REDUCTION OF MOUNTAIN SICKNESS WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D.

, Director, Institute for Traditional Medicine, Portland, Oregon Increasingly, people are traveling into the mountains. In 1997, it was reported that there was a traffic jam at the upper levels of Mount Everest, earths highest peak, as so many mountaineers scrambled to reach the top during the short window of time when the weather permitted such a feat. Aside from trekkers, there are many people visiting high altitude destinations for purposes of vacation and exploration, such as Lhasa (Tibet), Katmandu (Nepal), and Machu Pichu (Peru). Mountain sickness, a condition which is brought on by the lower level of oxygen, and, to a lesser extent, the reduction of air pressure, usually affects people at altitudes of 2,500 meters or more (8,000+ feet), though sensitive individuals may show some symptoms above 2,100 meters (7,000+ feet). There is an increasing percentage of individuals affectedand more dramatic effects occuras the altitude increases. In fact, experienced mountain climbers, as well as those who have little prior high-altitude exposure, have been known to suffer severe consequences, sometimes death, at altitudes of 9,000 feet and higher, as a result of mountain sickness. Dr. Peter Hackett, himself a climber, observed numerous trekkers passing through the town of Pherich, at 4,200 meters (14,000 feet) on the trail to Mt. Everests peak, and described, in his book Mountain Sickness (1), his growing knowledge of the health problems that occurred. The incidence of mountain sickness for mountain climbers during typical ascent was reported to be 65% at 4,200 meters and, in other observations, for those climbing Mt. Rainier in Washington, it was 66% at altitudes up to about 4,500 meters. Mountain sickness generally produces symptoms about six hours or more after arriving at high altitude or after increasing altitude by more than 300 meters (above the level of 2,1002,400 meters) in a day. Most skiers avoid mountain sickness because they spend less than six hours at an altitude where the problem might arise and then spend the night at an altitude for which mountain sickness does not occur. Adaptation to high altitude, with alleviation of symptoms, usually requires 13 days, though it takes about two weeks to attain complete acclimatization. Symptoms associated with acute mountain sickness may include: Headache Fullness or tightness in the chest Insomnia Irregular breathing (especially at night) Lassitude Loss of appetite Loss of coordination Nausea Edema of eyes and face Vomiting Reduced urine output Cough Weakness Shortness of breath Legs feeling heavy

Some of these symptoms may be experienced while climbing mountains or working at high altitudes and may not be due to mountain sickness, but are the result of other factors, such as exertion and failure to drink enough fluids. However, exertion and inadequate hydration can also worsen actual cases of mountain sick-

ness. Therefore, it is important to become familiar with its symptoms and signs, so that one can respond appropriately if mountain sickness occurs. Since the disorder can have fatal consequences (most often from pulmonary edema), it is important that the response to mountain sickness include no further climb in altitude; in severe cases, there should be a prompt decline in altitude by at least 300 meters, preferably more (6001,200 meters in response to pulmonary or cerebral edema). The most common symptom of altitude sickness is headache, which may partly result from the bodys attempt to maintain high oxygen levels for the brain, thus increasing blood flow to the head. The main physiological response of medical concern is the development of edema. In particular, one can suffer from cerebral edema (which may result in persistent headache, incoordination, and lassitude; it usually does not occur below about 6,000 meters), and/or from pulmonary edema (resulting in fullness of the chest, irregular breathing, difficult breathing; it may occur at 3,000 meters). Either of these are potentially fatal. While fluid is escaping from the blood vessels and accumulating in the brain, lungs, or face (the latter condition not being dangerous except when eyelid swelling is so severe that it impairs vision), the individual becomes quite dehydrated, and it becomes increasingly important to drink fluids (which are often difficult to get as the altitude increases, since the very heavy bottles of water are not