"Mountains My Lab" - Part 11



Posted by Jeremy Windsor on Aug 07, 2020

Jim Milledge has been one of the UK's leading figures in mountain medicine for many years. In 2018 he completed a long awaited memoir - "Mountains My Lab". Although Jim's intention was not to publish the book widely he has granted us permission to reproduce extracts on our blog. Over the course of the next year we'll bring you images and text that describe Jim's extraordinary life. 

Part 1 includes an overview of Jim's life. Part 2Part 3Part 4Part 5Part 6Part 7Part 8Part 9 and Part 10 can be found in earlier posts.

In Part 11 Jim returns home from the Silver Hut Expedition and makes plans that will eventually see him working in India for more than a decade...


Betty and I had a delightful trip back from Nepal and India by sea from Bombay (Mumbai). We arrived home in time to attend the Haldane Centenary Symposium organised by Brian Lloyd and Dan Cunningham at Oxford. Born in Scotland in 1860, JS Haldane had been an important respiratory physiologist based in Oxford in the early years of the 20th century. He had led one of the first expeditions to high altitude to study acclimatisation: the 1911 Pikes Peak Expedition in the Rockies. 

Fortunately for me they had not got round to holding this meeting until July 1961 so that I was able to report the results of our “Oxford” experiments to this international meeting of cardio-respiratory physiologists. This was my first presentation to any sort of scientific meeting and, with results hot off the press, very much in line with Haldane’s work on control of breathing, it caused quite a stir!


Attendees of the Haldane Centenary Symposium in Oxford July 1961


Griffith Pugh had managed to get me a grant from the Medical Research Council to enable me to spend 4 months with him writing up the results of the expedition. In the end the Silver Hut expedition members produced 20 papers in peer-reviewed journals, together with 16 other papers, articles and books. For most of us scientists it turned out to be a career-changing experience.

Betty and I had slowly come to the view that, after our time in Hong Kong, that we wanted to prepare for working in the third world in some capacity. After our visit to Nepal in 1958, we felt drawn to that country with its huge unmet medical needs. This idea was reinforced, especially for Betty, after her 9 months working at the Mission Hospital, Shanta Bhawan, in Kathmandu. We both realised that, if we wanted to offer ourselves to work in hospitals, even in the third world, we needed first to get proper post-graduate training. This was why I had taken the job in Southampton Chest Hospital and obtained my membership of the Royal College of Physicians. We had also been in touch with Stuart Craig, the India Secretary of the London Missionary Society (LMS), my father’s employers, to see whether they could possibly send us to join the United Mission to Nepal.

However, following my experience in the Silver Hut, and my discussions with Griff Pugh and especially with John West, I now felt I wanted to try for a career in academic medicine. Betty was disappointed but loyally acquiesced. I informed Stuart Craig and he was very understanding.


Christian Medical College and Hospital, Vellore

Vellore is a town in Tamil Nadu state in South India that lies about halfway between Chennai (Madras) and Bangalore.

I started to look around for a lecturer job in one of the UK’s medical schools. Then, out of the blue, Stuart rang me and said there was an Indian doctor from the Christian Medical College and Hospital in Vellore (CMC) visiting London and that he wished to meet us. We agreed to meet him under the clock at Victoria Station. There was this very distinguished, tall, grey-haired Indian gentleman waiting for us. Dr Jacob Chandi was a neurosurgeon and, after specialist training in the USA, had opened the first neurosurgical unit in India. He was at that time the Principal of CMC. He invited us to join the staff of CMC. They did not have a respiratory physician and were very short of anaesthetists, Betty’s area of expertise. This seemed to us to be the right place for us both and we accepted his invitation.

Foreign members of staff at CMC were supported by various missionary societies and the LMS supported us during our 10 years there. So, first they sent us to have an introductory course at St Andrew’s College, Selly Oak, Birmingham. We enjoyed our 2 terms there, winter and spring, where we were given practical and theoretical teaching. 


Darjeeling conference on high altitude, 1961

In December 1961 I was invited to attend a conference on high altitude run by the Indian Army and Himalayan Mountaineering Institute (HMI) in Darjeeling, where Tensing Norgay was Chief Instructor. The Indian army had realised that the Chinese, having taken over Tibet, now presented a threat on their northern border. Furthermore, any Chinese troops stationed on their side of the border would be well acclimatised to the altitude of the Tibetan plateau, whereas any troops that the Indian army might be send rapidly up to the border would be both un-acclimatised and unfamiliar with the harsh environment. There were, at that time, very few people in the world interested in the medical and physiological problems of altitude, hence my invitation. Sukhamay Lahiri from the Silver Hut Expedition, then working in Calcutta, was also invited.

