every charge. Not only am I not a physician, but I am not a psychologist, and what I have to offer will only vaguely resemble psychology. Chuck insisted that I come down here and hold forth on something having to do with the psychological aspects of mountaineering. As I remember my instructions, it was—'talk about how you choose party members for Himalayan expeditions\ I am sure this must be a fascinating topic for all of you. I don't know how you have existed this long without being briefed. I'll just go ahead and do that, however, since I do not have anything else to talk about. (Laughter)

I did mail a bibliography to Chuck. Unfortunately it was mailed too recently to have arrived yet, but it had some very fine items in it. One of them is 'A Case Study of Communication Feedback and Sustained Group Goal Striving', by Dick Emerson. I have another report from the same Everest Expedition, by James Lester, and I want to read you the introduction to it.

'Dear Team Member: All the information I have to date indicates that no one has been able to get one smidgeon of meaning out of my last report. Now all great men have been misunderstood in their own time, but in my own case, I want to make an effort to remedy this. Therefore, I am enclosing a copy of a much simpler statement of the same results and conclusions. I hope this might give you a slightly clearer picture of this part of the study and not make matters worse.

' Hello, hello, did anybody read this far?

As ever, Lester'

Well, as a matter of fact I have read the revised version, and I do not think I will talk about it, because it is just terribly, terribly psychological. Instead, I will settle for a brief summary.

I have a three point outline for this whole talk, and what I really want to focus on is the second point in the outline, but I had to have a third point, so I threw in Lester's Report, his whole voluminous report, and I will just reduce it to the characters desired in a teammate and in a leader. This is now focusing on expedition mountaineering, and for these two items we actually have solid, concrete data, which are summarized in this report of Lester’s.

After' we came back, he submitted a questionnaire to each member of the party, asking us to list the members of the expedition with whom we would most wish to return on similar expeditions as a teammate, and similar y as a leader Then the answers were quantified and computerized and turned out, and the reports are still flowing. You can never shut off these com¬puters once you get them geared up. (Laughter). But his final report comes up with this startling material, and I’ll just read a couple of sentences, and that will finish his report. First of all 'maturity is the main concommitant of choosing a man on the two key criteriaThat means, for both a teammate and a leader maturity is the primary concern of all the members. Now mature seems to have been closely allied with seeing him as free from inner turmoil or confusion or self-doubt, and as showing m his relationships a basic respect for the others feelings and individuality

The others with whom the majority were willing to return were those who make their teammates generally feel comfortable respected, unthreatened, and cheered, calm, easy-going cheerful, considerate, sensitive to his own impact on others, free from preoccupation with own self and own talent or problems, and able to co-operate with others with a give and take on a task.

Well now, I really have included this only to show you the results of scientific psychological investigation. I take all this to be so patent as to be totally useless as far as the interest of this group goes. It seems to me that what is much more important, when you come to consider teammates for an expedition, has something to do with what I will call a sense of reality, and indeed if you really want to jazz it up, let's call it congruent senses of reality.

What kind of basic set of values does the proposed member fly by? What's important to him? Where on the spectrum of psychological possibilities does he fall ? And let me just outline the extremes of the spectrum in which I am interested here. We all assume that when a guy is going to go to the Himalaya that he is really keyed up about mountaineering, but there are a number of different possibilities along this path, are there not? At one end we can have what I've heard described as the mountaineering fanatic, 'the berserker', whose motto is, 'At All Costs'. That's one extreme, and over here on the other end is the guy whose customary reply is, ' I've had it'. You know—after all, why do men climb mountains? (Laughter)

And, somewhere in the middle, considering the drive that you are generating toward the goal, a middle ground would be, ' Well, let's talk it over'. ' We better consider this closely.' Now I am submitting to you that it is highly important to assess the position of your potential teammate on this kind of a spectrum. I will use the research done by Emerson to illustrate my point, so we can just set the foregoing to one side, and we will come back to it.

Now the real core of my presentation has a whole flock of terms that I'll try to make understandable. First of all, we have to be clear what we're talking about, and it just so happens that mountaineering parties fall into a general group category which is not necessarily limited to mountaineering parties. We are talking about the behaviour of relatively small, goal-oriented groups. They are aiming at a specific goal, and they are operating under stress.