easily transported to the higher altitudes where natural flowing water is not available; melting snow requires fuel and considerable preparation time). Reduction of urinary frequency and development of dark colored urine (representing its concentration of biochemical substances in small volume) reflects both the lack of adequate water ingestion and the loss of fluids from the blood to the tissues. In addition, digestion becomes impaired. Some of the nausea and vomiting that occurs is secondary to the experience of severe headache (as experienced, for example, by migraine sufferers at normal altitudes), but Dr. Hackett suggests also that appetite is also generally weakened and malabsorption occurs. These conditions may further lead to limited fluid intake and also nutrient deficiency. AVOIDING MOUNTAIN SICKNESS Aside from the herbal therapies to be described below, there are certain important steps to take to avoid mountain sickness. Dr. Hackett lists these: 1. Whenever possible, do not fly or drive to high altitude. Start below 3,000 meters (10,000 feet) and walk up. However, if taken passively to altitude, do not exert yourself or move to a higher altitude for the first 24 hours. 2. Once above 3,000 meters, limit your net gain in altitude (your sleep altitude) to 300 meters per day (1,000 feet). You can climb higher than that in one dayin fact, it may be beneficial to aid adaptationbut you must descend far enough that the overnight is spent at this altitude. 3. For every 1,000 meters gain in elevation, take an acclimatization day. This means that after three days of climbing about 300 meters per day, take one day without further climbing. 4. Prevent dehydration by consuming a minimum of 1.5 liters water per day (or enough water to assure clear urine), avoid overexertion, consume a high carbohydrate diet, and carry potent diuretics in case edema occurs. HERBAL MOUNTAIN SICKNESS PREVENTION STRATEGIES FROM CHINA Since the 1950s, but mainly since around 1970, millions of Chinese people have been transported from typical Chinese altitudes of 0650 meters (02,000 feet) to Tibet, primarily in the area of Lhasa, where the city altitude is 3,500 meters (12,000 feet), and much higher altitudes are inhabited in the immediately surrounding areas. This high altitude is usually attained during a three day truck drive up the mountainous border region (often from Chengdu in Sichuan Province), though air transport has been available to a limited extent since 1980.

Adjacent to Tibet is Chinas Qinghai Province, which has many towns at high altitude: Chinese people from the lower altitude provinces have also been relocated here, to live at altitudes of 3,0004,500 meters (10,000 15,000 feet). Mountain sickness is a common reaction as people first reach their destinations in Tibet and Qinghai Province. The symptoms, sometimes quite severe, and the need for rest in order to prevent developing symptoms, would often cause a delay of about 10 days in getting to work. The problem was so common and so disruptive that many Chinese researchers investigated possible preventive treatments for the condition. One of the most widely used remedies has been Codonopsis Combination, also known as Compound Codonopsis Tablet, which has been used since the 1970s. No reports were found detailing the precise ingredients of this formulation. The effectiveness of Codonopsis Combination (Compound Codonopsis Tablet) was reported by Sun Jianchang and colleagues at a hospital of Chengdu military command (2). Soldiers going to Tibet were treated with the formula, taking 5 tablets twice daily for 20 days starting 3 days prior to arriving at altitude. They were reported to be free of some common signs of mountain sickness, such as vomiting, anorexia, and weakness, and they had a lower incidence of dizziness, headache, palpitation, shortness of breath and nausea than a control group which did not take the herbs. In 1982, Peng Hongfu, at the Institute of Army Hygiene, Academy of Army Medicine (Beijing), published his report (3) on use of Chinese herbs to counteract mountain sickness. This work was an attempt to improve on Codonopsis Combination, which had performed reasonably well, but with about half the individuals using it still getting some degree of mountain sickness. In selecting remedies to test, Fang considered that the main problems were qi deficiency affecting the lungs and dampness accumulation. According to the principles of traditional Chinese medicine, qi deficiency and dampness