Darjeeling is one of the “Hill Stations” beloved by the British Raj. In the hot weather the whole government of Bengal used to move from Calcutta to Darjeeling, where the altitude of around 2,000m made the climate delightfully cool. Now it was December and really cold at night but still very pleasant during the days, when we had sunshine and clear skies. One morning Sukhamay and I went up to Tiger Hill and had exceptional views of the sunrise on Kanchenjunga and Everest in the far distance. We had the view spot to ourselves, which was wonderful and, I gather, never possible now.

The conference was very interesting with much army brass and even the Foreign Minister, Krishna Menon, present. At one of the receptions I had a short talk with him. I suggested that they should form a crack army unit to develop mountain warfare techniques, which could then be rolled out to other infantry units. He brushed aside this suggestion: no, all the infantry must be able to fight in the mountains. Less than 3 years later, after provocation from India, China invaded India’s northern border, routing the ill-prepared Indian troops, many of whom were suffering from acute mountain sickness, having been rushed up to altitude with no time to acclimatise. Lahiri and I saw the Silver Hut there in the grounds of the HMI and I cherish a photo I took of Sukhamay, Tensing Norgay, and an Indian climber, outside it.


The Silver Hut in Darjeeling

L to R: Brig Gyan Singh, Tensing Norgay, Sukhamay Lahiri


 Also at the conference was JBS Haldane, the son of my hero, JS Haldane. He had also been at the Centenary conference at Oxford the previous July. He was a mathematician and biologist and probably better known than his father. A great bear of a man, he had the facility of rubbing colleagues, the press, and especially authority up the wrong way.  In this he was even more abrasive than his father. He had been pushed out of various university posts in Britain as a result of this trait. He was a great admirer of Gandhi and he and his wife (also a scientist) sought sanctuary in the Statistical Institute in Calcutta. However, he had had a row with the authorities there and was now doing freelance research and teaching from his colonial-style bungalow.

After the Darjeeling conference, at his invitation, I visited him in Calcutta. He was dressed in Indian style white cotton shirt and dhoti and had a group of young men round him. He was conducting a study of house geckos (lizards) to establish whether geckos are territorial. He had found a way of capturing and marking the dozen or so geckos resident in his bungalow. Then his students, with clipboards, noted which geckos were in each room every few minutes. In this way, with no fancy equipment, he was able to answer the question! I thought it was a great example of making the best of a situation. He had lost his position, had no funding or equipment but was able to carry out real biological research and teach a worthwhile project to students.


To India and Christian Medical College 

So it was that in March 1962 Betty and I found us again on a P&O liner on our way to India. We arrived in Vellore In April and met our senior missionary colleagues, Don and Rachel Patterson. Don was a radiologist at CMC.

A remarkable American lady, Dr Ida Scudder, started medical work there with just a couple of beds on the veranda of her father’s bungalow in 1902. She had a particular vocation to help the women in India, who at that time were not allowed, by custom, to be treated by a male doctor and, of course, there were no female doctors. So she started first a nursing school and small hospital and later, a medical school for girls. The work increased and by 1947 she was joined by other missionary and church organisations and the school became a university-affiliated college for men and women.


Entrance to Christian Medical College, Vellore

 

College Campus from College Hill in 1962


The Hospital and College

The hospital then had about 600 beds. It was in the centre of the town, and the college about 4 miles south, in the countryside, in a beautiful tree-filled campus.  A special feature was that all the students and staff were resident on one or other of these 2 sites. We lived on the college campus in various houses during our 10 happy years there.

CMC Vellore Hospital had the first cardio-thoracic surgical unit in India, started by an American surgeon, and, when we arrived, headed by American-trained Indian surgeon, Dr Gopinarth. I worked closely with this team. In those days, the early ‘60s, there was still a lot of rheumatic fever in India, which, in many patients, resulted in narrowing of one of the heart valves, (mitral valve stenosis). This could be relieved by closed heart surgery. We did a lot of these operations as well as lung surgery for tuberculosis (TB), and cancer. But we saw many other heart patients who could only be treated by open-heart surgery which Dr Gopinarth was keen to start to provide.

