LIBRARY SUBMARINE MEDICAL CENTER

FILE COP» NO. 1

I !

L !

I- i

! j

u.s RINE

Conn

!i ; i

REPORT NO. 438

CASUALTIES IN INDIVIDUAL SUBMARINE ESCAPE

i i

by

Howard Moses LT MC USNR

Bureau of Medicine and Surgery, Navy Department Research Project MR005.14-3002-4.17

Approved and Released by:

C, L. Waite, CAPT MC USN COMMANDING OFFICER U.S. Naval Submarine Medical Center 24 October 1964

t p P Pf)\f r n rn P nun« i n

ffSpK ■' -VyA

- ^=7-» jpg»

SUBMAKJNE MEDICAL CENTER

ilLECOPYNO.- ■ t

i i

CASUALTIES IN INDIVIDUAL SUBMARINE ESCAPE TRAINING

OUTLINE

I. Historical Review of Individual Submarine Escape

A. S.E.A. B. Free Ascent C. Buoyant Ascent D. Limitations of scope of this paper

II Summary of Casualties

A. Introduction

1. Source of data 2. Location of training casualties

B. Clinical factors in the etiology of submarine escape training casualties

1. Review of training procedures 2. Etiological factors in S.E.A. casualties 3. Etiological factors in free ascent casualties 4. Etiological factors in buoyant ascent casualties

a. Techniques at New London and Pearl Harbor

5. Entrapped air spaces 6. Etiological factors in recompression chamber fatalities

G. Clinical characteristics of submarine escape training casualties

1. Air embolism

a. Review of etiological factors b. Ascents

'!) Past 2} Day of ascents - depth and number „3) Depth of accident

(a) Survivors (b) Fatalities, including methods of ascent

c. Onset of signs and symptoms - depths and/or time

(1) Survivors (2) Fatalities

-1-

d. Symptoms and signs

{1) Listing, with number of cases (a) Survivors and fatalities (b) Fatalities

e. Interval between onset of symptoms and signs and beginning of treatment

(1) Survivors (2) Fatalities

f. Treatments

(1) Review of history (2) Survivors

(a) Recurrences - (see extra-alveolar air)

(3) Fatalities

g. Post-treatment examination

(1) X-rays of survivors (2) Autopsies of fatalities

2. Extra-alveolar air

a. Listing

(1) Isolated Cases (2) Cases occurring with air embolism

b. Ascents

(1) Past (2) Day of accident - number and depth

(a) Just prior to appearance of extra-alveolar air

(b) Type of ascent 1. Those occurring with air embolism 2. Isolated extra-alveolar air

c. Onset of signs and sumptoms - depth and/or time

(1) Those in air embolism cases (2) Isolated extra-alveolar air

d. Signs and symptoms

(1) Listing with number of cases (2) Discussion

e. Time interval between onset of symptoms and signs and beginning of treatment

f. Treatment

(1) Those occurring with air embolism (a) Recurrences

(2) Isolated extra-alveolar air

g. Post-treatment examination

(1) X-ray

3. Miscellaneous

a. Listing b. Decompression illness

(1) Etiological factors (2) Onset of symptoms and signs (3) Symptoms and signs (4) Treatment

c. Vestibular injury d. Pulmonary squeeze e. Hysterical syncope

(1) Confusion with air embolism

D. Clinical characteristics of recompression chamber casualties

1. Introduction and etiological factors 2. Air embolism

a. Preceding exposures to pressure b. Onset of signs and symptoms - depth and/or time c. Signs and symptoms - with number of cases

(1) Differential diagnosis

d. Interval between onset of signs and symptoms and treatment

-3-

e. Treatment

(1) Recurrences

f. Post-treatment examination (X-rays)

3. Extra-alveolar air

a. Onset

(1) Those occurring with air embolism (2) Isolated extra-alveolar air

b. Signs and symptoms - listing with number of cases c. Treatment

(1) Interval until begun and actual treatment

(a) In air embolism cases i,b) Isolated extra-alveolar air

d. Post-treatment examination (X-rays)

4, Miscellaneous

a. Decompression illness b. Hysteria c. Etc . ? d. Allergy ?

E. Statistical analysis of escape training casualties

1. Introduction 2. Incidence of casualties at all three tanks

a. Aeroembolism

(1) Casualties/total number of ascents (2) Fatalities/total ascents (3) Fatalities/total casualties

b. Extra alveolar air

(1) Casualties/total ascents

3. Incidence of water training casualties by year and method of ascent

-4-

a. Comparison with New London tank workload (as representative)

4, Chamber casualties

5. Escape training experience at the New London tank

a. Introduction b. Combined incidence of air embolism and extra-alveolar

air casualties for different methods of escape

F. Summary

G. Appendix - Breakdown of all recorded cases

•5-

I. Brief History of Individual Submarine Escape Methods.

A. S.E.A.

As a result of the large loss of life resulting from the sinking of its submarines in the second and third decades of this century, the U.S. Navy began investigating safe methods of individual escape from bottomed submarines. The project was initially directed by LT C. B. MOMSEN, who had designed his "lung" (or submarine escape apparatus). This was essentially a closed-circuit SCUBA, with a reservoir bag, a CO2 absorbent-containing cannister, and a flutter valve to vent the expanding gas in the bag on ascent. The device was strapped to the chest, inflated with air or Op, and could carry the survivor to the surface, subsequently being utilized as a life jacket. Experiments with, and limited use of this device began in the late 1920's, mainly at the mine tank at the Naval Gun Factory, and in the open sea from diving bells. The Escape Training Tanks at New London and Pearl Har- bor were built to provide training for the fleet, the former commis- sioned in 1930, the latter in 1932. Initially, the New London tank was operated by the crew of the salvaged submarine hull S-4, which was also used for experiments on submarine escape techniques. They trav- elled to other facilities as well, training crews in submarine escape techniques. In the early days of the tanks, the operating personnel observed trainees through portholes in the sides, not entering the WE~2r except to operate a roving diving bell. Later, probably in the late 1930's, the instructors mastered skin-diving techniques enough to maintain close underwater supervision.

B. Free Ascent

In 1946, at the New London Tank (in 1951 at Pearl Harbor), in- structors and select trainees began regularly using the technique of free ascent (or free escape), although it was used unofficially for many years previously. The method is based upon the principle that an individual, buoyant with total lung volume at the surface, will be buoyant at any depth with his lungs fully inflated. The object then is to maintain enough air in the lungs at a given depth to afford pos- itive buoyancy, and yet not allow the pressure of the expanding intra- alveolar air to exceed 60-100mm Hg (3-4 ft. of water). Should the latter occur, the air will enter extra-alveolar tissues and blood ves- sels, with potentially grave results.

