Table Of ContentSAUNDERS
An Imprint of Elsevier Science
The Curtis Center
Independence Square West
Philadelphia, PA 19106
BOVE AND DAVIS’ DIVING MEDICINE
ISBN 0-7216-9424-1
Copyright 2004, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by
any means, electronic or mechanical, photocopying, recording, or otherwise, without prior permission of the
publisher (Saunders, The Curtis Center, Independence Square West, Philadelphia, PA 19106-3399).
First Edition 1976. Second Edition 1990. Third Edition 1997.
Library of Congress Cataloging-in-Publication Data
Bove and Davis’ diving medicine / [edited by] Alfred A. Bove—4th ed.
p. ; cm.
ISBN 0-7216-9424-1 (alk paper)
1. Submarine medicine.
2. Diving.
I. Title: Diving medicine.
II. Bove, Alfred A.
III. Davis, Jefferson C. (Jefferson Carroll), 1932-1989
[DNLM: 1. Diving. 2. Naval Medicine. QT 260.5.D6 B783 2004]
RC1005.K583 2004
616.9′8022—dc21
2003041520
Acquisitions Editor: Todd Hummel
Senior Project Manager: Natalie Ware
Designer: Steven Stave
Printed in the United States of America
Last digit is the print number:
9
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2
1
NOTICE
Diving medicine is an ever-changing field. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current product information
provided by the manufacturer of each drug to be administered to verify the recommended dose, the method
and duration of administration, and contraindications. It is the responsibility of the treating physician,
relying on experience and knowledge of the patient, to determine dosages and the best treatment for each
individual patient. Neither the Publisher nor the author assume any liability for any injury and/or damage
to persons or property arising from this publication.
The Publisher
To my Wife Sandy, who endured watching long
enough and then became my partner in both diving
and diving education.
Memorial
HUGH GREER, M.D.
Hugh D. Greer was a former contributor to Diving Medicine and a recognized authority in the
neurologic aspects of diving. He died suddenly while swimming on October 2, 2001. Dr. Greer
was born in Madison, Wisconsin in 1932 and joined the Navy Reserve as a midshipman in 1949.
After completing college at Dartmouth, he was commissioned as a Lieutenant Junior Grade
in the Navy and was a member of Underwater Demolition Team 22 until his discharge in 1956.
He attended Medical School at the University of Kansas and received his medical degree in
1960. He interned at the Mary Hitchcock Hospital from 1960 to 1961 and continued his training
in neurology at the Mayo Clinic. Dr. Greer pub-
lished several papers in clinical neurology and
was board certified in neurology and psychia-
try. He joined the Santa Barbara Clinic as a clin-
ical neurologist in 1964, where he remained
until his death. Over his many years at the
Clinic, he developed expertise in the neurologic
aspects of diving and became recognized as an
international expert. Dr. Greer was formally
trained in diving medicine through the National
Oceanic and Atmospheric Administration
program in 1978. He served as an adjunct sci-
entist to the USC Institute of Marine and Coastal
Studies and was a diving medicine consultant
to the Catalina Hyperbaric Chamber, Santa
Barbara City College, and a number of commer-
cial diving companies. He was a fellow of the
Explorers Club of New York. Along with Dr. Paul
Linaweaver, he directed the southwestern divi-
sion of the Divers Alert Network. Throughout
his career, he continually published in the liter-
ature of diving medicine and contributed the
chapter on the neurologic aspects of diving in
the second and third editions of this text.
Dr. Greer contributed to the governance of
the Santa Barbara Clinic by serving at various
times as the President of the Board of Trustees
and as President of the Board of Directors.
Dr. Greer was a fellow of the American
Academy of Neurology, a fellow of the
American Academy of Electromyography
and Electrodiagnosis, and a member of the
Undersea and Hyperbaric Medical Society.
He is survived by his wife, son, two daugh-
ters, and six grandchildren.
Paul G. Linaweaver, M.D.
SUK-KI HONG, M.D., Ph.D.
