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Caisson Disease1 CAISSON DISEASE1 BY A. E. BOYCOTT COMPRESSED air has been used for a long time to keep out the water in making tunnels, sinking shafts and the like in watery ground. A rigid metal tube or caisson is driven into the earth and filled with air compressed to the pressure necessary to keep out the water. The mon excavate the earth, fix the lining of the tunnel or the foundations of the bridge, &c, as the case may be, from inside, working in the compressed air. They enter and leave the tube by a small chamber at one end provided with doors, which open on the one hand to outside air and on the other to the compressed air. This 'air-lock' is furnished with taps whereby the pressure within it is first brought to atmospheric pressure; the men then enter, close the door to air, open the cock which is in communication with the caisson, equalize the pressures in the caisson and the air-lock, and then open the other door and so enter the caisson. They leave by following the reverse process. 1 The important literature of caisson disease is contained in, or may bo readily found through, the following:— (1) Paul Bert, La Presslon Varomttriqiie, Paris, 1878. Full account of all the earlier literature with the classical researches of the author. (2) E. H. Snell, Compressed Air Illness, London, 1896. Besides a critical account of the theories of caisson disease, gives the author's experience as medical officer of the Blackwall Tunnel. (3) R. Heller, W. Mager, and H. von Schrotter, Luftdruckerkrankimgen, Vienna, 1900. A monumental work of more than 1,200 pages. The abstract of previous work is very full, and an elaborate account of the caisson work at Nussdorf on the Danube is given, together •with a number of animal experiments and a theoretical discussion. See also v. Schrotter, Der Sauerstoffin dcr Prophylaxic and TJierajrie der Luftdntckerkrankungen, Berlin, 1906. (4) The researches of Leonard Hill and his collaborators, J. J. R. Macleod, C. Hani, and M. Greenwood, are summarized up to 1903 in the Journal of Hygiene, Camb., iii. 1903, 401. Their more recent work will be found in the Proceedings of the Royal Society, Lond., B, lxxvii. 1906, 442 ; lxxix. 1907, 21 and 284; Journal of Physiology, xxxiii. 1905, Proceedings, G and 7; xxxv. 1906, Proceedings, 6; Transactions of the Junior Institution of Engineers, Lond., xviii. 1907, 56. (5) H. M. Vernon, ' The solubility of air in fats,1 Proceedings of the Royal Society, Lond., B, lxxix. 1907, 366. (6) The experiments to which personal reference is made here were carried out in 1906-7 with the aid of the large pressure chamber presented to the Lister Institute by Dr. Ludwig Mond, F.R.S., by A. E. Boycott, G. C. C. Damant, and J. S. Haldane. The animals used -were chiefly goats; experiments on deep diving were also made by Lieut. Damant, R.N., and Gunner Catto. Further details of the results already obtained will be found in the Journal of Hygiene, Camb., viii. 190S, Journal of Pathology and Bacteriology, Camb., xii. 1908, and in the Report of the Admiralty Committee on Deep Diving (C. N. 1549/1907). [Q. J. M., April, 1908.] Downloaded from https://academic.oup.com/qjmed/article-abstract/os1/3/348/1591624 by University of California-SB user on 04 April 2018 CAISSON DISEASE 349 The other great class of workers in compressed air aro divers. A diving bell is practically a caisson which is sunk bodily to tho bottom and hauled up again at the completion of the work so that the men may get out. A diving dress consists of a waterproof suit of indiarubber and canvas joined round the shoulders to a rigid metal helmet and neck-piece. Air is supplied by pumps and is delivered to the helmet by a long flexible pipe. The air fills the helmet and the upper part of the dress about tho chest, and escapes into tho water through an adjustable valve in the side of the helmet. The pressure on this valve is the hydrostatic pressure of the depth of water between the valve and the surface ; to keep up a supply of air, therefore, the air in the helmet has to bo compressed to a little more than this hydrostatic pressure. Tho diver descends and ascends by climbing along a ropo fixed to a sinker on the bottom; he is also attached to the surface by a rope which contains a telephone wire. The terminology of air pressures is not altogether free from confusion. One atmosphere equals 760 mm. of mercury or 14-7 lb. to tho square inch (commonly taken as 15 lb.), and is practically equal to one kilogram to the square centimetre, 33 feet (5^- fathoms) of sea water or 34 feet of fresh water. If pressures are specified without qualification, reference is