C. Buoyant Ascent

In 1946, the British Admiralty begar. investigating the known cases of escape from actually sunken submarines of all nations. It was found that, in those cases studies, most of the successful escapes

-6-

were made not with the use of a S.E.A. (Momsen Lung, British Davis S.E.A., German Draeger apparatus - all esentially similar), but rather by free ascent or buoyant-assisted free ascent (buoyant ascent). This was a result of malfunctioning S.E.A.'s and/or poorly-trained crews. The buoyant ascents were made using inflated S.E.A.'s, life jackets, pillowcases, etc. After preliminary investigations the British built their submarine escape training tank (at Gosport) to train their crews in buoyant ascent techniques. The U.S. Navy also investigated this technique, and it was adopted as its official method of individual sub- marine escape, to be taught to the entire fleet, in late 1956. Essen- tially, the method uses an inflated life jacket, as an assurance of positive buoyancy to carry the escapee to the surface.

D. Limitations of scope of this report

This report is intended only as a presentation of the three methods of individual submarine escape (S.E.A., free ascent and buoyant ascent) by an analysis of the reports of casualties and available statistics. It does not, however, exhaustively cover air embolism theory, collectiye and individual submarine escape theories and techniques, or techniques of flooding compartments preparatory to escape. It is rather a clinical evaluation of submarine escape training experience.

II. Summary of Casualties

A. Introduction

Available as clinical reports, or recorded on NAVMED 816's (U.S. Navy Diving Accident Reports) are 62 cases of casualties resulting from water work involved in submarine escape training, from 1928 to 1957. Of these, 39 were in the New London tank, 11 in the Pearl Harbor tank, 3 in the Mine tank at the Naval Gun Factory, 1 at NMRI, and 8 in the open sea. Seventeen (17) recompression chamber casualties were as- sociated with submarine escape training, 11 at New London, 4 at Pearl Harbor, 1 on a tender (U.S.S. ORION), and 1 reported by the British tank at Gosport.

Numbered reference is made throughout this report to the break- down of cases presented in the appendix.

B. Clinical factors in the etiology of submarine escape training casualties.

1. Review of training procedures

Training in individual escape from submarines has usually consisted of a pressure test to 50 p.s.i.g. (112 ft. - the maximum depth

-7-

of the escape training tanks) in a recompression chamber, and at least three escapes from various depths in the tanks. The latter varied some- what since the inception of training, depending on the method(s) of es- cape in use and the workloads of the tanks. It has usually consisted of escapes from 18, 50 and possibly 100 ft. At times individuals with especial interest were allowed more than the minimal apparatus training, with additional instruction in free ascent. At the present time, in- struction for the average U.S. Navy trainee consists of a 50 p.s.i.g. pressure test in the recompression chamber, preliminary "ladder training" to about 10 ft., one 18 ft. and two 50 ft. buoyant ascents in the water. Only instructors and SCUBA operators are taught free ascent and escapes from deeper than 50 ft.

2. Etiological factors in S.E.A. casualties

In theory, submarine escape using the S.E.A. should have no higher casualty rate than the average closed-circuit SCUBA rig. The device is a "circular" type of re-breathing apparatus, requiring only that the individual respire through the mouthpiece of a previously- charged bag. In some cases, the casualties were due to losing the mouthpiece, or failure to use the device properly. The most common cause for this was a phenomenon noted by many submarine medical offi- cers: The trainee would complain of inability to respire into the de- vice, commonly because of too much back-pressure in the bag, rarely due to a so-called "lack of air". This would usually occur at about 50' to 30' on the ascent, and would be accompanied by dizziness, or a feeling of suffocation, with resultant panic. The trainee would then let go of the ascending line and swim quickly to the surface, holding his breath or releasing it too slowly. The important feature here is that, essen- tially the individual was making a buoyant or fast free ascent on the upper portion of his ascent. S.E.A. ascents, correctly made, with ade- quate re-breathing into the bag, at a slow rate of ascent, do not seem to have resulted in any casualties (with the possible exception of some poorly-documented cases: Nos. 4, 5, 6, 7, and 8). All of the S.E.A. casualties seem to have occurred in the aforementioned manner.

3. Etiological factors in free ascent casualties

With the advent of free ascent training came the additional difficulty of attempting to maintain intra-alveolar pressure below a critical value by exhaling air, but, at the same time providing ade- quate buoyancy for ascent. Subjectively, tne individual's only gauge for this fine balance was keeping "behind" or abreast of his bubbles. If he exhaled too much, he would have to swim a short distance to re- gain buoyancy. Those who rose faster than their bubbles (an empirical standard) or swam too high to regain buoyancy could possibly exceed the

-8-

critical intra-alveolar pressure. There are, however, apparently cor- rectly performed ascents, to be discussed later, which do result in casualties.

4. Etiological factors in buoyant ascent casualties

There is a small percentage of individuals who naturally lack buoyancy with fully-expanded lungs (negative buoyant). Also, if a normally-buoyant individual attempts an excape in black or murky water, he may lose his orientation, not being able to determine whether he is rising or falling, and not being able to see his bubbles to gauge the speed of his ascent. Because of these two factors, plus the afore- mentioned finding that the majority of successful individual escapes from actually disabled submarines were free or buoyant ascents, buoyant ascent was chosen as the currently accepted method of individual sub- marine escape. Due to the very fast ascent with an inflated life jac- ket, transthoracic pressure increases rapidly. The escapee must main- tain a margin of safety by keeping ahead of the pressure build-up. Failure to do this might result in air embolism or extra-alveolar air extravasation.

Initially, the Pearl Harbor and New London tanks differed in their techniques At New London, the escapee would hyperventilate in the escape air lock, fill his lungs to full capacity, begin exhaling a small quantity of air, and then exhale constantly all the way to the surface. At Pearl Harbor, however, the escapee would perform simi- larly, except that he would exhale a very large quantity of air almost down to residual volume before beginning his ascent, and then exhale any accumulated gas from the expanding lung volume during his entire ascent. At the present time all training tanks are using the latter method. Theoretically, the expansion of the residual volume in an average individual through an ascent of 2.5 atmospheres 50 ft. would not exceed the total lung capacity. So fat, in the escapee with normal lungs, this has proven to be the case

5. Entrapped air spaces

An important hazard of free ascents has been re-emphasized in buoyant ascent training. It is the possibility of entrapped air spaces in the lungs resulting from pre-existing lesions, congenital anomalies, or mucous plugs. Concentrated efforts at the autopsy table, as well as routine post-traumatic X-rays, have recently demonstrated lesions which seem to have effected a ball-valve action on air inspired under pressure. The air thus entrapped, on expansion offers a circum- scribed area of excessive intra-alveolar pressure. This results in extra-alveolar extravasation, even though the individual is exhaling properly; obviously, it would make little difference here whether the

-9-

individual exhales completely before or during ascent - the air remains entrapped behind its barrier.

6. Etiological factors in recompression chamber casualties

Although differing in the environment in which they occur, recompression chamber casualties tend to follow somewhat the same pat- tern as those encountered in water training; since this is the trainee's first exposure to pressure in a small, closed compartment, it is uti- lized as a test of emotional stability as well as for the ability to equalize middle ear and sinus spaces with the rising ambient pressure. Frequently, instances of hysteria and anxiety reaction occur, indistin- guishable from organic damage. As a result of their efforts to force air into their Eustachian tubes or sinus orifices, candidates may de- velop extremely high pharyngeal and transthoracic pressures. This, plus the possibility of entrapped air spaces, simulate the conditions of an improperly performed free or buoyant ascent. Traditionally, the pressure test has been to a maximum of 50 p.s.i.g. (112 ft»). Suppos- edly, if a trainee could equalize to this depth, he could at least be able to start any escape from the bottom of the tank.