That goal, incidentally, must be clearly definable in terms of success or failure. This is what makes mountaineering parties so admirably suited to this sort of research, because the goal is so definite. You either get up or you don't get up, and that's success or failure. You do not have to jazz it up with a lot of psycho¬logical trimmings. In this subject the concepts that we will be dealing with are four in number. First is motivation. We are considering how enthusiastic, or how indifferent towards the goal, a man is. And that is part of what we were just talking about when we spoke of a sense of reality.

So, we are considering enthusiasm and indifference, and out of enthusiasm there arises the second concept, which is energy mobilization, and this is energy mobilization in a goal-relevant direction. That generally means uphill.

The third concept is uncertainty of outcome, and this is one of the critical ones. Those who are definite in the realm of this particular variable, and who are certain that the outcome is going to be unsuccessful, we call pessimists. The others who are certain of success, we call optimists. In between we have those who are simply unsure whether they are going to succeed or fail. The relationship between these variables is pretty well established by experiment. First of all, it is clear that if you have a high enthusiasm, you have a high energy mobilization and in the proper direction. That goes without saying. But now, one that requires a little more thought is that the uncertainty of outcome has a direct relationship to one's enthusiasm. As long as you are uncertain of the outcome, you tend to be more enthusiastic, but once that uncertainty is removed, and you are certain either of failure or of success, well, then you become more indifferent, and as soon as you become more indifferent, you release less energy.

We all are together so far? Enthusiastically? {Laughter)

All right, now we get down to the really interesting element of the experiment. It involves communication, the transfer of information. And information in the situation that we are discuss¬ing can come from either of two sources, from other members of the party, or from the environment. That is pretty darn obvious also. You can see that black cloud in the west, or you can see that mass of snow moving down the hill at you, and you say—aha, information. (Laughter) And then you can go ahead and talk about it, and say— ‘don't look now but'. And— someone else says— I think he's trying to tell us something', and this is all communication between members. In fact, when we get real technical we don't call it communication anymore, but feed¬back, and if you want to drive strong sociologists mad, use that term—positive feedback, negative feedback. It's great. We almost had Emerson cracked up long before he reached Base Camp.

This positive and negative bit, if the communication which you receive is optimistic, and if you reply optimistically, that's positive feedback, and likewise if you receive negative information, that means pessimistic information about the outcome of the venture, and you reply pessimistically as well, that's still positive feedback. Now, if you turn all this around and reply pessimistically to optimistic and optimistically to pessimistic, that's all negative feedback.

Now we're approaching the denouement. You take a really _ gung ho expedition party member, you know,—6 at all costs'. He's enthusiastic. Suppose you feed him any kind of communication. What kind of feedback is he going to give you? Negative? Right. And that sneaky Emerson tested us on this all unbe¬knownst. He had a little pocket switch hooked to his miniphone vest recorder—{Laughter)—and he'd come out of the tent in the morning, and,— ‘Ah, man, beautiful day! Shouldn't have any trouble getting to Camp Two. Now if his companion happened to be a beady-eyed, little, high enthusiast—like Hornbein for example,—striving for balance of uncertainty with every ounce of his being, he would say, ‘Yeah, nice weather, but I don't like the look of the black cloud in the west'. (Laughter)

You see, maintaining the uncertainty of the outcome because of his high enthusiasm, and the next thing you know he was throwing on a pack three times as large as himself and releasing energy in a goal-oriented direction.

There's only one point left to make, that this type of behaviour has its dangers, because it tends to produce at least a semi- independent system, the independent system being the party of highly enthusiastic members, who react to the environment in a dampening fashion. That is, they blunt the edge of any pessimistic information which it might present to them, such as by, ‘Well yes, the avalanches are bad today, but there's a gap of at least fifteen minutes between them. ‘What more do you want ? ' (Laughter) And the other members of the party are very apt to think, ‘Well, what more do we want? That's reasonable.' And so the party rolls on up the mountain releasing immense amounts of energy, as it heads for its doom.

