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 this year we'll bring you images and text that describe Jim's extraordinary life.
Here's our final instalment. It's 1967, Jim and his family have just completed a 4 year term working at the Christian Medical Centre in Vellore. With a year off they travel to San Francisco so Jim can take up a research fellowship with the American Thoracic Society...
After our first term in Vellore, we were to have a year’s furlough. During this time it was usual for professionals to do a refresher course in their field. I was fortunate in that I had had a lot of continuing medical education in Vellore, but I felt that I lacked formal training in research. So I got in touch with Dr John Severinghaus, an academic anaesthetist in San Francisco who was one of the few scientists in the world interested in high altitude medical research at that time. He arranged for me to have a research fellowship with the American Thoracic Society for which I was very grateful.
The USA 1967-68
I found out that the steamship company, P&O, ran a scheduled service every month from London to Los Angeles, via Bombay, Colombo, Perth, Sydney, Auckland, Fiji, Honolulu, Vancouver and San Francisco. We picked up the ship at Bombay and, with tickets to San Francisco, were able to “slip ship” in New Zealand, and catch the next ship a month later for no extra cost. Margaret was now 4 and John 2.
We had a very pleasant time on board and calling at all the places on the way. I got off at Sydney and did a lecture tour speaking at Friends of Vellore meetings, medical groups and church groups, about Vellore. I adapted my talk according to the audience. It was, of course, mainly about Vellore, but sprinkled with slides of the Himalayas and included a bit of altitude physiology.
I visited Sydney, Melbourne, Hobart, Canberra and Brisbane. Meanwhile, Betty and the children went on to Christchurch, New Zealand and stayed with a Vellore friend there. I flew to join them and we had a trip around the South Island in a rented car. I did more speaking at similar groups there too before we went across to the North Island and motored up to Auckland to stay with Ed and Louise Hillary.
On some nights of our trip we camped, though Wally Romanes (from the Silver Hut), put us up in a mountain hut he was building on Mt. Ruapehu for one night. He and I climbed to the summit the next day in rather indifferent weather.
Ed and Louise Hillary were very kind and looked after us at their home in Auckland until our ship arrived to take us on. So across the Pacific we sailed, stopping at all these exotic ports with a swim and I attempted surfing at Waikiki, a beach in Honolulu.
Our family with Ed and Louise Hillary at their home in Auckland. L to R: Ed, Margaret, Louise, Betty, John and myself.
We arrived in San Francisco in July 1967 and after a long wait to get through customs and immigration, we found no one to meet us. So we took a taxi to the Cardio-Vascular Research Institute (CVRI) where John Severinghaus worked and I walked into his lab. He was very surprised to see me. Apparently my last airmail letter giving him date and time of our arrival had never reached him! However he rose to the occasion, phoned his wife Eleanor and they insisted we come and stay with them until we could find our own accommodation.
They soon found a place for us to stay, housesitting for a faculty member who was away in Europe. This was a very nice house in Mill Valley looking out to Mount Tamalpias. It came with a resident 18-year-old niece of the owners! Subsequently, we found and moved into a student cabin on a Southern Baptist Seminary campus, also in Mill Valley. All these places were in Marin County, across the Golden Gate Bridge from San Francisco. So my daily commute was a lovely drive across this bridge and through Golden Gate Park to the CVRI that overlooked the park.
The ‘hippy’ movement, centring on the Haight-Ashbury district and the Golden Gate Park, was at its height that year, 1967-8, and was just below the CVRI where I worked. That first summer was all love and “flower power” but by the next year the drug cartels and others had moved in and it was turning sour. My two Canadian teenage nephews, exploring the scene later that year, were relieved of their wallets at knifepoint by a couple of teenagers in that district.
As a Fellow of the CVRI, I spent my time learning research techniques and trying to answer the question as to where exactly in the lung the leak of fluid took place when an animal was made hypoxic. This was to try and understand the mechanism of high altitude pulmonary oedema (HAPE), a sometimes lethal form of mountain sickness (see my case of HAPE, in a Sherpa on Makalu). In this project I was not successful, though none have succeeded since.
The whole atmosphere of the CVRI was very exciting with many charismatic team leaders. Besides my own chief, John Severinghaus, there was Julius Comroe, the head of the Institute, whose book, “The Lung” got me (and John West) fired up about lung function and respiratory physiology. There was John Clements who was one of the co-discoverers of lung surfactant and others at the cutting edge of cardio-respiratory physiology. They were all very approachable and the easy exchange of views and news with them and other fellows made for a dynamic atmosphere of learning.