usually intended to the readings shown on ordinary gauges—i.o. pressures in excess of atmospheric pressure. These may also be described as e.g. '+ 15 lb.' or '15 lb. positive' to distinguish them from readings in absolute pressure, i.e. the whole pressure starting with a vacuum as zero instead of atmospheric pressure. Thus + 45 lb. is 4 atmospheres absolute or 3 atmospheres positive or 100 feet of sea water. Diving work in general differs from caisson work in that in the former tho men experience short exposures to high pressures, and in the latter long exposures to lower pressures. Most caissons aro not worked above +301b. and often at less than 1$ atmospheres, though they have gone to + 45 lb., and more. The shifts are usually six or eight hours at the lower and two or three hours at the higher pressures. Divers frequently descend to 20 fathoms (120 feet = + 531b.), and not uncommonly to about 25, stopping less than half an hour at the greater depths. The deepest authenticated dives are those of Damant and Catto, who descended to the bottom in 210 feet (= +94 lb.). It is important not to class as caisson disease all the ills from which workers in compressed air suffer. Caisson men may bo poisoned by carbon monoxide or sulphuretted hydrogen, and divers by carbonic acid; both groups are obviously somewhat liable to death by violence. The illnesses occurring in men working in compressed air which aro directly due to that occupation do not for the most part arise while they aro under pressure but during, and especially shortly after, decompression. It is only a failure to appreciate tho elementary principles of physics which has given rise to the idea that any material alterations in the circulation, respiration, &c, are produced mechanically by exposure of the whole body to increased air pressure. Tho pressure is transmitted instantaneously throughout the fluid mass of the tissues and equally in all directions. It is indeed not always possible, without making certain Downloaded from https://academic.oup.com/qjmed/article-abstract/os1/3/348/1591624 by University of California-SB user on 04 April 2018 •350 QUARTERLY JOURNAL OF MEDICINE tests, to tell from one's common sensations whether one is in air at + 45 lb. or at atmospheric pressure. The only parts of the body which are directly affected by the pressure are cavities containing gas which are not in communication with the exterior. Any gas in the stomaoh or intestines will thus be compressed while under pressuro and the surrounding parts forced in. Of more moment •is the air in the middle ear. As the pressure rises this air is compressed and the membrana tympani forced inwards. The ear is exceedingly sensitive to the change, and a few strokes of the pump in the experimental pressure chamber are detected in this way long before the ordinary spring gauges move from zero. Unless the Eustachian tube is soon opened, very acute pain is produced, and the membrane may be torn or haemorrhage take place in the middle ear. It is thus difficult or impossible to go into compressed air unless the Eustachian tubes can be opened easily, either by swallowing, forcible expiration with closed mouth and nose, or—perhaps best of all—by yawning. Those unaccustomed to compressed air or with any catarrh may experience a good deal of inconvenience from this source; with practice, however, men can generally be compressed as quickly &s 20 or 30 lb. a minute. If any difficulty occurs, it is of course greatest during the earlier stages of compression, when the absolute volume of air in the middle ear is changing most quickly. The opening of the Eustachian tube is valvular outwards ; decompression causes no trouble, and the expanding air readily escapes into the pharynx. The increased density of the air at high pressure may be made obvious by the impossibility of whistling owing to the fine vibrations of the lips being damped. Obstruction is felt on breathing through a tube (as in taking samples of expired air for analysis) owing to the greater viscosity of the air, and in this way the ventilation of the lungs must be to some extent impeded; there is, however, no evidence that this produces any physiological effect. The increase of oxygen pressure in the air does not increase the respiratory exchange. It has been clearly shown by several observers that an increase of oxygen in the air breathed up to 90 % at atmospheric pressure (=air at +50 lb.) produces no alteration in the quantities of CO2 given off or of oxygen absorbed. Hill and Macleod did not find that compressed air ^e>* se made any material difference in the CO2 output of rats and mice.
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