I had been at the Southampton Chest Hospital when the surgical team there had started this type of surgery in 1959 and, though not part of the team, I took an interest in the whole business of heart-lung bypass, both the gadgetry and the physiology. So I was able to be part of the team of surgeons, anaesthetists and technicians as we worked towards starting this highly sophisticated surgery. We had to make our own heart-lung machine and practised on dogs before attempting our first operation on a human patient. After the team became proficient at this work, I left the theatre team and worked more in the intensive care post-op ward. Most patients needed ventilating post-op for a day or two and the machines we had were sophisticated American ones. They needed a high-pressure source of gas to power them, i.e. an oxygen or compressed air cylinder. I invented a much simpler machine, which could be run on a mixture of air and oxygen or just on an air compressor. If it went wrong, it could be fixed quite simply with a screwdriver and spanner.

One of the main aims of CMC was to train Indian men and women to become doctors and to practice good medicine, especially in rural settings. Many of these hospitals had been started by various Medical Missions but now had by then been inherited by the various dioceses of the Church of South India and were already being run by local Indian doctors but were usually short of medical staff.

Betty worked in the anaesthetic department and apart from giving anaesthetics in the main hospital and the eye hospital; she developed simple techniques of anaesthesia suitable for these small country hospitals. She taught these techniques to trainee doctors at Vellore and also made a number of trips to some of the mission hospitals to teach anaesthetic techniques to the local doctors or nurses.

Our first home was in the Quadruplex, a building near the rural hospital (see below) with two flats in one side of the common entrance and accommodation for junior doctors on the other side. We had the ground floor flat.

Amongst the staff families, resident on the campus, were quite a number of children. One day Betty threw a party for some of them.  Parents came at the end of the party and took their children home. There were a brother and sister whose parents could not pick them up so I was to see them home. Crossing the field behind our flat, we were in single file through the hip high grass. The boy, aged about 7, was in front, followed by his younger sister. He had obviously forgotten that I was there, because, as we reached the far side of the field, he piped up, “Well, it was quite a good party, even though there wasn’t any ice cream.” We obviously had a lot to learn about running a children’s party!

Betty was actually pregnant with our first child when we went to Vellore and Margaret was born the next year on Valentine’s Day in the main hospital. Two years later John was born. As well as the main hospital, CMC also planned to develop patterns of medical service, which were relevant to the huge needs of rural India. So a small “rural hospital” was opened next to the college campus within walking distance of our house. Shortly before John was to be born, they opened a midwifery unit next to it. In order to encourage local women to come and have their babies there, rather than in their village huts, Betty decided she would have John in this unit. So it was that when she went into labour one evening, we 3 went down to the unit and as labour progressed quite quickly I stayed there with Margaret while the Indian midwife delivered Betty. John was fine as was Mum. It was now about 11.00 pm and the midwife and assistant announced they were off home. There was no one else about. It was expected that Granny or an aunt would, of course, accompany expectant mums from the village. So, nothing for it, at that time of night, but that I should stay and since there was no one to look after Margaret, she also stayed and we slept in the next-door room to Betty and the baby. Our houses had screened windows to keep out the mosquitoes but that was not the case in this village-type building and in the morning, Margaret and I were covered in bites. 

Tuberculosis (TB) was common in India and one of the things I did was to start a TB clinic. New drugs had been discovered and shown to be effective. I had had experience of using them at Southampton but in England it was still believed that admission to a sanatorium, along with drugs, was the best treatment. In India, that was just not possible and trials were under way in Madras testing the need for sanatorium treatment. These showed that, providing the patients took the drugs regularly, they did just as well when treated at home as those admitted to sanatoriums for the first 6 months, and even continued at work (many of them were manual labourers). The trials also showed that there were no contacts infected with TB amongst those treated at home.

So we treated our TB patients at home. However, in order to be sure they took the drugs (which the Indian government supplied), we only enrolled patients from the local area and they had to come to the clinic to receive them. If they failed to show up, we had community nurses who visited them at home. Some years later this pattern of treatment became the World Health Organisation’s policy for developing countries.


Community nurses visiting a TB patient in Vellore, 1964


Medical students being taught at the bedside, 1964

 

For a year or so I took charge of one of the 3 general medical “firms” (teams of doctors, consisting of juniors, middle grade (registrars) and seniors (consultants) Each firm together, looked after a number of patients, did out-patients and were on call for emergency admissions on one day a week.  Throughout my time at Vellore I was involved in teaching both post-graduates and under-graduate medical students.

 

The Second Schoolhouse Expedition, 1964

After the Silver Hut Expedition, I assumed “that was it” as far as high altitude research was concerned. So I was surprised and pleased to get a letter from Sukhamay Lahiri asking me if I would be interested in joining him in an expedition to study the differences between Sherpas and lowlanders like us in response to altitude.