accumulation can be addressed by tonifying the spleen and lungs and by including herbs to drain dampness. He experimented with five formulas, including Codonopsis Combination as the control. His main focus of adjustment was adding hoelen to help remove water accumulation. The new formulas were Codonopsis and Hoelen Combination and Astragalus and Hoelen Combination; the latter available in three slightly different formulations (formulation details were not revealed by the author). Codonopsis is described (4) as having the ability to invigorate the function of spleen and stomach, to replenish the vital energy [qi] of the spleen and lung, to promote the secretion of body fluids. Astragalus is described as having the following functions, among others: to replenish the vital energy [qi]; to regulate water metabolism and reduce edema. Hoelen is described as having the ability to regulate water metabolism and resolve dampness, to reinforce the spleen and stomach, to pacify the heart [sedative action; alleviates insomnia]. Peng reports on a study in which troops were sent to Lhasa and the surrounding areas, with altitudes of 4,300 5,400 meters. The troops were all male, and most were aged 1822. Three days before arriving at the Tibetan plateau, they began taking the herbs and continued to do so for two weeks after arriving. Evaluations of the reaction to the altitude were done by symptom survey, rating the overall responses to altitude as none, light, moderate, or heavy. The study was carried out during the period 19741977, with over 400 participants. According to the report, the group who took Codonopsis Combination had 45% reporting no mountain sickness and 38% reporting light reaction, and the rest (16%) having a moderate to heavy reaction. With the new Astragalus and Hoelen Formulas, a higher proportion, 57%, reported no mountain sickness, while a lower proportion, 31%, showed a light reaction, and only 12% had a moderate to severe reaction. Thus, the newer formula appears to have slightly increased the rate of avoiding mountain sickness. Unfortunately, since there was no true control group (receiving nothing or a placebo), it is difficult to know if the improvements were highly significant. For perspective, we can consider the reports of other individuals going to similar altitudes. In another article on

the subject (5), it was mentioned that 7780% of persons going to Tibet or Qinghai experience some degree of mountain sickness at altitudes of 4,400 to 4,900 meters. As mentioned above, incidence of mountain sickness among climbers at other sites is reported to be about 6566% (3435% with no mountain sickness) at 4,200 to 4,500 meters. One would expect that among a more general population who are not experienced climbers, such as those sent to Tibet and Qinghai, the incidence of mountain sickness might be somewhat higher, as would also be expected for the slightly higher altitude range (about 300 meters). Thus, the figure of 7780% having some degree of mountain sickness (2023% having no mountain sickness) appears comparable to other figures given in the literature. If the ingestion of herbs can prevent mountain sickness in 4557% of individuals, as reported above, that would be a substantial improvement. In Pengs article, the same herb formulas given to the soldiers were tested in treatment of hypoxya (low oxygen) in laboratory animals. These experiments are relatively easy; animals are placed in a chamber (with or without administration of herbs, depending on the group) and the air is slowly withdrawn, mimicking the problem of going to higher altitude. The survival of the animals over time is then monitored. There are two kinds of hypoxia that can be introduced in the laboratory. One is that which mimics high altitude, in which case the oxygen level becomes low as the total air pressure is reduced (hypobaric condition), and the other is accomplished by using a reduced oxygen air at normal pressure (normobaric condition; same as at sea level). These different laboratory conditions can yield different kinds of results. Pengs work was with hypobaric conditions. In one test, control animals had a mean survival time, at the very low pressure condition used, of 6.76.8 minutes; by contrast, with use of the herbal formulas, the survival time increased to 16.526.1 minutes, with the lowest results from Codonopsis Combination and the best results from Astragalus and Hoelen Combination. In another experiment, using intermittent hypoxia, survival of