Apart from my own research project, I helped with John Severinghaus’ team projects, which included continuing studies of the control of breathing at altitude. Thus I went with him and Shame Cotev, another fellow, to the Barcroft Laboratory on White Mountain at an altitude of 3,800m.
Also with Soren Sorensen, another fellow, I went to Cerro de Pasco, a mining town at 4,300m in the Peruvian Andes. We travelled up there by truck from Lima, which is at sea level, in one day, and of course had moderate mountain sickness the next day. Amongst other projects we studied the cerebral circulation of some of the high altitude residents. We showed that they had lower than normal blood flow to the brain, even when breathing oxygen, due to the increased viscosity of their blood with its high red blood cell count. This may account for some of the symptoms of chronic mountain sickness.
We had got to know one of the mining engineers there, who was French. After we had finished our research he invited us to come down on the Amazon side of the Andes to a patch of jungle, which he and his friend, had been allocated. There they planned to raise pigs, feeding them on food grown on their land. We camped there in luxuriant, beautiful jungle surroundings which were just bliss after quite hard working and living at altitude. He had built a cabin and had chickens. We dined on these and jungle produce such as heart of palm, gathered from the jungle, which was delicious.
Interestingly, during our year in the States, with the widespread introduction of the Boeing 707 jet airliner, flying became cheaper than sea travel. So, after a very happy year, we returned to England by air. We had 4 months furlough staying in Selly Oak, not far from Betty’s parents in Kidderminster. They were sorry to see us leave for Vellore for our second term of 4 years and we more or less promised that this would be our last term at Vellore.
John Severinghaus and me at the Barcroft Laboratory on White Mountain
Vellore Second Term
During this second term we lived in a larger house, which was where the Webbs had lived. John Webb, professor of paediatrics, was now director of the whole institution, but his wife had gone home with their children as they were now teenagers and were at school in England. So we hosted John in what became our house. This meant we did a lot of entertaining which we enjoyed but was more work especially for Betty. I continued with much the same work as before, except for a year or so when headed up a general medical “firm” i.e. a team. This involved more general medicine and more teaching of medical students.
Ciba Symposium 1971
In February 1971, I was invited to attend a Ciba symposium on high altitude physiology in London. Ciba was a pharmaceutical company, which used to run these symposia on various rather esoteric topics. This one may have been the first conference purely on high altitude physiology and medicine, as not many people in the world were interested in the subject at that time. Attendance was only by invitation and numbers were deliberately kept small to encourage discussion. The total number of participants was only about 25, drawn from South America (mainly Peru), the USA, including Severinghaus, and UK, including Griff Pugh.
There, in the evening between the 2 days of the symposium, at a social function, I met John Nunn. John was a Birmingham medical graduate who had just returned from the Colonial Medical Service in Malaya. We had met when I was a houseman and Betty a senior house officer in the General Hospital, Birmingham. John became an anaesthetic registrar at the General and taught Betty the then new anaesthetic techniques of muscle relaxants and controlled ventilation; techniques which she was able to use subsequently in Hong Kong and later in Kathmandu and Vellore. Now John was professor of anaesthetics in Leeds and had been appointed to head up a division of anaesthetics in the newly built Medical Research Council’s Clinical Research Centre (CRC) at Northwick Park Hospital, Harrow. This brand new Hospital and CRC was to open later that year. I mentioned to him that Betty and I would be returning to UK the next year. He said I should keep in touch with him.
Return to UK, Northwick Park Hospital
In the summer of 1972 we returned to England and settled in a rented house in Ware, Hertfordshire. I got in touch with John Nunn, now working at Northwick Park and in January ‘73 I was appointed by the MRC as a member of his team. It was a very exciting time at this new venture.
Unlike other new hospitals of the time, which were old hospitals moved to new premises, this was a brand new venture with a completely new staff of young keen consultants wishing to combine clinical and research work.
A year later I applied for and got 1 of the 2 last planned physician posts at Northwick Park Hospital. These were advertised as joint appointments under the MRC and NHS, 50:50 jobs. Half my time was to look after patients, particularly with chest diseases, as a general physician with a special interest in chest disease; and half to do research. My salary was paid half by MRC and half by the NHS. For me this represented a dream job description and I was fortunate to be able to keep this contract until I retired, 23 years later, in 1995 on my 65th birthday.
Dr John F. Nunn, head of the division of anaesthetics at the MRC Clinical Research Centre, Northwick Park Hospital 1972-1991.
During these years we lived in Rickmansworth, an easy commute to the hospital in Harrow. Betty worked part-time at Northwick Park and at St Vincent’s, a small orthopaedic hospital in Northwood Hills.