Suk-Ki Hong, author of the chapter on breath-hold diving in the second and third editions of
Diving Medicine, died on October 4, 1999. Dr. Hong’s studies in diving physiology encompassed
both human breath-hold diving and saturation diving and were performed in collaboration with
colleagues in Korea, Japan, Europe, and the United States. His publications concerning breath-
hold diving covered 35 years and constitute the most thorough record in the literature on all
aspects of breath-hold diving. Throughout his career, Dr. Hong received numerous awards for his
work in diving medicine. His scientific legacy is not only the impressive volume and quality of
his research publications but also the many
students and fellows who now follow in his
path and have gone on to productive scientific
careers in many parts of the world.
Dr. Hong’s generosity with his ideas, his
comprehensive knowledge, and his unselfish
good nature earned him the enduring respect
and genuine affection of all who had the good
fortune to know him. Even though he was a
famously hard worker, setting high standards
for himself and his associates, he was always
constructive and truly interested in bringing
out the best in people. His desire to excel was
always tempered by his humanity, sense of
fairness, and lively sense of humor. His family,
friends, and colleagues sorely miss him.
Charles V. Paganelli
Arthur J. Bachrach, B.S., M.A., Ph.D.
Taos, New Mexico
Former Director, Environmental
Stress Department
Naval Medical Research Institute
Bethesda, Maryland
Human Performance Underwater
Peter B. Bennett, Ph.D., D.Sc.
Professor of Anesthesiology
Duke University Medical Center
Durham, North Carolina
Inert Gas Narcosis and High-Pressure Nervous
Syndrome
Alfred A. Bove, M.D., Ph.D.
Emeritus Professor of Medicine
Temple University School of Medicine
Philadelphia, Pennsylvania
Marine Poisoning and Intoxication
Diving in the Elderly and the Young
Cardiovascular Disorders and Diving
Medical Evaluation for Sport Diving
Frank K. Butler, Jr., M.D.
Associate Professor of Military and
Emergency Medicine
Uniformed Services University of the Health
Sciences
Bethesda, Maryland
Attending Ophthalmologist
Naval Hospital
Pensacola, Florida
U.S. Navy Diving Equipment and Techniques
James M. Clark, M.D., Ph.D.
Clinical Associate Professor of
Environmental Medicine in Pharmacology
Institute for Environmental Medicine
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania
Toxicity of Oxygen, Carbon Dioxide, and
Carbon Monoxide
Carl Edmonds, M.B., B.S., D.P.M.,
M.R.C.Psych, F.R.A.N.Z.C.P.,
M.R.C.P.(Lond), Dip. D.H.M., F.R.A.C.P.,
F.A.F.O.M.
Director, Diving Medical Centre
Ocean Royale
Manly, N.S.W., Australia
Marine Animal Injuries
Glen H. Egstrom, Ph.D.
Emeritus Professor, Department of
Physiological Sciences
University of California at Los Angeles
Westwood, California
Diving Equipment
Human Performance Underwater
David H. Elliott, D.Phil.(Oxon), F.R.C.P.,
F.F.O.M.
Robens Institute of Health and Safety
University of Surrey
Guildford, Surrey
England
Aseptic Necrosis of Bone
Medical Evaluation of Working Divers
Joseph C. Farmer, Jr., M.D.
Professor and Chief, Division of
Otolaryngology/Head and Neck Surgery
Duke University Medical Center
Durham, North Carolina
Ear and Sinus Problems in Diving
Massimo Ferrigno, M.D., F.C.C.M.
Assistant Professor of Anesthesia
Harvard Medical School
Staff Anesthesiologist
Brigham and Women’s Hospital
Boston, Massachusetts
Breath-Hold Diving
Edward T. Flynn, Jr., M.D.
Naval Sea Systems Command
Washington Naval Yard
Washington, District of Columbia
Medical Supervision of Diving Operations
Contributors
T. James Francis, Ph.D., M.F.O.M.,
Dip D.H.M.