The other consideration is that it develops tremendous tensions, especially if you've read this report, and if you happen to be one of the less enthusiastic types. You're going to call their attention to reality. ⁴ Man, you aren't facing the facts! You're headed for disaster, and I don't intend to have any part of it.' ⁴ Ah, you're just pessimistically feeding me back negatively.' And there will immediately develop the kind of friction with which I feel we're all somewhat familiar, whether we've been on expeditions or not.

So how can such friction be avoided, and how can we com¬pensate for this tendency to ignore the pessimistic information with which nature presents us? This brings us back to my original point, the importance of picking teammates who have a somewhat similar sense of the realities, the importances, the priorities to be placed on attaining the summit, on any given climb. The trouble is, I'm sure that's not the end of the story, because there's always the possibility of a mixed party, where you balance enthusiasms, and perhaps end up with an even greater release of energy in the whole party. That's one possibility. The other is that you bog down at Advance Base Camp and wrangle the rest of the pre-monsoon period, so I just don't know the ideal set-up. I'm throwing these out as suggestions for further considera¬tion.

VOICE: On the Everest Expedition, of course, everyone had climbed so often with everyone else that special personality tests were certainly unnecessary, but perhaps in the Peace Corps, and in other organizations where people are thrown under stress situations, do you use personality tests? Do you think that such testing might be applicable in mountaineering?

WILLI UNSOELD : Well, what you said wasn't quite accurate with respect to the Everest Expedition. Your suggestion, although very reasonable, was inaccurate on two points. First, we had not all climbed together. Many of us had never met before. And secondly, we were subjected to personality testing. That's the interesting thing. Luckily, I was already over in Nepal, so I missed all these sessions. But the rest of the group spent three consecutive days at the Institute of Personality Assessment Research in Berkeley, where they were subjected to intensive tests, from which they derived a composite personality profile for each member.

Incidentally, one other element of Lester's research was on compatibility, on what constitutes compatibility, and how it might be predicted. He corroborated the current theories of compati¬bility, that you tend to like people who are like yourself, and the people whom you like you tend to interpret in terms that you would apply to yourself. It's a self-reinforcing business. This was corroborated. But prediction is another matter. You'd think that with all the data from the personality profiles we could have predicted who would like whom on the Everest Expedition, but such was not the case. There was no power of predicting who was going to like someone else on the expedition, and Lester just says, ' as might have been expected—. (Laughter)_

Now as for the Peace Corps, they didn't run formal personality tests or sensitivity training, at least in my day, though that was fairly early. They may now. We subjected them to more practi¬cal tests, such as living together during the three months of train¬ing, and I suppose this would be the rough and ready, pragmatic equivalent. They also made out a peer group rating, where the various individuals would rate the other people in terms of how they saw them as potential successes in the Peace Corps, and also with which members would they rather room when they were overseas. This was given considerable attention when they were posted to the countries to which they were going. The final point is that the single most accurate predictor of success in the Peace Corps was the set of peer group summaries obtained as early as three weeks after the group had first met. This was the single item in all the psychiatric examinations that they were subjected to which correlated highest with success.

VOICE : Are you saying, then, that if instead of having put you through the so-called objective tests at the Institute of Personality

Assessment Research, they had put you out in the field for a week or two, and seen what happened, they would have gotten better results?

WILLI UNSOELD : I would judge so, yes. Apparently the profes¬sionals have not yet come up with measures which are predictive in character.

DISCUSSION

VOICE: If someone was walking across frozen tundra and his feet got frostbitten, should he take his shoes off, or not?
WILLI UNSOELD : This is a terribly difficult hypothetical question to answer. I think the principle here is that if he thaws and really warms his feet, he may have to be carried, and if there's great danger of everybody else perishing because they have to stop and carry this one fellow with painful feet, clearly he's far better off to walk with the frozen feet, and I would think it would be best for him probably to keep his shoes on, and keep walking, than to endanger the rest of the party.

VOICE: What items for protection against poisonous snakes should be taken on an expedition?

VOICE : There are specific antitoxins and antivenins that I know are available. They make sense if you are going to specific areas where such snakes are a problem.

VOICE : How can you take on an expedition antibiotics that can only be obtained on prescription?