test animals was greatest with Codonopsis and Hoelen Combination, with 100% surviving pressures corresponding to 11,000 meters elevation (Mt. Everests peak is about 9,400 meters), compared to 50% for controls. Clinical studies were also done with ganoderma preparations (5). Tableted extracts of ganoderma were given to troops starting the first day of their journey by truck into the mountains (on the way to being stationed in Tibet or Qinghai), and continued for six days (herbs taken twice per day, 3 tablets each time). Reactions to high altitude were rated as non-reacting (work unaffected, but there could be a light response that would persist for no more than two days), mild, medium, or serious. Accordingly, it was reported that 86% of the participants were non-reacting and 13% had a mild reaction, avoiding headaches and vomiting. Both extract of cultured mycelium and extract of mushroom produced the same results. Laboratory studies confirmed the benefits of the ganoderma preparations in animals exposed to reduced oxygen. In other reports, ginseng, tienchi ginseng (sanqi), gynostemma (jiaogulan; it has active ingredients in common with ginseng), and eleuthero ginseng (ciwujia) were found to be of potential benefit in protecting against mountain sickness, as demonstrated by the laboratory hypoxia testing. The general theory is that herbs having qi tonification properties, such as codonopsis, ginseng (and varieties thereof), astragalus, and ganoderma, aid the utilization of oxygen, thus preventing the adverse reactions to low oxygen. Hoelen is added to eliminate the edema that accompanies more severe altitude sickness. A recent study by Chen Jianzhong, et al., (12) involved administration of ginseng and hoelen, prepared as a concentrated decoction liquid. The liquid was administered in three doses, to total 100 ml per day (derived from 10 grams ginseng and 20 grams hoelen), during the day before departing from Chengdu to Tibet. A control group was not treated. The participants in the study had already spent time living in Tibet and were spending time both in Tibet and Chengdu (or other lowland areas). Both the treated and untreated groups experienced higher heart rates and blood pressure after arriving in Tibet. However, the treated group had a normal ECG axis, but there was significant deviation from normal in the control group. Also, the treated group had a much shorter time required for resting before going back to work in Tibet (about 7 days) compared to the control group (usu-

ally about 10 days, but this time it happened to be 15 days). Since these individuals had previous experience going to Tibet, they could act as their own controls to some extent. For example, in the treatment group, when they last went to Tibet, 12.9% were hospitalized due to mountain sickness, while on this trip, having taken the herbs, only one person (1.4%) was hospitalized. The control group on this trip had 10% hospitalized. In all, it was reported that 2/3 of the treatment group had a reduced level of mountain sickness compared to the previous trip. Ginseng was the focus of another study, conducted by Fang Zhong and his colleagues (13). Individuals going to Tibet from Chengdu were given 20 grams of ginseng powder (Jilin red ginseng) starting two days prior to the trip by airplane. These individuals had prior experience going between these two sites: in fact, on average, six trips before this one, and they experienced mountain sickness. This time, 30% of the group experienced no mountain sickness, or only a light reaction that lasted a brief time; 56% of the group had less mountain sickness than on previous trips. A matched control group was also monitored: those taking ginseng had a lesser increase in heart rate and lesser change in electrocardiogram than those not using ginseng. As with the previously mentioned study, rest time before getting back to work was also shorter with use of ginseng, with results almost the same as in that study. A ginseng-based formula, Sheng Mai Yin, was tried by Zhang Zaohua and Song Lanzhi (14). Residents of Lijiashan Village (at 2,500 meters) were given a liquid preparation of this formula at 10 ml. each time, three times daily for five days, providing the extract of 3 grams of ginseng, 6 grams of ophiopogon, and 3 grams of schizandra each day. These individuals then drove to Kunlun Mountain (4,475 meters). After arriving, they stopped taking the herbs and took some measurements on the next day. The researchers measured