Going High The Story of Man and Altitude, by Charles S. Houston, M.D. Published by the author and The American Alpine Club, 1980. 211 pages, 35 illus. including 17 b & w photographs, bibliography. Price $10.00.

Charlie Houston is a modest man whose contributions to mountaineering are well known to anyone interested in climbing. Galen Rowell has pointed out the significance of his four early expeditions to the Himalayas in his preface to Going High. Anyone who has read K2 The Savage Mountain, by Houston and Bates, will appreciate the high calibre of Charlie’s qualities as a climber and compassionate human being. Charlie’s accomplishments in other fields are equally outstanding but, possibly, less well known to climbers. After obtaining his M.D. degree in 1939 from Columbia, he joined the Navy and in 1947 participated in one of the most fundamental studies of the effects of prolonged low-pressure chamber hypoxia in man—Operation Everest. After this research study Charlie became physician, internist and cardiologist with active practices in Exeter, New Hampshire, Glenwood Springs, and at the Aspen Clinic in Colorado. From 1962 to 1964 he was director of the Peace Corps in India and Special Assistant to the Peace Corps Director in Washington for two more years. Since 1964 and until recently he was Professor of Medicine and Environmental Health at the University of Vermont Medical School. For the past twelve years his direction of the high-altitude studies on Mount Logan has clearly demonstrated his ability as an administrator and medical investigator. His most important scientific contributions were the earliest recognition of high-altitude pulmonary edema as a clinical entity in the United States in 1960, and his discovery of high- altitude retinal hemorrhages at Mount Logan in 1968. More recently Charlie has established his unique ability as a teacher by the organization and presentation of popular courses on medicine for mountaineers and symposia on hypoxia. Could anyone be more qualified to write a book on high altitude!

Going High is essentially three books in one volume. The first fifty-one pages succinctly describe the development of our knowledge of oxygen, the atmosphere and high elevations attained initially by hot air balloons and later by mountain ascents. The description of Perier’s discovery by means of a crude mercury barometer that the atmospheric pressure was lower on the Puy de Dôme (3500 feet) than at the monastery at the foot of the mountain is eloquent and exciting.

The second part of Going High consists of a clear description of the physiology of respiration, circulation, hemoglobin and the cell. The material is written for the layman and the excellent drawings aid the reader in understanding even somewhat complex physiologic mechanisms, such as cellular oxidative metabolism.

The chapters on altitude illness and acclimatization constitute less than half of the book. One wishes that these sections had been expanded, since some topics such as the significance of the results of Operation Everest are covered in only one paragraph. All chapters in the book are superbly illustrated with one-page reproductions and photographs accompanied by brief pertinent summaries and descriptions.

I found very few aspects of the medical section that I could take issue with. Still, there were a couple. For instance, there are perhaps too many brief case reports without significant commentaries. Then, too, while Charlie condemns anecdotal evidence as “a notoriously fickle source,” he uses such “evidence” to recommend the careful use of a powerful diuretic (furosemide) in the treatment of high-altitude pulmonary edema. I question this. A diuretic is only useful in treating pulmonary edema due to heart failure, where it acts by lowering the elevated filling pressure of the left ventricle which is forcing fluid from the pulmonary capillaries into the alveoli. In high-altitude pulmonary edema, on the other hand, the left ventricular filling pressure is normal or decreased—hence a diuretic cannot “squeeze” edema fluid out of soggy lungs. Why use a drug in the mountains which, according to Charlie, “can cause severe dehydration, a dangerous decrease in blood volume and shock,” especially when we have no clear evidence that it is helpful? I recently encountered a climber who had moderate pulmonary edema in the Sierras. He was brought down to a hospital near Yosemite where he felt greatly improved and requested that he be allowed to drive home with his companion. The physician agreed but, following Houston, gave the patient Lasix. Their trip home was interrupted by twenty stops at gas stations and the patient was incapacitated for two days by weakness and dehydration. The results of the “treatment” were far more incapacitating and prolonged than the pulmonary edema!

Another mild criticism I have is that the “bony box” theory of the mechanisms of symptoms and neurologic deficits in “high-altitude cerebral edema” is championed by Houston in Going High without alternative mechanisms being presented. This concept assumes that hypoxia causes the brain cells to take up water resulting in edema of the brain. The brain swells up and, unlike the liver or other visceral organs, the brain has no place to enlarge since it is enclosed in “the bony box” of the skull. Swelling of the brain, according to this theory, causes headaches, disturbances of mental function, loss of consciousness and central nervous system injury with resultant neurologic deficits such as ataxia. Unfortunately cerebral edema in the absence of hypoxia is not always accompanied by the signs and symptoms seen at high altitude. In patients with cerebral edema that are due to brain tumors, less than half have headaches. In Going High the patient described on page 127 had severe cerebral edema without a headache. Intracranial pressure can be raised to over 500 mm. of saline (about 4x normal) by intrathecal infusions of saline without headache. It is well known that the removal of even a small amount of spinal fluid will often be followed by intense headache. It is more likely that the signs and symptoms of high-altitude cerebral edema are due to hypoxic nervous tissue injury and that swelling of the brain is an accompanying phenomenon and not a causative one. For this reason the term “high-altitude anoxic cerebral injury” would be preferable to “high-altitude cerebral edema.”

A few topics of interest to climbers could have had more systematic coverage in Going High. These include: 1. The mechanisms responsible for the progressive decrease in maximal physical exercise capacity at increasing altitudes, as shown only in the vivid graph in Figure 31. 2. The causes of high-altitude deterioration in climbers who spend prolonged periods of time at elevations greater than 18,000 feet. 3. High-altitude systemic edema, i.e., swelling of the feet, face and hands.

This handy volume is recommended for anyone who is interested in the historical, physiologic and medical aspects of high altitude. The clear style of writing and the wide range of topics makes it a delight to read and a valuable reference. Charles Houston, in addition to his other accomplishments, has now established himself as a skillful author.

Herbert N. Hultgren, M.D.