C. Clinical characteristics of submarine escape training tank casualties

1. Air Embolism: Of the 62 escape training casualties directly or indirectly related to waterwork, 44 showed clinically and/or on au- topsy the signs and symptoms of air embolism. Eight (8) of these were fatalities. Air embolism has many causes, their manifestations de- pending upon the site of entrance of gross air into the vascular sys- tem (venous or arterial).

The circumstances in submarine escape are those of any living situation: The lungs are filled under increased atmospheric pressure, and, as the escapee rises through the water, the air within the lungs expands. The tissues of the lung have certain limits of elasticity, and when the transthoracic pressure becomes 60-100mm Hg greater than the ambient pressure, gross bubbles of air are found to extravasata into the extra-alveolar tissues and blood vessels. Should an individ- ual vent off his lung air before the pressure builds up to the critical range, he can avoid this, assuming there is no entrapped air space.

These gross intravascular air bubbles, whatever their method of entry, are carried via the pulmonary vein to the left heart and into the aorta. The clinical signs and symptoms of air embolism are caused primarily by air bubbles carried to, and blocking cerebral vessels, and, in some cases, the coronary arteries. (Early attempts at treatment used a head-down position to lessen the former, with equivocal or negative results).

-10-

Thirty-one (31) cases of aeroembolism had undergone previous ascent training and/or pressure tests the same day; only 10 had per- formed escapes in the past. The number of ascents per man on the day of the casualty ranged from 1 to 5, averaging 3, their depths varying from 7-1/2 to 100 ft. Of the depth of ascent of the actual casualty, 8 ascended from 30 to 35 ft.; 5 from 12 to 18 ft.; 18 from 50 ft. and 13 from 100 ft. (some varying 10 ft). One death was from 15 ft., one from 30 ft., 3 from 50 ft. and 3 from 100 ft. ascents. Of these fatal- ities, the 15 and 30 ft. ascents were using S.E.A.'s, and were performed in the open sea from diving bells. Neither case regained consciousness, and there is no record as to whether the S.E.A.'s were functioning or used properly. Two (2) of the 100 ft. ascent fatalities were using S.E.A.'s and were struck before surfacing. One of these (No. 14) held his breath and the other (No. 21) lost his mouthpiece, so that, in ef- fect, both made improper free or buoyant ascents holding their breath. Two (2) 50 ft. (Nos. 34 and 36) and 1 - 100 ft. (No. 45) ascent fatal- ities were free ascents; the former two were struck upon surfacing, the latter while ascending. All died before or immediately after being placed in the recompression chamber. They were thought to have made well-controlled ascents. The third 50 ft. casualty (No. 50) was a buoy- ant ascent. Doubt as to how well he exhaled was resolved by autopsy evidence of focal emphysema distal to a broncholith. Of all the acci- dents, it is definitely stated that 27 did not exhale, exhaled inade- quately, or rose too quickly. This was especially characteristic of the S.E.A. casualties, all of whom used their appliances incorrectly, discarding the mouthpieces, and exhaling inadequately or not at all.

The onset of signs and symptoms occurred "within a few min- utes" to 10 minutes after surfacing in 24 cases of aeroembolism. Of these, 4 relatively mild, cases occurred within 3 to 10 minutes, 11 "upon Surfacing" or in less than one minute, and 9 at some level in the water (usually between 40 and 10 ft.). Of the 8 fatalities, 2 were struck while still ascending in the water, 4 at or just before the surface, and 1 within a fev minutes after surfacing. As a group, they exhibited embolization earliest.

The symptoms and signs of the aeroembolism cases were pre- \yt dominantly those of central nervous system involvement. In order of frequency, these wereyQunconsciousness or dizziness (32), focal par- alyses (18), convulsions and incontinence (17), extra-alveolar air (Pneumothorax, and mediastinal and subcutaneous emphysema) found on physical examination, X-ray, or autopsy, or very commonly indicated by chest (mostly substernal) pain (16), localized anesthesias, pares- thesias, and pains (15), visual disturbances of complete or partial vision loss, eye muscle imbalances, and pupillary changes (7), focal pareses (4), signs of shock which might have a neurologic or cardiac origin (8), dyspnea of neurologic, cardiac, or pulmonic origin (6),

-11-

psychic changes (1), nausea and vomiting (l), and headache or "eye pain",, mentioned a few times "but probably present in more. The fatalities were all, of course, unconscious and eventually in shock. Five (5) hai con- vulsions, 2 had subcutaneous emphysema, 1 had focal paralysis,, ani 1 had hemoptysis.

In those aeroembolism cases which survived, reconrpreüsion was begun whthin an average of three minutes in 23 cases. Ir, 7 cases, recompression was begun within six to ten minutes after the appearance of signs and symptoms. In one case (No. 29) treatment was begun after 1-1/2 hours, but this involved only progressive sensory changes in one hand, with substernal and precordial chest pain and may have been due to extra-pulmonary air dissecting in the chest and on to the brachial plexus. Another case {No. 11) treated after two hours, did survive, but had signs and symptoms for the following two days. Four (4) sur- vivors (NOS. 5, 6, 7 and 10) received no recompression. One fatality (No. 4) was not recompressed, one was treated after 30 minutes (No.14), (found unconscious, and perhaps dead at 35 ft.), 2 were treated wltnin 5 to 6 minutes, and 2 within 2 minutes. These figures are significant in a consideration of the location of the treatment recompr^ssicn chamber, and the time necessary to pressurize the victim.

The treatments have "been somewhat variable. With the ear- liest casualties, little was understood of their etiology. Various theories and reports suggested accentuated effects of the Valsalva ma= neuver, central nervous system or fast tissue bends, or hysteria. From these evolved the animal experiments and resultant theories which re- lated the casualties to air emboli resulting from excessive transthoracic pressure. Recompression would decrease the size, of the obstructing bub- ble, allowing it to pass on or be absorbed. The earlier casualties vere apparently recompressed to a depth of relief, with perhaps some added pressure as a margin of safety. Decompression from the treatment pres- sure was empirical or according to standard decompression tables; witn the advent of the present standard U.S. Navy decompression and treatment tables in 1943, casualties began to be treated in a relatively standard" ized manner, Recompression was to a depth of 165 ft. (73.4 p.s.i.g.), sometimes deeper, with subsequent decompression over a 19 (tab^e 3) to 37 (table 4) hour period, depending on how soon relief of signs and symp- toms were obtained

Of the 36 air embolism survivors, 4 cases recovered without and recompression therapy, 1 with 15 lbs., 3 witn 25 tc 30 lbs, 6 with 40 to 45 lbs., and 2 with 60 to 70 lbs. of recompression for periods varying from 30 to 120 minutes. In an attempt to decrease the long treatment schedules of tables 3 and 4, table 2 was used successfully on 2 casualties (Nos. 22 and 23) in 1947, one of which recoverid slowly (No. 22). Of the remainder, 15 survivors were treated initially on

-12-

table 3 and two on table 4 (to 180 ft. - Nos. 51 and 54). There were recurrences of aeroembolism manifestations in 4 cases. One (l) case (No. 11), treated with 25 lbs. for 10 minutes was not re-treated; 2 recurrences on table 3 (Nos. 37 and 47), both at 30 ft. during treat- ment, were re-treated successfully on table 4; the fourth case (No.56) recurred twice after initial treatment on table 3, each time being re- treated on table 4 (X-rays later revealed a lung lesion), Two (2) cases of aeroembolism which also had manifestations of extra-alveolar air had recurrences of the latter during treatment. They will be discussed later under extra-alveolar air casualties.