DR. SILVERSTEIN: I can tell you that every year for the past five years I've met with various members of expeditions, talked with them about medical problems, and then, through prescriptions, given them the drugs. Fortunately, by and large, they found no occasion to use them, but I think if they did have occasion to use them, they would have used them intelligently. I think the brunt of this discussion today has been one of second aid, and of taking care of things which otherwise would cause serious illness and damage. I think the fear of giving you the drugs is really fear of your not understanding what the central problems are.

VOICE : Are there any adverse effects from taking of salt tablets?

VOICE : During World War II there were considerable spy alarms that air force bases were being poisoned by sabotaging the salt tablet dispensers. It turned out that this was just because people thought salt tablets were good. You take a little glass of water and a couple of salt tablets and throw them down and get an immediate rebellion in your stomach. I've never taken salt tablets on any expedition. I’ve always argued that the best way to get your salt is in your food, lots of it.

You cannot drink a great deal of water, however, unless you have some extra salt, either very lightly salting the water or in the form of bouillon. I personally do not go for the salt tablet. I think it is much better to salt your food heavily.

VOICE : Dr. Houston, will you say something about the Colum¬bian-Andean Expedition and their use of potassium and steroids for acclimatization?

DR. HOUSTON : As far as potassium is concerned, the report that you refer to did seem to show some marginal benefit from taking potassium supplements. A more controlled study of this, run in Colorado last year and the year before, seemed to show that there was really no difference between those who took potassium and those who took a placebo. I do not think the whole story is in on potassium. Usual foods, salted foods and fruit juices probably give you as much potassium and balanced electrolytes as are needed.

Now as far as the steroids are concerned, I do not know of any work that's been done in giving steroids at altitude, and I would myself be hesitant to do this except on an experimental basis. There are too many hazards attached. I think you might very well run into the kind of problem that you run into when you take dexedrine or benzedrine for that extra spurt of energy. One exception is the use of cortisone eye tablets or eye ointment, which is one of the nicest and easiest ways of relieving snow blindness.

VOICE : Would you take along dexedrine, for tight situations?

DR. SILVERSTEIN: I can tell you that I have, and I only had occasion to use it once, and Pm sorry I used it. I don't think there's any hard and fast rule about this. If you have to stay awake it may be different. Maybe Willi can tell us better about this. My feeling is that when you get to the point where you consider taking dexedrine you should ask which way are you going. Are you going up or down? If you are going up then you are clearly doing the wrong thing by taking such a drug. If you need the dexedrine to help you get down, then I can only say it depends upon how desperate the situation is. Maybe Willi can answer that.

WILLI UNSOELD: All I can say on that is that we did carry dexedrine on Everest, and we saved it for the ultimate extremity. When we met that ultimate extremity and administered the dexe¬drine, it was to Bishop and Jerstad, and it didn't seem to make any difference to them. I personally feel that we were all so far gone by that time that there wasn't anything left for the dexedrine to work on.

DR. HOUSTON: I think that was a good point. There wasn't anything left to work on. What you need then is calories and rest. One of the side effects of the amphetamines is that it destroys appetite. Every reducing tablet has an amphetamine in it. When you are at high altitude one of the problems is eating adequately. And when you are very, very tired, sometimes it is very difficult to eat. I think in taking dexedrine you would be setting off a potentially dangerous physiological condition.

MODERATOR: Sorry, we can't take any more questions. It's been very kind of you all to come and be with us, and to contribute to the great success of this meeting. Thank you Willi, and thank you all.

Acknowledgements:

This Symposium was held under the auspices of the New York Chapter of the A.M.C., many of whose members gave generously of their time and energy to make the Symposium a success. Particular credit is due Charles Rosenthal, Chairman of the Symposium; Arthur Fitch, Chairman of the Section's Mountain¬eering Committee; Regina Reynolds, and her able assistants Robb Heinemann, Jack Dierdorff, and Leon Greenman, for notices and publicity; John Locke for arrangements; Gordon Shellard for registration and tickets; and Paul Khan for recording. Without the assistance of the latter, publication of these proceedings would not have been possible. TUKUCHE PEAK¹ (6,920 metres)

 

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