Ed Hillary had continued the aid programme for Sherpas, which he had initiated at the end of the Silver Hut expedition, by building more schools in Sherpa villages, where he was invited to help. He had led an expedition of New Zealanders to the Khumbu in 1963, known as the First Schoolhouse Expedition, to do just that, and was proposing a second expedition in 1964.

Sukhamay had negotiated with Ed to join him on the second expedition with a physiological “wing” to carry out this study. Sukhamay was now on the staff of Presidency College, Calcutta and had obtained a grant from the Indian Council for Medical Research. I managed to get leave from CMC for 3 months and so it was that in the post-monsoon season, mid-September, I found myself with Sukhamay and a number of New Zealand climbers, including Ed Hillary, trekking out from the Kathmandu Valley for Solu Khumbu. The Chinese were busy building the “Friendship Highway” to link Kathmandu with Lhasa and our path criss-crossed this road for the first two days of our trek.  We had a good 14-day trek. Ed had just published a book on the First Schoolhouse Expedition. He called it, “Schoolhouse in the Clouds”. A good title, I thought, but one of his fellow Kiwis said, “You missed a trick there Ed, you should have called it ‘Higher Education’!”

We made our Base Camp at Lukla in the Dhud Kosi Valley (2,900m). One of the projects for this expedition was to build an airstrip and Ed had identified this alp as a possible site. To build it meant breaking down the terraces and returning the site to its original 10° slope. Sherpas and Sherpanis did the manual work. To flatten the surface of the landing strip they linked arms on each other’s shoulders as in their traditional dances and stamped up and down the strip singing their dance songs!

This airstrip has served the Sherpa community well over the last 50 years. It remained a grass/dirt strip for many years but now has been given a black top, control tower and terminal building. I hear that it is the second busiest airfield in Nepal. It also serves the many tourists making the Everest Base Camp trek. Landing at it is very dramatic, as the wooded hill and mountains rise up steeply from its upper end, so that pilots are committed to a landing after a certain point. There is no going round again. I was not involved in its building but saw some of it when we came back to Base Camp during our time there. Other projects included two schoolhouses and a bridge over the Dhud Kosi below Namche Bazar.


Looking east, down to the site of our camp. Then across the Inukhu Valley, in shadow, to the Mera La (pass) with Peak 41 to the left and Mera peak to the right


Our lab tent, Haber Sherpa, exercising


Breakfast with Sukhamey Lahiri at Lung Samba camp -10 0C


Sukhamey and I established our physiology camp just over a pass on the ridge between the Dhud Kosi and the Inukhu Khola Valleys at an altitude 4,880m. The camp was on a small level patch of ground in a boulder field commanding fine views of the Inukhu Valley and the mountains beyond. After establishing the camp and acclimatising, we found we could make the journey from Lukla in one day. Of course the accommodation was not as deluxe as the Silver Hut. Our lab was a tent, as were our sleeping quarters. This being the post-monsoon season, as time went on it became very cold at night and we would wake up to find our sleeping bags with a rim of frost from our frozen breath. The weather was mostly good with clear sunny days and clear crisp nights. 

We carried out the same sort of studies as we had done in the Silver Hut but this time comparing Sherpas with ourselves; lowlanders. We had 4 Sherpas with us most of the time who were our subjects and for lowlanders, besides the 2 of us; we had visits from other lowlanders, who were fellow members of the expedition.

We repeated the “Oxford” type of study on the control of breathing, measuring the hypoxic (oxygen deprivation) and CO2 ventilatory responses. We found, to our surprise, that while the CO2 response was the same between Lowlanders and Sherpas, but the hypoxic (lack of oxygen) response was much less in Sherpas. I learnt later that this was also the case in Andean highlanders.

We found the same results between, when we looked at the effects of breathing with added or reduced oxygen mixtures when exercising. This made big differences to our ventilation but had little effect in Sherpas. However, a number of studies since have cast doubt on this finding and it may be that with only four Sherpa subjects, we happened to have an unrepresentative sample. However, other studies have found the same results as we did.

We also studied the acid-base balance in the blood and cerebro-spinal fluid in our two groups and made measurements of the alveolar to arterial oxygen difference. We showed that this difference was significantly less in Sherpas, especially on exercise. This indicated that Sherpas had higher diffusing capacity in their lungs, an important advantage especially at high altitude, which helps to explain their phenomenal performance at altitude. This finding has been confirmed by later studies on larger numbers of Sherpas and Tibetans.