the level of atrial sodium-peptide, a blood component that has been shown to have a close relationship to blood oxygen transport. Usually, this compound is found in abnormal levels when the heart and lungs are in a pathological condition that reduces oxygen transport. Comparing individuals taking Sheng Mai Yin with a control group not taking the herbs, and also comparing laboratory animals (rats) transported to and from the same altitudes (with Sheng Mai Yin group and control group), it was shown that Sheng Mai Yin inhibited the decline in atrial sodium-peptide. The animal studies also revealed a likely basis for pulmonary edema and consequent death from this disorder: high altitude conditions reduced the phospholipid content of blood cells, which caused a loss of stability in the alveoli, which could cave in due to the lack of blood cell fullness. The effect of gynostemma was compared to Compound Codonopsis Tablet by Chen Yaozhang and colleagues (15). One group of participants took a train from Chengdu to Geermu City (in Qinghai Province) and then, on arrival, began to drive to Lhasa. Gynostemma extract, in granule form, was given starting in Chengdu (12 grams each time, three times daily), and Codonopsis Tablet was taken starting the same time, 4 tablets each time, three times daily, for a total of 12 days. Another group took the plane from Chengdu to Lhasa and then took a bus, the same day, to an Army station at 4,370 meters. They began taking the herbs five days prior to the flight. A control group took none of the herbs. According to the report, for those going by train and truck, 75% of those taking the gynostemma granule and 65% of those taking the Codonopsis Tablet had essentially no mountain sickness reaction (the difference being insignificant), but only 28% of the control group reported no reaction. For those going by plane, then gynostemma treatment appeared to perform better than the Codonopsis Tablet, with no major reactions in 80% of the gynostemma group, 57% of the Codonopsis Tablet group, and only 30% of the control group. PROLONGED EXPOSURE TO LOW PRESSURE AND LOW OXYGEN Persons who live at high altitude experience changes in their blood that help compensate for the low oxygen levels. There are more red blood cells retained in circulation and more hemoglobin to carry oxygen. Such changes take about a week or two at high altitude to develop (with 80% adaptation accomplished in about 10

days). Most mountain climbers do not spend this much time at high altitude and thus have to deal only with acute reactions to altitude. Rats exposed to low pressure (corresponding to 5,0006,000 meters altitude) for two weeks respond with increased RBC and hemoglobin counts (10). This response was virtually eliminated if the rats were given Jianghong Pian (literal: reduce the red tablet). The formula is comprised of astragalus, carthamus, eupolyphaga, cinnamon bark, and rhubarb. Presumably, the herbs reduced the bodys need for higher RBC and hemoglobin by reducing the oxygen utilization requirements of the body and enhancing the oxygen carrying capacity of the blood cells. Such treatment for humans would only seem suitable for moderate-duration visits to high altitude; for example, when remaining at an altitude for two to three weeks. During this interval, altitude-related problems may still arise during exertion due to incomplete adaptation. For longer duration visits, one would benefit from simply having the blood system undergo the usual adaptation to the higher altitude via blood system changes, which is likely to eventually occur even if herbal therapies are continued. However, with increased time at high altitude, one can develop a persistent qi deficiency syndrome, as revealed by Chinese studies. Guo Yonghui, at the Institute of Traditional Medicine of Qinghai Province, evaluated persons who were living at high altitude for a long time (11). He observed that qi deficiency was a common syndrome. This condition was diagnosed for 41% of those living between 2,000 and 3,000 meters, in 57% of those living between 3,000 and 4,000 meters, and 69% of those living between 4,000 and 5,000 meters. Persons who had moved to high altitude from a lower altitude were more likely to develop a qi deficiency syndrome (even after years at the high altitude) than those who were born there (52% versus 39%), implying some difficulty in fully adapting to the high altitude. For both the native born and immigrant populations, qi deficiency syndrome occurred