Consultant
Diving Diseases Research Center
Plymouth, Devon
England
Pathophysiology of Decompression Sickness
Frank St. C. Golden, M.B., Ph.D.
Consultant in Environmental Medicine and
Honorary Lecturer
University of Portsmouth
Portsmouth, Hampshire
England
Hypothermia
Hugh D. Greer, M.D.
Deceased
Santa Barbara, California
Neurologic Consequences of Diving
R.W. Bill Hamilton, Ph.D.
President
Hamilton Research, Ltd.
Tarrytown, New York
Mixed-Gas Diving
Shannon E. Hunter, M.D.
Chief Resident, Otolaryngology/Head and
Neck Surgery
Duke University Medical Center
Durham, North Carolina
Ear and Sinus Problems in Diving
Eric P. Kindwall, M.D.
Associate Professor Emeritus, Department
of Plastic and Reconstructive Surgery
Medical College of Wisconsin
Milwaukee, Wisconsin
Former Director of Hyperbaric Medicine
Froedtert Memorial Lutheran Hospital
Brookfield, Wisconsin
A Short History of Diving and Diving Medicine
Peter R. Lynch, B.S., M.S., Ph.D.
Emeritus Professor of Physiology
Temple University School of Medicine
Philadelphia, Pennsylvania
Marine Poisoning and Intoxication
Allan D. Marks, M.D.
Emeritus Professor of Medicine,
Endocrinology Section
Temple University School of Medicine
Philadelphia, Pennsylvania
Diabetes and Diving
E.Wayne Massey, M.D.
Clinical Professor, Neurology Division,
Department of Medicine
Duke University Medical Center
Durham, North Carolina
Neurologic Consequences of Diving
Igor B. Mekjavic, B.Sc(Hos), M.Sc., Ph.D.
Institute of Biomedical and Biomolecular
Sciences
University of Portsmouth
Portsmouth, Hampshire
England
Senior Scientific Consultant
Department of Automation, Biocybernetics,
and Robotics
Institut Jozef Stefan
Ljubljana
Slovenia
Hypothermia
Simon J. Mitchell, M.B., Ch.B., Dip D.H.M.,
Dip Occ. Med., Ph.D.
Diving and Hyperbaric Physician
Department of Diving and Hyperbaric
Medicine
Prince of Wales Hospital
Randwick, N.S.W.
Australia
Pathophysiology of Decompression Sickness
Richard E. Moon, M.D., C.M.
Professor of Anesthesiology and Associate
Professor of Medicine
Duke University
Medical Director
Center for Hyperbaric Medicine and
Environmental Physiology
Duke University Medical Center
Durham, North Carolina
Treatment of Decompression Illness
Tom S. Neuman, M.D.
Professor of Medicine and Surgery
University of California at San Diego
Associate Director, EMS
Director, Hyperbaric Medicine Center
UCSD Medical Center
San Diego, California
Pulmonary Barotrauma
Near Drowning
Pulmonary Disorders
Duke H. Scott, M.D.
Medical Advisor
YMCA Scuba Program
Chicago, Illinois
Diabetes and Diving
x
Contributors
David J. Smith, M.D., M.S.
Formerly Commanding Officer
U.S. Naval Hospital, Rota, Spain
Chief of Staff
Tricare Management Activity
Falls Church, Virginia
U.S. Navy Diving Techniques and Equipment
Larry “Harris” Taylor, Ph.D.
Senior Research Associate
Diving Safety Coordinator
University of Michigan
Ann Arbor, Michigan
Diving Physics
Maida Beth Taylor, M.D., M.P.H.
Associate Clinical Professor, Department of
Obstetrics, Gynecology, and
Reproductive Medicine
University of California
San Francisco, California
Senior Clinical Research Physician
Women’s Health and Reproductive Medicine
Eli Lilly & Company
Indianapolis, Indiana
Women in Diving
Stephen R.Thom, M.D., Ph.D.
Associate Professor of Emergency Medicine
Institute for Environmental Medicine
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania
Toxicity of Oxygen, Carbon Dioxide, and
Carbon Monoxide
Michael J.Tipton, M.Sc., Ph.D.