As with the Silver Hut expedition, we gave ourselves the day off on Sundays and, if the weather was good, we might go climbing. One Sunday we explored a snow peak along the ridge to the north. After an up-and-down section along the ridge we went up a snow couloir to a second ridge, which ran along some way to the summit.

Two weeks later, Sukhamey, Sherpa Penuri and I set out to complete the climb. Having got to our last high point we followed the ridge, which was excitingly narrow in places, to a perfect snow-domed summit at about 5,500m. It was a perfect day and we had fine views of peaks to the north including the dramatic south face of Peak 41 and Kangtega. We called the peak ‘Nima Khangstsi’. In Sherpa, Nima means Sunday and Knagstsi is one of the words for a peak.  

Often in the evenings we would go up the ridge and look down to the Dhud Kosi and across to the mountains beyond, Kariolung and Numbur.  On some evening the valleys would fill with clouds but we would be above them.


Dhud Kosi Valley filled with cloud. Numbur and Kariolang beyond


We completed our work and went down to join the rest of the party at Lukla. After going up the valley to Namche and Kumjung we were able to return to Kathmandu by air from the new airstrip at Lukla.


Life at Christian Medical College & Hospital (CMC)

Back in Vellore, our life, though very different from that in Britain, was very pleasant. We were a large international group, and as mentioned, all senior staff and students were resident on either the college or hospital campuses. Salaries for the Indian staff were not generous and we ex-patriots were supported by missionary societies on the basis of need rather than status. That is, we were paid an “allowance” dependent upon the cost of living in the country we were working in. All of us had more or less the same income whether we were senior or junior doctors, nurses, paramedics, teachers, or pastors. This allowance was adequate but not over-generous. Fortunately, Betty was very good at making the most of what we had. One time our Mission Secretary visited us and Betty produced a dish of cold pressed tongue. This was a dish she had learned from an American friend. Our servant, Vellu, bought the raw tongue in the market very cheaply. Then Betty or Vellu scrapped it and boiled it with saltpetre and various herbs and spices then pressed it for some hours. Our guest was surprised to be served this dish, knowing our meagre income and assuming it was expensive, imported, tinned tongue!

Our housing was provided by CMC and we lived on the College campus in a succession of houses according to our needs. Our missionary society supplied a means of transport for me. During our first, five-year term, they supplied us with a scooter for getting to the hospital from the college. We could get the whole family on this for short trips.


 Whole family aboard!


I drove, with Betty on the pillion, John standing between my knees and Margaret on Betty’s lap or when bigger, on the spare wheel behind Betty! During our second term of four years they supplied us with a car, an Indian-made Triumph Herald.

There was a large enough group of staff children to have a primary school on the college campus to which Margaret and John went. Betty worked in the anaesthetic department part-time as her family commitments allowed. She sometimes worked in the eye hospital giving anaesthetics especially to children (adults would usually have a local anaesthetic).

Our social life was very full with many friends and groups amongst staff and students. With no TV or theatres and limited cinemas, we had a lot of DIY entertainments. These took the form of plays, musicals, skits etc. I enjoyed singing in the college chapel choir.  There were annual student and staff entertainments, which were often very imaginative. Nurses, I remember, put on one skit. It was an interview for candidates wishing to enter the nursing college. “Why do you want to become a nurse?” asks the Nurse tutor. Candidate, “Because I want to do away with suffering humanity!” comes the answer, delivered in a broad Indian accent.

In the hot weather, in May, we usually went up to the Hills, either to Kodikanal in the Palni Hills or to the Nilgiri Hills. During our first term we would meet my parents at Kodi along with other missionaries from various parts of South India. There for 2 years my mother directed Gilbert and Sullivan operettas with my father and me in the chorus. In the Nilgiris we stayed at a beautiful tea estate, Korakundah, in a very remote corner of this plateau at 6-8,000ft. The tea grown there is one of the highest teas in the world.  I used to go there for a consultation at their estate hospital twice a year. The estate doctor would collect problem cases for me to see and advise about. They put a bungalow at our disposal with a cook. There were small rainbow trout in the streams and lakes and the manager taught me to fish and tie my own flies. Our cook (employed by the tea estate) would make a very nice fish pie from my catch. 

In 1995, after we had left, the estate became organic and now its tea is highly prized especially in Germany. It even has its own web page.

So our first term at Vellore drew to a close in April 1967.


Part 12 can be found here.


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