In 1974, when I was appointed to the consultant post of general physician with special interest in respiratory medicine (chest physician), I was the only such physician. As the hospital become more established and busier, more consultants were appointed and a second respiratory consultant, Mark Harries, was appointed. He proved to be an excellent partner in running our respiratory medicine department and a good friend. However, he did have a capacity to ruffle the feathers of management and other consultants and one of my jobs was to follow and smooth them down again! Tragically, soon after I retired, Mark contracted a melanoma and died.
An extra job I was given was as “clinical tutor” with responsibility for the post-graduate education of our medical junior doctors. Later I became Chairman of the Medical Staff Committee.
About this time the MRC decided to close the Clinical Research Institute and its staff had to find other jobs. As I had this 50:50 contract I was fireproof and the MRC continued to pay their share of my salary until I retired some 5 years later and I was able to continue to spend half my time on my own research.
Finally, for the last three-and-a-half years before retirement, I became the first Medical Director, a post created by one of the many re-organisations the NHS went through, and so I became more involved with hospital management. This was an interesting new experience and enjoyable in that it involved not only “keeping the show on the road” i.e. helping to run the hospital efficiently and within budget, but we had the opportunity to do three new things:
-We brought in St Marks, a small specialist hospital for colo-rectal disease, recognised as a “centre of excellence”, that had to move from its isolated and dilapidated site in London. Apart from the management of this merger, I had the task of integrating the two consultant bodies, quite a delicate job!
-As mentioned, in 1990 the MRC decided to close their Clinical Research Centre. So, with the enterprise of a charismatic research vet, Colin Green, we opened the “Northwick Park Institute of Medical Research” in the MRC vacated area of the Hospital. This area included the Animal House, which, when it was built in 1971, was the largest in Europe. It opened as I retired. I am glad to say that, 23 years later, this venture is still thriving as an independent research institute financed entirely from the research grants of groups wishing to work there.
-We negotiated to become a teaching hospital, part of St Mary’s Medical School and so part of Imperial College London. Medical students from St Marys and The Royal Free Hospital came to Northwick Park for clinical teaching.
So for me it was it was an interesting and quite enjoyable experience. Though I would put it in the category of “not to be missed but not to be repeated”! A tricky part of the job was that, to a degree, one was responsibility of the behaviour and practice of fellow consultants, without any power to discipline or sack them. Fortunately there was only one who gave me a problem in this respect. He was a physician who spent more time and energy on his private practice than on his NHS work and was also inclined to be rude to patients and “difficult” with fellow consultant colleagues. I did “tick him off” and it had some effect.
Kongur a mountain in Xinjiang (that part of China to the north of Tibet), was, when we went there, one of the highest unclimbed peaks at 7,724m. Mike Ward and Chris Bonington were fortunate enough to get permission for us to go there in 1981. The Chinese, who had taken back Xinjiang as part of China, had kept it “off limits” to Westerners. Chris and Mike made a reconnaissance in 1980 and the next year we put together a team consisting of four climbers (Chris, Peter Boardman, Al Rouse and Joe Tasker) and four scientists (Mike Ward, Edward Williams, Charles Clark, and myself). Also in the team was David Wilson from the Hong Kong civil service, who was a Mandarin speaker, came partly as our own translator, if necessary. He also has some climbing experience. He later became Governor of Hong Kong and now sits in the House of Lords as Lord Wilson! Finally we had Jim Curran, a climber, artist and photographer, as cameraman.
We were very fortunate in that China was just opening up to the west and the firm of Jardine Matherson, a Hong Kong trading company with long China connections and great enterprise was keen to get back into China. They readily acted as our sponsors and a number of their folk came out with us and spent a few days at our Base Camp and climbed an easy snow peak nearby. This was also a good acclimatisation day for us. I have never been on such a well supplied expedition. Amongst other, parts of their business, they represented White Horse Whisky in China so supplied us with a generous quantity of this! And during the time we were there they sent us a dozen bottles of champagne, which arrived on the day when the climber arrived back at Base Camp after their successful climb. Only one bottle was broken.
Just getting there was very enjoyable. We had a few days in Hong Kong as guests of our sponsors. Then we had a few days in Beijing, a flight to Kashgar and up the Karakorum Highway by truck, to the Karakol Lakes (3,600m). After a couple of days acclimatising there, we trekked up to our Base Camp in 2 easy days using, yaks, Camels and a few porters. This was my first experience of these Bacterin Camels, with two humps. A standard porter load is 30 Kgs, a yak, 60 Kgs but these camels take 120Kgs! They have long legs and can easily ford streams and even rivers, as they did on the way to Base Camp.