more frequently with aging at the high altitude. However, qi deficiency also occurs more frequently with age at low altitude. The qi deficiency syndrome might be associated with different traditionally-defined organ systems in different individuals: it is mainly associated with either the spleen, lung, heart, or kidney systems, or some combination of two or more of these organ systems. Guo reported the unsurprising result that as altitude increased, lung qi deficiency was the more likely condition to be experienced. He pointed out that at low altitude, qi deficiency often is associated with aging and affects primarily the spleen and kidney, while high altitude causes an earlier, environmentally induced qi deficiency that more often affects the lungs. Although he did not suggest any herbal therapies for these conditions, clearly, regular ingestion of qi tonic herbs, and those that benefit the lungs in particular, would be a logical choice based on his observations. Blood stasis is also a problem at high altitude. According to a study by Jiang Zhengqian in Lhasa (16), there is a condition known as plateau sickness that occurs with persons living on the Tibetan plateau. Individuals with this condition have polycythemia, cardiac disease, hypotension, and other conditions that are related to living at high altitude for a prolonged period. In a survey of 370 outpatients at the TCM clinic in Lhasa, 89 suffered from this condition. Further, a total of 252 of the patients surveyed had signs and symptoms of blood stasis, observed in terms of sublingual vein enlargement and discoloration, blood-stasis type coloration of the tongue body, and blood-stasis type nail bed coloration and response to pressure (slow return of color after pressing). Of the 89 with plateau disease, 84 had blood stasis symptoms, but even among those with ordinary diseases (that are common at all altitudes), blood stasis was found in 60% of the individuals. Incidence of blood stasis increased with greater duration of living at the high altitude. It was found in 81% of those living in Tibet more than 20 years, but only in 36% of those living in Tibet under 10 years (age may have been a partial contributor to this phenomenon). Relaying an earlier study, Jiang points out that the specific viscosity of whole blood in long-term residents of Lhasa was 7.2 for males and 5.6 for females, which is slightly higher than that for newer immigrants, but much higher than that for people living close to sea level (4.9 for men, 4.6 for women). At

his clinical facility, virtually all patients receive treatments that include blood vitalizing herbs, and a treatment for plateau sickness involves removing blood stasis...clearing up the ying system and removing heat from the blood, warming yang and dispelling heat, invigorating qi and strengthening the spleen.... This method, he reports, produces relatively satisfactory short-term results. ADAPTOGENS IN LABORATORY TESTS The term adaptogens was coined in the 1940s to attempt to describe the concept that certain herbs (or isolated chemical compounds) could help laboratory animals in experiments resist severe stresses, that is, help them to adapt to a difficult condition. The hope was that such substances could also help humans adapt to stressful conditions. Testing of adaptogens often includes exposure of animals to low oxygen, low temperature, and continual highlevel physical activity (induced by threat of pain or death). These experiments reflected some of the situations sometimes facing humans. The underlying concept, using a modern medical viewpoint, was that the adaptogen aided the homeostasis mechanisms. From the traditional medical viewpoint, the adaptogen supported the rectifying qi, that is, the normal qi of the individual that not only maintains homeostasis under non-stress conditions, but also helps resist pathological qi that causes disruption. As an example of the continuing work in this field, Bao Lihua and his colleagues at the Harbin University of Medicine (6) tested a ginseng and royal jelly liquid mixture, using American ginseng (which is now cultivated in Heilongjiang Province in China, of which Harbin is the capital city). Mice were exposed to low pressure or to low temperature (11 C). Protective effects of the tonic liquid were noted to be dose-dependent and it was claimed that this mixture was protective whereas the similar product made with Chinese ginseng was not. It is known that American ginseng contains a considerably