The first fatality (No. 4) was dead before recompression to 46 ft. (20 p.s.i.g.), and pressure was stopped after 10 minutes. The second fatality (No. 5) was not recompressed. Without pulse on removal from the water, he was given central nervous system stimulants in efforts to revive him. Although probably found dead in the water at 35 ft., the third fatality (No. 14) was recompressed to 80 p.s^i.g. for one hour. The record does not indicate presence of a pulse. Fatality four (No. 21), treated initially on table 4, continued to convulse despite sedative^ and died after an unrecorded time interval. The use of sedatives instead of further recompression to relieve the con- vulsions should be reconsidered in the evaluation of this apparent lack of response to pressure. The fifth fatality (No. 34) was taken to 165 ft., but was dead in less than one minute. It was recorded that 0g was administered at 165 ft. for this case. Fatality six (No. 36) was recorded as dead before entering the chamber, but was never- the less recompressed to 70 ft. before efforts at reviving him were discontinued. He had been recompressed within 2-1/2 minutes of ar- rival at the surface. Fatality seven (No. 45), entering the chamber 6 minutes after the onset of signs at 50 ft. on a 100 ft. free ascent, died after 4-1/2 hours on table 4. Fatality eight (No. 50), recom- pressed within 2 minutes after being struck at the surface, died be- tween 165 and 220 ft. (2 minutes of recompression). Stimulants and artificial respiration were also used. Two fatalities (Nos. 21 and 45) lived, therefore, long enough to be treated on parts of table 4. The majority of deaths occurred within two minutes of the onset of manifestations of the aeroembolus.

Chest X-rays were taken after removal to a hospital, but demon- stration of the etiological pathology was recorded on the NavMed 816*s of only 3 cases (Nos. 56, 57 and 62). These three had all made normal ascents. Most of the cases with gross extra-alveolar air had X-ray evidence of this. The majority of the films taken may not have been read by physicians familiar with lesions or conditions of the lung caused by or liable to cause intra-alveolar over-pressurization during the rapid decompression of the ascents.

-13-

Autopsies were performed on ail fatalities, with the exception of the most recent (No. 50); they were performed by physicians net com- pletely familiar with the findings in a possible aeroembolus victim. The autopsy on fatality eight was performed by two patrxiogists, both meeting the above requirement (one a former diving medical officer). It was the only case recording microscopic findings„ All autopsies revealed essentially most of the following findings; Intra anc extra- vascular air in most of the tissues. Especial emphasis was placed on the lungs, heart, and blood vessels, and incorrectly in some, the brain. The lungs revealed gross hyperemia and hemorrhagic areas, with what the examiners termed "emphsematous changes". Subpleural blebs were found, and air was present in the loose connective tissues surrounding the bronchovascular trees. In some cases it was found dissecting up into the mediastinum, and on into the subcutaneous tissues cf the ,::hest and reck. Minimal pneumothorax was found in at least one case (No. £0), .lich also had gross evidence of entrapped air. Air was present in

the left chambers of all hearts, and in the right side of one (No. 50) with patent foramen ovale. All had coronary artery air bubbles. All of the brains examined had air in the superficial and deep arteries and veins. The eighth case (No. 50), on microscopic section, was noted to have dissection of a portion of the cerebrum "by extra-va.scu.iar bubbles. Due to the methods of dissection, injection, and removal of brains, as well as post-mortem changes, intravascular bubbles in cadavers are not necessarily antemortem ones. Because of the uncertain time intervals before death, as well as the obviously complicating factors of recom- pression during treatment and subsequent post-mortem decompression, no definite conclusions can be drawn as to the origin of most; of the intra-and extra-vascular bubbles. Some methods of collection and an- alysis of the gas might provide information on future fatalities, but post-mortem changes with decomposition would introduce further compli- cating factors.

Extra-alveolar air: Of the 60 escape training casualties, 23, had the signs and/or symptoms of extra-alveolar air present as mediastinal and subcutaneous (including cervical) emphysema. Two of these also had pneumothorax. Sixteen of these cases occurred in air embolism cas- ualties, six occurred as separate entities. There were no deaths known to be due directly to the extra-alveolar gas, although t"?o aeroembolism fatalities (No. 14 and No. 36) had this entity grossly visible before death.

With the exception of 3 who had undergone extensile past training, these casualties had made no ascents prior to the day cf their accident. The number of ascents made on the day of, or previous to the appearance of ectopic air in the tissues averaged about three, and ranged from 0 to 6. The depths of these varied from 18 ft. to 110 ft. The depths of the last ascent before appearance of the signs and symptoms were: one

-14-

from 18 ft., 2 from 35 ft., 14 from 50 ft., and 5 from 100 ft. The methods of escape of those 16 occurring with aeroembolism have been noted above. Of the remaining 6, there was one 50 ft. S.E.A. ascent with apparatus used correctly, one 100 ft. S.E.A. ascent with breath held the last 10 ft., and four 50 ft. free ascents; of the latter four, two were normal ascents, one had difficulty with a prior 100 ft. free ascent and ran out of air at 50 ft. for 10 ft. (held breath), and the other (No. 62) had X-ray evidence of pulmonary nistoplasmosis with a positive histoplasmin skin test (he had made a normal ascent).

The times of onset of signs and symptoms in those occurring with aeroembolism were immediately or less than 3 minutes after surfacing in 11 cases, 10 minutes after surfacing in one case, and during ascent in 4 cases. In the six cases occurring alone, 3 had their onset on or before surfacing, or a few minutes thereafter, (Nos. 24 and 50), two had a very mild onset shortly after surfacing, with progression to an obviously pathological condition later in the day, and one (No. 27) had the onset on the following day. The signs and symptoms of extra- alveolar air were, in order of frequency: substernal or chest pain (19 cases-2confirmed by X-ray, although other probable confirmations were not noted on accident reports), subcutaneous (including cervical) and mediastinal emphysema (10), sore throat, voice changes and dyspha- gia, occurring with other more obvious gross evidences of tissue air (3), hemoptysis in concurrent aeroembolism (2), and pneumothorax (2). Substernal or chest pain was considered evidence enough of some intra- mediastinal air even though clinical examination or X-ray did no reveal it grossly. In a review of pre and post-ascent chest X-ray on 100 buoy- ant ascents, British physicians noted subclinical mediastinal emphysema in one of the first 70 cases. The actual incidence of such an occurrence is only speculation.