Professor of Human and Applied Physiology
University of Portsmouth
Portsmouth, Hampshire
Head of Environmental Medicine Division
Institute of Naval Medicine
Alverstoke, Hampshire
England
Hypothermia
Richard D.Vann, Ph.D.
Assistant Research Professor
Department of Anesthesiology
Duke University Medical Center
Vice President, Research
Divers Alert Network
Durham, North Carolina
Inert Gas Exchange and Bubbles
Mechanisms and Risks of Decompression
Dennis N.Walder, M.D., F.R.C.S.
Emeritus Professor of Surgical Science
University of Newcastle upon Tyne
Consulting Surgeon
Royal Victoria Infirmary
Newcastle upon Tyne
England
Aseptic Necrosis of Bone
Contributors
xi
Advances in diving medicine have intermit-
tently followed and led the past 100 years of
astounding engineering developments in
practical operational diving. Two milestones
in treating the triad of decompression sick-
ness, nitrogen narcosis, and oxygen poisoning
were Haldane’s increase in helmet ventilation
to avoid the effect of CO2 compounding nitro-
gen narcosis and the permanently sensible
concept of multiple exponential uptake and
elimination of inert gas in albeit indefinable
body microtissues during compression and
decompression.
In the 1920s and 1930s, dedicated diving
medical giants related to the U.S. and British
Navies laboriously established improved
tables for limited air diving, derived in part
from Haldane’s concepts of staged decom-
pression to “avoid formation of gas bubbles.”
These groups then responded to the sugges-
tions of Hildebrand in 1924 and to civilian
open-water diving trials concerning the use
of helium to avoid the narcosis induced by
nitrogen in deep air diving. These groups
developed equipment and procedures to
facilitate decompression by using helium
with high levels of inspired oxygen in both
working and decompression phases (the
tables were baptized in the severe challenges
of the salvage of the U.S.S. Squalus). In labo-
ratory experiments on human divers, these
groups explored the degrees of hyperoxic
exposure that would avoid the drastic diving
hazard of oxygen convulsions.
These early advances in suited hardhat
diving and in the prevention and therapy of
decompression sickness were refined in
Navy laboratories by trial and error in large
numbers of practical tests. These allowed
empirical adjustment around a theoretical
base. The rules were established and the
equipment designed to encase the diver,
provide security and stability at the work
site, and provide for safe passive extraction
back to the surface when necessary. Before
1940, diving that required backup and devel-
opments by diving medicine was essentially
limited to naval services.
The extensive damage resulting from World
War II turned Navy salvage diving methods
development back to shallow air diving for
clearing harbors alongside Army Engineer
diving. However, before and during that war,
a new form of diving evolved in Italy, the
United States, and the United Kingdom: pure
oxygen diving with rebreathing and carbon
dioxide absorption in closed-system “pendu-
lum” and “circuit rebreathing” designs. The
resulting Self-Contained Underwater Breath-
ing Apparatus—-scuba—-provided complete
independence from the surface. The require-
ment now was to closely match detailed
engineering design with the human physio-
logic demands of covert, long-duration sub-
mergence astride an underwater “chariot”
or, for neutral-buoyancy underwater swim-
ming, with “fins” over long distances at
variable depths. The specific stresses were
temperature, the toxicity of oxygen, and
carbon dioxide accumulation, none of which
was solvable by medical guidance alone.
These military operational advances were
generally not well known because of their
initial highly secret status, but the neutral-
buoyancy shallow diving method using pure
oxygen opened wide new areas of basic phys-
iologic research interest important to oxygen
therapy, respiratory and circulatory regula-
tion, blood gas transport, the concept of
damage by free radicals, improved therapy of
all decompression sickness, and expanded
recognition of the usefulness of oxygen in
diving gas mixtures to limit inert gas uptake
and accelerate its elimination.