higher concentration of ginsenosides than Chinese ginseng, so if the studies were done with relatively low dosages, the Chinese ginseng may have failed to perform well in this study. In an earlier study, (7), ginsenosides from Chinese ginseng were shown to protect mice from low pressure hypoxia in a dose dependent manner at 100200 mg/kg (but were not effective at lower dosage). In another study, ginsenosides at 540 mg/kg protected mice subjected to hypoxia, reducing lactic acid levels and preventing changes in cyclic nucleotide levels in the cerebrum and myocardium (8). It would appear that royal jelly in the combination product did not make a significant contribution to protective effects. In the book Applications and Pharmacology of Chinese Medicinal Materials (9), a listing is provided of the herbs that had been investigated and shown to enhance tolerance to hypoxia. These are items that were evaluated in laboratory animals and reported in the Chinese medical literature prior to 1986. The listing includes the blood-vitalizing herbs salvia, sanqi, bulrush, and carthamus; the tonics ganoderma, rehmannia, epimedium, ophiopogon, and yu-chu (a type of polygonatum); the heat-clearing herbs ardisia, chyrsanthemum, sophora, antelope horn, and hemsleya; and miscellaneous herbs chuan-shan-lung (a species of dioscorea used for arthralgia), fo-shou (called finger citron, used for dispersing qi and dampness), and trichosanthes fruit (used for clearing phlegm). The blood-vitalizing herbs may be of special value since at high altitude there is increased likelihood of blood clots (thrombosis), especially deep vein thrombosis of the calves. This may be the combined result of lower amounts of water and higher amounts of red blood cells flowing through the vessels. BROADER APPLICATIONS In response to this work with mountain sickness and hypoxia, it has been proposed that such herbs would aid in athletic performance for those who undertake extreme levels of exercise (at normal altitude) that tax both the oxygen carrying capacity of the blood and the air intake level of the lungs (e.g., for distance racers). Sports

performance studies have been done which purportedly show better performance when ingesting these tonic herbs prior to racing. As further response, the Olympic Committee has banned the use of such substances (especially ginseng) prior to competitive events to remove the possibility of enhancement of natural performance. Further, since lack of oxygen destroys cardiac or brain tissues when a blood clot blocks the arteries, it might be presumed that ingestion of these tonic herbs would limit the damaging effects of heart attack or stroke. Finally, in cases of emphysema and other degenerative lung diseases, these herbs may prevent further collapse of the alveoli and improve the blood oxygen levels. By selecting tonic herbs with blood-vitalizing properties (e.g., ganoderma and tienchi ginseng) or mixing tonics (e.g., codonopsis, ginseng, astragalus, gynostemma) with blood-vitalizers (e.g., salvia, carthamus, or peony), one should be able to enhance blood circulation and oxygen utilization for preventing catastrophic events associated with aging, as well as avoiding temporary problems, such as mountain sickness. Similar treatment strategies have been developed independent of the mountain sickness work (and are reported effective in laboratory animal and clinical research), relying on traditional Chinese medical principles. SUGGESTED HERBAL PROTOCOL According to the studies conducted thus far, it appears reasonable to begin ingestion of herbal prophylaxis for mountain sickness at least 3 days prior to arriving at high altitude (about 2,100 meters) and to continue the use of the herbs for the entire duration of a high altitude visit. Although the clinical trials described above reported that pretreatment with herbs would protect against mountain sickness even when herb ingestion ceased upon arriving at high altitude, it seems prudent to reinforce the protective effects by continuing use of the herbs. The cessation of herb ingestion at arrival gave researchers the chance to make observations, including ECG, heart rate, and blood tests, with the herbs cleared from the system in order to illustrate true prophylactic action. In other situations, the herbs would be recommended to be used for several more days, as they were in some of the studies. In general, qi tonic herbs, such as codonopsis, ginseng (and varieties thereof), astragalus, and ganoderma are