The time interval between appearance of clinical signs and symp- toms of extra-alveolar air in those cases without aeroembolus, and be- ginning of recorapression therapy was: immediately in one case, 1-1/2 hours in another, 3 hours in a third, and 12 hours in a fourth case. Two (2) cases (No. 27 and 62) were not recompressed.

The treatment of the extra-alveolar air present in the 16 cases of aeroembolism was, by necessity, the treatment of the more serious intra- vascular air. This is listed above under aeroembolism treatment routines. Two (2) of these cases, both survivors, had recurrences of extra-alveolar air during treatment. One (l) case (No. 19) had relief of his embolus at 50 ft., but with recurrence of chest pain, and he was recompressed on table I (this was primarily an aeroembolus case, occurring one year after introduction of standard treatment tables). He again had recurrence of chest pain, with pneumothorax appearing during decompression. Increasing mediastinal emphysema led to a superior vena syndrome, and this second

-15-

recurrence was unsuccessfully treated with 0 at 20 ft., the pneumo- thorax was reduced via syringe. .Another case of aeroembolism (No.29) had recurrence of previous chest pain on ascent during treatment table 3, but was not re-treated.

Of the 6 cases of extra-alveolar air without aeroembolism, 2 were not recompressed. One (l) of these (No. 27) had subcutaneous and medi- astinal emphysema with onset on the day after the ascent; the other (No. 62), an individual with X-ray evidence of old histoplasmosis lesions (calcified), who had onset of substernal pain immediately after ascent. Three (3) cases were treated, without recurrence, on table 3. A sixth case (No. 24) was treated with 50 p.s.i.g. (table 1 ?), but had a re- currence the next day which was re-treated successfully on table 3. His original manifestations of subcutaneous and mediastinal emphysema had occurred later in the day of the ascent.

As noted above, X-ray evidence was recorded in only 3 cases of extra-alveolar air, although other probable confirmations were not on the reports. To these must be added the one subclinical case, previ- ously mentioned, at Gosport. Even pre- and post-ascent chest X-rays on all escapees will not reveal every case of extra-alveolar air (as in the case of No. 62).

3. .Miscellaneous: Of the 60 casualties resulting from escape training water work, 11 were not due to ovcr-pressurization of intra- alveolar gas. Eight (8) of these were cases of decompression illness (6 in instructors), one was due to ear injury (No. 42), one pulmonary "squeeze" (No. 43), and one hysterical syncope (No. 59). Because of their particular etiology, these cases will not be examined in great detail, nor will they be considered statistically to be a direct result of submarine escape ascents, per se.

All cases of decompression illness had obviously overexposed them- selves to air under pressure through repeated dives, or, in some cases, recompression chamber tending after a day of escape tank work. The necessity for adequate decompression after multiple dives was not con- sidered in most, and where it was, the decompression was insufficient.

In 3 cases, the onset of bends was 1-5 minuses after surfacing from the last dive, in 5 cases, the onset was 2=5 hours later.

With the exception of one case of akin bands (immediate onset) all had the characteristic pain in upper and/or lower limbs.

The recompression therapy, in every 2ase table 1 was started after 1/2 to 5 hours' time from onset of symptoms and signs. There were no recurrences or fatalities.

=16-

One case (No. 42), had dizziness, "crackling" sensations in his left ear and right lateral nystagmus upon surfacing from a 45 ft. free ascent. He had made three good 50 ft. free ascents previously that day. Within 3 minutes he was recompressed to follow table 3, but, since there was little alleviation of complaints, he was switched to table 2 and described as a case of possible vestibular injury.

One minute after surfacing from a 100 ft, skin dive, a former tank Officer in Charge, (No. 43) experienced substernal pain, dyspnea, and hemoptysis. This was his first "bottom drop" skin dive in the tank, and his probable thoracic "squeeze" (lung compression beyond residual volume) was not actively treated. Chest X-rays were negative.

Another trainee (No. 59), after a normal 50 ft. buoyant ascent (a previous 18 ft. buoyant ascent was also normal), fainted at the surface. He was recompressed within 2 minutes to 165 ft., and at no time exhib- ited signs of neurological damage. He had regained consciousness before 165 ft. in the chamber, and complained only of dizziness and slightly blurred vision when erect, subsiding when recumbent. This was diagnosed as primary syncope, probably due to anxiety reaction or hysteria, even though the man appeared stable emotionally. He was decompressed on standard Navy decompression tables with no further difficulties. The number of cases of primary syncope, without other neurological signs, which may have been misdiagnosed as aeroembolism and treated as such (supposedly "successfully") can only be a matter of conjecture. The difficulty, at times, of the clinical diagnosis of aeroembolism in such cases can only lead to a rule that all of them must be treated on stand- ard treatment tables 3 or 4. This to avoid the possibility of a fatal- ity or permanent damage.

D. Clinical Characteristics of Recompression Chamber Casualties

1. Introduction and etiological factors:

In addition to the casualties occurring in the water phase of training, there are recorded 17 cases of recompression chamber casual- ties.

Every trainee receiving submarine escape training is required to first undergo a pressure test of 50 p.s.i.g. (112 ft.). Aside from obvious differences in milieu, the pressure test has important similar- ities to the water training. A trainee holding his breath or one with a lung containing an entrapped air space, will develop the same increase in intra-alveolar pressure as a trainee on ascent in the water. The difference is that in the dry chamber, the individual is respiring freely, whereas in the water he obviously can only be exhaling.

-17-

3

2. Air Embolism

Of the 17 chamber casuals is, the-;«, were 10 cases of aeroembolism none of which was fatal. Only cr.i :f these was specifically noted to have held his breath on ascent,

For all these cases it was their first exposure to pressure, with the exception of one who failed to equalise ear pressure on a similar test one week previously,.

Where recorded, the onset of trie signs and symptoms of air embo- lism was at 10 to 20 ft. on the chamber ascent in 5 of the cases, upon surfacing in 2, and within a few minutes of surfacing in 3 cases.

The signs and symptoms were similar to those of the previously described water training aeroembolism cai^s. In order of frequency, they were: paralysis and/or paresis (5), convulsions (4), dizziness and/or vertigo (4), sensory changes such as anesthesias, or pain (4), visual disturbances of loss of vision, eye muscle imbalances, etc. (4), unconsciousness (3)., extra-alveolar air (2), nausea and vomiting (2), deafness and tinnitus (1), skin rash (1), headache-mentioned specifi- cally in only one case, but probably present in many more. Here, more- so than with the aeroembolism casualties of water ascents, there was difficulty in making a differentia], diagnosis with possible decompres- sion Illness. The signs and symptoms in 2 cases (NGS„ 65 ani 77), con- sisting mostly of sensory changes with sonxa weakness, might have been diagnosed as decompression sickness, except that the onsets occurred so quickly (before or at the surface) efter a l!dive", with bottom time for that depth being less than the nü-decempressiun limit.