Loaded camels, crossing Koksel River on way to Base Camp
We had a very pleasant Base Camp beside the Koksel Glacier at about 4,000m. The climbers managed to make the ascent on their second attempt although with considerable difficulty, involving a four-night bivouac due to a storm, before they were able to climb the last 500m of difficult rock.
Successful climbing team on Kongur summit July 1981, first ascent.
On the descent from the summit Pete Boardman was nearly killed when abseiling. The abseil rope dislodged a rock, which caught him a glancing blow on the head, and he slid down the rope. Fortunately his glove caught in the abseil karabiner and stopped him from sliding off the rope to his death!
Boardman and Tasker returning from the summit of Kongur
Meanwhile we four scientists got on with our science. Our science consisted of comparing us scientists, average mortals, with these four very experienced and outstanding high altitude climbers. We found that to a degree their physiology had moved towards that of Sherpas. (See Kongur - The Elusive Summit by Chris Bonington) We studied the climbers when they returned to Base Camp between trips pushing out the route and ourselves when they were higher up the mountain. But we also made some 3 day trips on our own. David Wilson and I climbed a couple of 5,000m peaks, one of which was named, Serala and I made a very enjoyable day trip to Base camp (solo) using skis to get there and back. I also had some skiing on slopes near Base Camp. It was a very happy expedition.
Also in 1981, John West, now settled in San Diego, California, invited me to go on a post monsoon Everest expedition that he was leading. I was fortunate that my fellow respiratory Physician, Mark Harris was happy to cover for me with the help of an Anaesthetist, Gareth Jones who had done some respiratory medicine. This left only 10 days after I returned from Kongur. It was called the American Medical Research Expedition to Everest, AMREE, and like the Silver Hut Expedition 20 years earlier, it aimed to combine altitude research with the ascent of an 8,000m peak. I was very pleased to be invited as the only non-North American. I was also pleased to go on an Everest expedition, at last, and to go through the icefall and into the Western Cwm. We did some research at Base Camp but mainly we worked at Advance Base Camp in the Western Cwm, where I spent three weeks, sharing a tent with John. For our lab we had an “off the shelf” tent called a “Weather Port” which served very well...
Looking down the Western Cwm with a small avalanche coming off the West shoulder of Everest. Our lab, the Weather Port, on the right
The most eye-catching part of the science was that one of the climbing scientists, Chris Pizzo, measured the barometric pressure on the summit of Everest (248mmHg) for the first time, and took alveolar gas samples, which were brought back and analysed in the USA.
We repeated many of the studies we had done in the Silver Hut, especially on exercise. But we also did sleep studies. An important study was by Lahiri on sleep and control of ventilation. Sleep at altitude is disturbed. In particular a pattern of breathing develops called “periodic breathing”. This consists of a few breaths, starting with small breaths, then increasing breath sizes, then smaller again and a pause – no breaths for 8-10 seconds. Then the cycle repeats and this may go on for hours. For a tent companion, it can be quite unnerving! It probably contributes to the feeling that sleep, at altitude, has not been refreshing.
Sleep recording in the Western Cwm (6,300m) on Everest, showing periodic breathing. Upper trace shows the chest movement. The lower trace is the oxygen level in the arterial blood. At sea this level would be around 98%
The above trace was from one of the climbers. Sherpas show far less periodic breathing. We think this is possibly because they have lower hypoxic ventilatory responses, as we had shown in 1964.
In the 1980s I had two very good trips with the Royal Navy and Royal Marines Mountaineering Club, first to Mt Kenya and then to Bolivia where we climbed two peaks, one of 6,300m and the other about 5,800m, with a very pleasant Naval sick berth attendant. This was after we had had a week doing some altitude research on mountain sickness. We were entirely unsupported here (no Sherpas). He was wonderfully organised and we honed down our time for having breakfast and getting away to only 20 minutes from the alarm going off. This was wonderful for me as I hate waiting around for fellow climbers or skiers to get ready for off – a weakness I know.
Jaonli is a mountain in the Indian Himalaya in an area called Garhwal. It is 6,600m and was first climbed from the north by an Indian Army team in 1977 led by Lt Col D.K. Khullar. Mike Banks, a well knows climber and ex-Royal Marine had led a party to attempt to climb it from the south but had failed. In 1991 he hoped to have a second attempt. I was invited together with a friend of mine, Mike Westmacott who had been on the ’53 Everest expedition and with whom, and his wife Sally, I had climbed and skied quite a lot. Altogether, we were a party of 6, all of us over 60, except Paddy O’Leary, who was only 59. So Mike had the bright idea of asking Saga to sponsor us. Saga is a travel firm specialising in active holidays for the older traveller. It was a natural pairing. They agreed, on condition that we supplied them with articles (and photos) for their house magazine and were very generous in their sponsorship.