reasonable choices for mountain sickness prophylaxis, and one might add a blood-vitalizing herb, such as salvia. For altitudes in excess of about 2,900 meters, diuretic herbs, such as hoelen, should be included in the treatment until the risk of edema is no longer significant. The Chinese sources sometimes failed to provide details about dosage. However, in the cases where tablets were used, the dosage was 35 tablets each time, twice daily. These tablets were made of dried extracts of the herbs. In cases of using herbal powders and liquid extracts, dosages of individual herbs (e.g., ginseng) or herbal formulas (e.g., Sheng Mai Yin) were in the range of 1030 grams per day. Unlike treatment of chronic diseases, these preventive strategies generally involved single herbs or small formulas of just a few herbs. For persons who plan to stay at high altitude for prolonged periods, the problems of qi deficiency and blood stasis should be addressed. For the most part, the same herbs can be relied upon for this purpose as for preventing mountain sickness. REFERENCES 1. Hackett PH, Mountain Sickness: Prevention, Recognition, Treatment, 1980 American Alpine Club, New York. 2. Sun Jianchang, et al., Prophylactic effects of Compound Dangshen Tablet on high altitude reaction: effects on symptoms and hemodynamics, Sichuan Journal of Traditional Chinese Medicine 1989; 7(1): 1315. 3. Peng Hongfu, Study of Astragalus and Hoelen Combination for preventing acute mountain sickness, Medical Journal of Chinese Peoples Liberation Army 1982; 7(3): 135138. 4. Him-che Yeung, Handbook of Chinese Herbs and Formulas, vol. 1, 1985 Institute of Chinese Medicine,

Los Angeles, CA. 5. Anonymous, Spot survey on the prevention of acute mountain sickness with ganoderma, Chinese Traditional Herbs, 1979; 6: 2931. 6. Bao Lihua, et al., Effects of American Ginseng/Royal Jelly Syrup in mice against anoxia and low temperature, Journal of Harbin Medical University 1992; 26(1): 1415. 7. Lu Ge, et al., Comprehensive evaluation of the antihypoxia action of ginseng root saponins, Journal of Shenyang College of Pharmacy 1987; 4(2):131135. 8. Fang Yunxiang et al., Effects of ginsenosides on ultrastructure and levels of lactic acid and cyclic nucleotides in ischemic myocardium of mice, Chinese Journal of Integrated Traditional and Western Medicine 1987; 7(6): 354356. 9. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, vol. 2, 1986 World Scientific, Singapore. 10. Zhang Jingming, et al., Pharmacology and toxicity of Jianghong Tablet, Chinese Traditional and Herbal Drugs 1988;19 (10): 458461. 11. Guo Yonghui, et al., Investigation of the relationship between altitude hypoxic circumstance and deficiency of vital energy, in Sinomed 87 International Conference on Traditional Chinese Medicine and Pharmacology Proceedings, 1987 China Academic Publishers, Shanghai. 12. Chen Jianzhong, et al., Observation of 120 cases of preventing mountain sickness by using Ginseng and Hoelen Combination, Qinghai Medical Journal 1986 (3): 4143. 13. Fang Zhong, Jiang Weiyu, and Yang Zhenghua, Observation on prophylactic effect of ginseng against acute high altitude reactions in 90 cases, Zhejiang Journal of Traditional Chinese Medicine, 1996 (5): 231232. 14. Zhang Zaohua and Song Lanzhi, High altitude conditions and qi deficiency (III)A trial of Sheng Mai Yin applied to prevent high altitude reactions, 1990 (6): 4244. 15. Chen Yaozhang, et al., Observation of preventive effect of Gynostemma Granule on acute high altitude symptoms, Medical Journal National Defense of Southwest China, 1993; 3(5): 257259. 16. Jiang Zhengqian, Survey and analysis of 370 highlanders for signs and symptoms of blood stasis, Journal of Traditional Chinese Medicine 1996; 16(3): 190193. NOTE: The transport of Chinese people, mainly Chinese troops, to Tibet is part of a repressive action of the Chinese government against the Tibetan people that has included political, social, cultural, and religious interference, torture, and killings. Most of the reported clinical trials involving mountain sickness prevention and treatment were conducted in hopes of making it easier for Chinese troops to enter and stay in Tibet. This is an unfortunate source of research information. It is hoped that the results of this research can have some benefit to the worlds population and that eventually the Chinese will have no need for further testing along these lines because the frequent mountain sickness problem will be solved by staying at low altitude.