Where recorded, the time interval between onset of aeroembolism and treatment was: in 2 cases 1~Z rlriutes, in two 1C-13 minutes, and in two about 30 minutes. The dsiaya wore probably aue more to the lack of or difficulty in making a dta^nouia, since all of these cases had an almost immediate onset (see above).

The initial treatment of the liit:i-.t":wv_t«j air was consistent: 9 cases treated on table 3, one on table 4. One (Nc. 64) was recompressed to 165 ft. (73 p.s.i.g.), and no tabl = recried, but table 3 is assumed. There were two recurrences: one (i.e. 7~) at l." : to on table 3, success- fully retreated on table 4j the other (No. 77), r, recurrence of convul- sions and unconsciousness aft-r table ">, recmoa both -cables 3 and 4 for successful further treatment.

No X-rays were recorded on any o: trc.->e ca^ualtiis, although they were probably taken on most ani recorded ir their health records.

3. Extra-alveolar air: There r\-r- -± -vases ct extra-alveolar air extravasation, two (Ncs„ 70 ani 7?) uf v'r 1 ~h nj.i?rred in cases of air

■.i H-

embolism. Of these latter two, one had the symptoms of interstitial air 5 minutes after aeroembolism occurred, the other almost immediately. Of the two isolated extra-alveolar air cases, (Nos. 63 and 75), one had an onset at 10 ft. on the chamber ascent, the other (as with some of the water casualties) later in the day.

The symptoms and signs, in order of their frequency, were: sub- cutaneous (including cervical) emphysema (3), mediastinal emphysema, in- cluding substernal or chest pain or fullness (3), voice changes accom- panying gross interstitial air (3), cyanosis (1 case), and dysphagia (1 case).

In the two cases occurring with aeroembolism, treatment occurred in about 10 minutes on table 3, without recurrence. The one case (No. 75) with delayed onset later in the day, after the chamber run, was treated on table 3 without recurrence. One case (No. 63) received no treatment.

No X-rays were recorded on the NavMed 816*3 of these casualties.-

4. Miscellaneous: Although there were two cases of aeroembolism whose signs and symptoms suggested decompression sickness, there was only one clear-cut case of the latter, (No. 69). This occurred in an instructor who made a chamber test (table 3) on a trainee (with chest pains later found not to be due to a diving accident) in the evening after a day of tank work. Symptoms of skin and limb bends with minor visual disturbances began one hour after surfacing and were successfully treated on table 2. Four cases of miscellaneous, minor disorders oc- curred during chamber work. Two of these were hysteria, although many more unrecorded cases of this have probably occurred. One (No. 66) hap- pened during compression (before ascent), and consisted of subjective numbness, paralysis, and dizziness; the other (No. 74), had dizziness, numbness and nausea after epistaxis at 25 ft. on ascent. The former was treated on table 3, the latter on an "abbreviated" table 3. One trainee (No. 67) noted his right arm '.'warmer" than the left after a chamber run, and was treated on table 1, with questionable relief. Another case (No. 68) with questionable visual disturbances and an al- lergic-type rash, received no treatment, and made subsequent pressure tests and ascents without incident.

E. Statistical Analysis of Escape Training Tank Casualties

1. Introduction

A complete statistical analysis of all casualties and the various methods of individual submarine escape training is impossible due to the unavailability of most of the necessary records from the pearl Harbor and British escape training tanks.

-19-

It is conservately estimated that approximately 250,000 escapes of a] "I types have been made in the three tanks since the inception of training. This does not, of course, include the routine daily escapes made by instructors working in the water, which would increase that fig- ure many times. Also not included are recompression chamber pressure "runs", a record of the number of individual chamber runs never having been kept.

2. Incidence of Casualties: The incidence of air embolism and extra-alveolar air casualties and fatalities during water training is as follows:

a. Aeroembolism:

Casualties/total ascents = 44 250,000 = .01856

Fatalities/total ascents 250,000 = .003$

Fatalities/total casualties r 8 44 = 18.2$

b. Extra-alveolar air:

Casualties/total ascents - 22 250,000 r .009$

(No fatalities)

3. Incidence of water casualties by year and method of ascent:

1 3 (1 fatality) 7 (1 fatality) 1 2 (1 fatality) 1 2 1 1 1 (1 fatality) 2 1 2 3 4 (2 fatalities)

1928 S.E.A. 1930 O OÜJ o-f*- 0

1931 Ö OÜJ QJTL Q

1933 O oÜi a A Q

1934 S.E.A. 1938 S.E.A. 1942 S.E.A.

F.A. 1944 S.E.A. 1947 S.E.A.

F.A. 1948 F.A. 1950 F.A. 1951 F.A. 1952 F.A.

-20-

1953 S.E.A. - 1 F.A. - 1

1954 F.A. - 2 (1 fatality) 1955 F.A. - 3 1956 F.A. - 1 1957 F.A. - 3 (1 fatality)

There is no significant correlation between the number of ascents per year and the incidence of casualties and fatalities. This is shown by comparison of the above with figures of total ascents in the New London tank (representative of the workload at all 3 tanks) - (See Page 96, MRL Report No. 264). (See Page 23 appended).

4. Chamber casualties are not included in the above figures, since for statistical purposes the total number of chamber runs is not known. Only air embolism and extra-alveolar air casualties are pre- sented, since only they are considered to be a direct result of the actual method of ascent.

5. Escape training experience at the New London tank:

a. Only the New London Submarine Escape Training Tank has maintained careful records of the total number of ascents, including the various methods, with files of the casualties. It is the oldest and busiest tank, putting through new recruits as well as re-qualifiers, all of which makes its records statistically more significant.

b. Statistics of the New London tank, using the three methods of individual submarine escape are as follows:

Air embolism and extra-alveolar air: 30 cases, 4 of which were fatalities (aeroembolism)

S.E.A.

Free Ascent

Buoyant Ascent

All types of Ascents

Casualties Per Total No. Ascents

12/193,000 = .006$

16/16,500 = .10$

2/6,500 = .03$

30/216,000 = .014$

Fatalities Per Total No. Ascents

1/193,000 =.0005$

2/16,500 = .012$

1/6,500 = .015$

4/216,500 = .002$

Fatalities Per Total Casualties

1/12 = 8$

2/16 = 12.5$

1/2 = 50$

4/30 = 13.4$

-21-

6. Open sea training:

Because of incomplete records, no statistical analysis of open-sea escapes can be given, either as training or under actual sub- marine bottoming conditions.

F. Summary:

An analysis of all known casualties and fatalities occurring as a result of submarine escape training has been presented; this has included a detailed clinical discussion of the individual escapes, in- cluding the methods used, the manifestations of injury, and the treat- ments given. Statistics have been compiled to illustrate the incidence of the casualties and fatalities, and their relationships to the vari- ous methods of individual submarine escape.