After World War II, wide civilian use of a
demand valve for self-contained, open-
system air breathing underwater swung the
cycle of diving medical interest back to
the classic naval guidelines for air diving.
The relative safety of the open-system
method for shallow air diving allowed many
millions of individuals to begin diving for
Foreword
sport. The result was a parallel expansion of
interest by civilian physicians in diving and
diving medicine while military interest
was low.
This book on diving medicine has pro-
vided a window on the continually expanding
scope of operational and scientific accom-
plishment related to all forms of diving, from
their beginnings to the extreme range of
present activity. The book is generally con-
cerned with the effects of self-imposed expo-
sures to stresses by otherwise healthy
persons rather than with spontaneous
disease occurring in working divers. Stresses
may be small or severe. Today, most sport
diving involves the relaxed, harmless, and
pleasurable activity of air breathing and
seeing during submerged swimming in con-
ditions of neutral buoyancy in clean, warm,
shallow water. This hardly requires the atten-
tion of diving medicine. In the usual properly
controlled circumstances of current open-
circuit diving, stress and its effects are incon-
sequential; problems relate to the potential
for accident rather than to intolerance of
stress.
However, diving is not just breathing
underwater, and all divers are not normal.
With increased degree and durations of
exposure to hydrostatic pressure, respira-
tion of inert and chemically active gases, and
severe thermal environments, the varied
forms of physiologic stresses inherent to all
types of diving may be intrinsically harmless
but can lead to personal hazard or death in
the unnatural underwater situation. The
commercial working diver or the military
combat diver continues to encounter the
most severe combination of stresses and
physiologic trauma of any form of human
activity. At the extremes of practical forms of
working diving, the individual is exposed to
resistance to breathing, toxic effects of
increased oxygen pressures, mental dulling
by nitrogen, neurologic derangement due to
the effects of physical ambient pressure,
incapacitating loss or excess of body heat,
and damage due to failure to avoid free gas
phase development in body tissues. Because
each of these stresses is a consequence of
exposure to the pressure or temperature of
water, or both, disease is always possible.
The composite result of multiple added
stresses is unpredictable and conducive to
accident or failure.
From my vantage point as an equipment
designer, operational diver, investigator, and
diving physician, I am impressed by the col-
lective breadth of scientific competence rep-
resented by the many contributors to this
text. Such detailed expertise was hard to
come by. How did it develop?
The evolution of clinical or technical close
communion has played a special large role in
accelerating research and development in
diving and diving medicine. The present
state of instantaneous voice or graphic com-
munication should be contrasted with the
previous limitations of worldwide direct per-
sonal communication by mail and ship prior
to World War II.
The expansion of interest and activity fol-
lowing World War II was directly aided by the
U.S. Office of Naval Research’s interest in
sustaining international medical research in
aviation and diving and other forms of phys-
iologic environmental stress. This effort
stimulated development of a National
Science Foundation and the National
Institutes of Health, with each new agency
actively supporting undersea biomedicine
for several decades. All of this individual and
agency
initiative,
communication,
and
national support gave rise to spontaneous
and wide activity in university laboratories,
including development of new laboratory
systems for pressure and thermal environ-
mental research. The composite of univer-
sity, industry, and naval interest investment
and work was worldwide.
Two large steps were responsible for the
special worldwide influence on the course of
international communication and the advance
of undersea activity and medicine. One was
the 30-year triennial series of International
Underwater Physiology Symposia. The other
was establishment of an Undersea Medical
Society, which in turn spawned a European
Underwater Biomedical Society and satellites.
All participants enjoyed the new practicality
of international travel and continuous direct
scientific communication. Interest in diving
medical research expanded concurrently with
the initiation and gigantic growth of an
offshore petroleum industry, diving for rec-
reation, and military clandestine diving -
equipment. Inevitably, hyperoxygenation
therapy research and application became
important for clinical disorders beyond the
scope of diving decompression incidents.
With all of the varied forms and purposes
of human underwater activity and the
expanding ranges of interacting stresses,
modern diving medicine must continue to
xiv
Foreword