Our team consisted of Mike Banks, Mike Westmacott, Richard Brooks, two Irish members, Joss Lynam, the grand old man of Irish climbing and Paddy O’Leary. Paddy was in charge of the Irish outdoor pursuits centre and was the member with who I seemed to get paired up with. He was a delightful companion and we got on well together. After a very pleasant 5 days trek from the road head, through pleasant countryside we reached our base camp at about 4,000m. From here, we had a view up the glacier to our peak and its two ridges reaching down to the left and right of the glacier. We made a route up through the glacier, weaving our way past crevices and towers to gain the upper smooth nevè, where we established our advanced base camp. From here we explored the route up the left hand (western) ridge.
The Jaonli team. Back row, Richard Brooks, Mike Banks Front row, Paddy O’Connor, Mike Westmacott, Joss Lynam. Jaonli at head of the glacier. Our attempted ridge is on the left
Paddy and I established a camp on this ridge and the next day explored along the snow-covered ridge towards the summit pyramid. Meanwhile other members were exploring the alternative route up the other, western ridge.
On the second day from our advanced base camp, Paddy and I reached a point where our ridge narrowed and the snow was of uncertain consistency. The top one foot of snow did not seem to be adherent to the snow below, so that we thought it could easily slide off down the very steep slope we were on. We were less than had a mile from the summit but, bearing in mind that we were both married with children, we decided that discretion was the better part of valour and we retreated. Meanwhile, other members had explored the other ridge but also did not find a feasible route to the summit.
Return to Delhi
When we got back to Delhi we picked up our accumulated mail, we had not contact with home since we had left Delhi. There was a letter from my Father informing me of Betty’s death. This had occurred on the day after she had undergone a minor operation in Northwick Park Hospital. It was, of course, devastating news. She had been so fit and healthy and had been windsurfing only a few days before. Margaret and John (then aged 28 and 26), with my father’s help had to deal with the immediate consequences of this tragedy.
Following retirement, on my 65th birthday in August 1995, I have been able to continue my interest in high altitude medicine and physiology and since retiring I have been on numerous expeditions to the great ranges, sometimes just for fun but more often with research projects included.
Our children grew up, went to school and university and made their own lives. Daughter Margaret lives in Yorkshire and has 2 boys, Evan and Joel, now 18 and 16. She is a teacher. John is a paediatrician, working in Auckland, New Zealand, and is married to Denise and they have a son, Matthew, born in 2016.
With Mike Ward and John West, friends from the Silver Hut Expedition, we published what has become the standard textbook in altitude medicine and physiology in 1989.
Me, Mike Ward and John West with the first edition of “High Altitude Medicine & Physiology” in 1989
We have published further editions at 5 or 6 year intervals. The 5th edition came out in 2012.
I continue to lecture to a variety of groups, including medical students and on the Diploma in Mountain Medicine course that David Hillenbrandt and I started in 2002. I occasionally write papers on the subject and am involved with various groups doing research in this field. Conferences on hypoxia and mountain medicine are a great way to keep up with numerous colleagues from many nations. Interest in mountain medicine and physiology has increased a lot since the Ciba Symposium of 1971 with up to 600 delegates now attending international conferences.
Jim lecturing to the Xtreme Everest 10th Anniversary Conference at the Royal Geographic Society, London, 2017 (Photo: Sue Ward)
It has been a wonderful interest to keep me occupied in retirement. I am very conscious that I have had much more than my fair share of good fortune (apart from Betty’s death). Perhaps the greatest good fortune has been my family and the many friends I have made and enjoyed along the way.
I must acknowledge the help and support of a number of people who have helped in this modest enterprise. First, to Harriet Tuckey, a friend, made during the years that she was writing her wonderful biography (“Everest: The First Ascent”) of my friend and teacher, Griffith Pugh, her father. She read and commented on most of the chapters. To Erica Neustadt, who did the same for some chapters. My cousin Jill Inskip did the same, especially for the earlier chapters dealing with our shared childhood. Finally, my grateful thanks, to my wife, Pat Howell, for her patience and support during these years of writing.
Thanks Jim for granting us permission to publish "Mountains My Lab"!