-22-

TABLE 1 - Number and Kinds of Escapes and Associated Casualties

ESCAPES Fiscal Year Total S.E.A. Free

1930 1299 1299 1931 1138 1138 1932 950 950 1933 955 955 1934 472 472 1935 622 622 1936 719 719 1937 1555 1555 1938 1445 1445 1939 1713 1713 1940 3831 3831 1941 8257 8257 1942 16359 16359 1943 26970 26970 1944 3021 3021 1945 3231 3231 1946 2094 1649 445 1947 7022 6618 404 1948 8698 8431 267 1949 7480 6987 493 1950 19718 16335 3383 1951 25559 19158 6401 1952 16686 15739 947 1953 6353 5563 785 1954 14726 12866 1860 1955 19512 18538 974 1956-57 18943 11958 438

Buoyant

6555

1930-1957 216,500 193,004 16,397 6555

■23-

BIBLIOGRAPHY

1. Adams, B.H., Observations on Submarine Lung Training, U.S. Naval Jfei._Biiü.j, 1931, 29:370-372. ;

2. Adams, B.H. and I.B. Polak, Traumatic Air Embolism in Submarine Escape Training, U.S. Naval Med. Bull.. 1932, 30:165-173.

3. Adams, B.H. and I.B. Polak, Traumatic Lung Lesions Produced in Dogs by Simulating Submarine Escape, U.S. Naval Med. Bull.. 1933, 31:18-20.

4. Alvis, H.J., Manual of Free Ascent from Submarines, Med. Res. Lab. Report No. 184, 1952. '

5. Behnke, A.R., Analysis of Accidents Occurring in Lung Training, U.S. Naval Med. gull., 1932,.30:177-185.

6. Brown, E.W., Shock Due to Excessive Distension of the Lungs During Training with the (Submarine) Escape Apparatus, U.S. Naval Med. Bull.. 1931, 29:367-370.

7. Brown, E.W., Individual Escape from Submarines, Yale Sei. Mag., 1931-32, 6(3):940:29-31.

8. British Submarine Escape Mission, Report of Submarine Escape Committee, Appendix I, 1946.

9. Bureau of Construction & Repair, Navy Dept. Submarine Safety: Respiration and Rescue Devices, 1938.

10. Chrisman, A.S., Submarine Esc?oe Training, J. Conn. State Med. Soc, 1938, 2:423-430.

11. Crocker, W.E., Principles and Technique of Free Ascent in Sub- marine Escape, J. Royal Nav. Med. Serv., 1955, 51:133-137.

12. Donald, K.E., W.M. Davidson and W.O. Shelford, Submarine Escape Breathing Air, J. of Hygiene (Gt. Brit.), 1948, 46:176-183.

13. Hoff, E.C., A Bibliographical Sourcebook of Compressed Air, Diving and Submarine Medicine, Bureau of Medicine and Surgery, Navy Dept., NavMed 1191.

14. Johnston, J., The Davis SEA, J. Royal Nav. Med. Serv., 1931, 17: 12-18. "

■24-

15. Karsner, H.T., Air and Gas Embolism, PP 124-126 In Human Path- ology, 7th Ed., Phila. J.B. Lippincott Co., 1949.

16. MacClatchie, L.K., Medical Aspects of Submarine Lung Training, U.S. Naval Med. Bull.. 1931, 29:357-366.

17. Mankin, G.H., Individual. Submarine Escape, U.S. Naval Med. Bull«, 1930, 28:18=28.

18. Peirano, J.H., H.J. Alvis and G.J. Duffner, Submarine Escape Training Experience, Med. Res. Lab. Report No. 264, 1955.

19. Walcher, K., Regarding Air Embolism, Translation, Gaz. Med Stras- bourg; 1876, Vol. 35.

20. Willmon, T.L., I.P. Duff and C.W. Shilling, Submarine Escape Training Pays Off, PP 199-214 in History of Submarine Medicine in WWII, Edited by Shilling, C.W. and Kohl, J.W., USNSB, New London, Conn., NMRL Report No. 112, 25 May 1947.

■25-

X

es

• H <M - c»1 -* CO H CU OJ

< 2

.p ■ a P

ent

ft.?

ath and

use SEA

■a «£ a w a co

P CO

CO 3

E to -H

e öS

e SEA,

and

o exhale

ent fm

eld

nd did

s CO

§ M

CM

+J T? P H cu cu CJ

CO O to o H .p CO M P

• " o •• o ■H <

CJ cc a) CO 0)

CJ S n

tt a! —< oJn^ o J2 o S£' JT O. 0)

4J • TJ 0 • £ to a) • X d a P-i 01 V &- cu ■p +J 3 43 43 •P E J-5 g TJ CO 0 H TJ

T3 c o o o 0> i-H ■p CM 0 P CM Cfl tn O ^H -rJ •*J IH -P >H <n TJ -H CO CD +3 CO CU cfl U Cfl M CD -H fc CM a -o

0) -H = OJ < a) 3 cu

< a) P TJ <M £ ^H ,D cd 0 u

&4 J" J3

* 1 TJ

i OJ i

to TJ a it

CO -H 10 *Q Q 0) D to U

P- a) «H 4) 0)

-4J

D. ■3 JS CO cu en u

UJ lH £ IA-H

0 Jf H a

TJ o E O o

CM CU O,*—.

CU <0 O

TJ a» P -r-1 o B ÜJ a» a P. as

tj to ai O to tu 0J t- o to ^ M 0) CJ CU CU 'w —1 a -u • tu tu ai ■P P ? M 01

CU -H UJ Qj IQ (H CO to M 'x; p a co to —i L iH J) D ft ä

TJ

0 o * ft J- cH t^ —i o UJ

t. CO +j 3 CU QJ 3 tU 0 TJ a TJ E

cd 0 § M 0)

3 CD 1- IH tfl o & JE 5 •P CJ CO CO O c CJ jC xj

CU CO U -H EC ft a! E

CM 01

cfl u Ö to <y M Q CM

CJ 0> CJ o as co H 4J

•8 tfl 1 p

I d £ E ■H • CO -P en

tfl L, Li • to to Li P O O t3 E U • TJ E -P X >, UJ a c

CM -M +>--* o a

tt-H -H o tu 1 0)

tU H s* O -H CM E

Ü ^ 1) CU CO > uA

0 □ cu 0 a 01 CM «H ft +J W CU P

O CO +3 »n

0E O

**e E

O -i

E <*-•*: 3 h Pi G tw^r IH CO H r-i B P ft ft d co P- oco O LT\

P 1- P \Q OJ O -H o §S 3 O *8 CU >

O M cu S5 ccce

a =% cu 0 E tfl cu H

LAO JP 43 5**4 L, 0 Qj 0

p > m_-r m—• -a- m ^j- ■«- (M e z a to CO +J

L- a

^t i-H ■H OJ -H -P COCO CO ft <M 0 43

Q (a to cu o ^ W SS^ 4->

01 ■P >H CM CO 10 OO < ro 3 \0 3 (0 CO M

XO UJ a □ 0) JS tfl IE ■H CO IH

p- £ E cu ft OJ

to > P CJ CO s «

■H OJ tu M - 0 E ^ □ -v * a o to tfl CO to to to co cO to a

5£ 3 a 3 3 ^ a 3 3 •-( t-H 3 -^ Son P tfl CO

*5 o to o o O 10 -H O O a) cu o to O -4 H -rH -H tO M +J ^•rl U -H CO CO

tfl K V tC to to o o to tu CJ CJ 0) CM tfl cj JS 11 m CO CU

5% «n 4J >, .-H CO to ■* >> JC to to > tfl CD CO -P S --1 - K-4 H j- □ C ^H 3 a .Ü M^4> a P x U c d to x

S i* CJ Jtf 3 cd -p — >- o ft as > O a 0 o td to

u o i* ty o O CJ 10 CM ft o CU CJ CJ > 3 co

0 P CO 0! en c/> Ü CO 1H a o o CJ o o CU CO CJ J- o ° a o P TJ ft

O □ jS c js a c p p X CM *H

Ö 3 ft co % o'x: = O CO

JB O -H p O 3 CD p to ft td p ;n « O rH CO U >- tfl

i cu 1 □ CD to to to CJ CO cu ä -H

O 0) 1 V ' 0) I a; ■ CO p +J 1 8 ' UJ 43 H p M ■p l* -p i- «M o a CM L. 14 uz or 3 3 3 3 3 3 3 3 u M • 3 H 3 KU UJ p to C W P to P CO 3 •O 3 O CO CO UJT >

* u E u a E » cP E u. a E t. o to • CU

s i CO

E U P . O tfl 4J M P

tU 1-4 1) -H a> —( <U T-f p p 1) -H CU *4 * 1/1 > +3 CJ !> 4J U > -P CJ o cc CO •-* 0 Cfl > -P CJ CM 4= U

o> <M ed OJ tH CO ü <M efl ft c ft p CU ">-« CO ^-.tw «J Q &* «i <u 6. CO 4- t*4 tß <M tu OJ CM =3 -H TJ

* cfl -P J3

D ^ b Cd CM H aJtM

<M

0) — t- •P ■P ■p -»-> +J O P 4J 4-> p uz <w CM CM CM <M m o CM ■ CM CM

o S O 3 o S O la IT\ IH .P <

CO W 0 s SD CO IT\ CO ro CO m en rH OJ 3

CM

n->6n r-i tO -P- CO

^—.*■-*

Cfl ^ 43 TJ 43

> CJ S TJ CO cu

CO 0 CO td 0 cfl

-J O to p > <M tfl CM ■

z< o co < eS S W LJ CO -p 5£ s s s CO CM CO 3 CO CO CO 0 UD u -P CO ■ ■ ■ H

+J T3 • 4-» -P OJ TJ CO -P +3 +J

*1£ CM o o

4J 4-< CM <M >8 tu rH IM <H <M P

CO w tf~\ f-i OJ

' W CO CO O M t—

§ H HiT\^

, TJ CU la OJ (H M

aj 0

-P ft 43 en >< en u K CO

< •-* TJ < cfl CU id 3 CU t- °" TJ ^-( ■ CU 4?

CO ü CO P H C □ < >> flj -H

Ek Pu

t/) r-J. O

,-i CO fc. <z J J *™'* cu

* a 'i uo 0J ,W I

S^3 ■ O 6D >> to

Mine

Tank

EDÜ-

o- SB Ml X 0 CO -P c tu H 3 J J -JP-

X EH B SB 2ÄS P O CO O Ü

Qj 10

tc E

o CD O O f-l u c C\J o^> ra cu*^. H o o CU H CD ^ CU i-H

UJ H\ V- o rn CM CJ J- rn )H no »H m t- L^ 0) o OJ O cr CU P o-^^ o---^ O'^^ < w p m tM"^ e*- Xi 3 CM e« CM C- CM t>-> Q <M^^ tu O ttJ^^ QJ *»^. tu-*-^.

CD tSCC a\ JO ^ CA XI C~ J2 h- £} h-

to -P 3

• to e

co V

UJ cu a CO CO

^' 2 02 CO < Z m> X

2* CJ ■

OJ S CU TJ

X

? >

J ?£ XT < 7 ™ J

£ S-+,

m X

3 >- 4 < < 3 3 *< < < <

< _i u <

s - OJ

1 m ^? J~\ MD Is-CO cr O 3

* en DO "rj ■ C Cfl H ,n n to » 2 S3 tp Q cp

5 * £ O 1 C I» 05 P

3

fcöfc '1 o

en w

P P <3>KP

rt n . D*

CT CO 4

x S>

n on m — m O >2

go T1 I-

>8 P8 P8 m n

p >-* ft ft 3

9 in

p. <D 0) h* < C W ID CT

l-fc p *n r+ p P - Q,

n

O P **

* -1 n to to n en

rr M CO n H« o H o M CT" ♦—t» w

P P P rt y= H f» *< a t/i

^M

•n W r- m

►n rt t-

M -T w cr

R <-+i

**3 D «

O C

re o rt a

x en m oi > oo H 2*

* °* a-. Q, .£- K- -J

^*

■p- 0 T1 a- ?Z *N (B «1 11 r* »Ü

•a [n U. 1 « n w £ 1 O

M- ID < c* W <> rr Q ft 0" Ü) O rt C 3

re a n r*

*—.'p 3 n»p; o §

—-3 >~i C p

-t O P O 4 D m p D P re c+

ft to -o »a as^i

a =*= rt P *-*) >— to CO- CO r+ -I fD «a ft)

r: o a P -JO 1 0s- 3 c*

i l— O 50 O c*

H r+ to to wj &5"

T "

C B>

(D P-

en (i M P > a.

c-i- v

• »a > i

> l-g."

a to H- c < v. w En p

(X> pr r- B CO C • c o few

p to > ■

O (»

c c P re -9 a> c ft tl r+ ^ »"IP 3 M p- &■ tn cr *< -a a m o O .. P c- I- h- P" P- o (-. (t w c in H p' o m s P- P i

. rx- c+ \ji m p

P i-t) h— 4-^

r» to P a rr *"! CT r-- rr, (t O Qi

p < t. r+ a p ID 3* O «< ro W r*

& c c

O •-* v, C r- C r* •

LI p -a m

d p ujjto •H i-, 3 .p

t>* to a! V >> 01 M

■p oo o u 3 H a P ä 3 -H -P cj £ • T3 O •H -U +J rH a

J3 -a

Q ja cu •« a

ft a ■ c *> *> a!

P H 1 o > a o» w

Q «a 3

ft 0) .& fe* fr& W P -Ö 0)

*s >> « T3

a P H

0) C □ □ to o

CQ 01 0J w U U a 0 u 0) 3 t! m J* (0 a

3 £1 85 O P ü ,o 0) *H

05 > H P

L ,53

0>

CD -H q oi n) m P

P<< a o>

I i e X

G 3 ■ « JS

a) i >> ' w -a ti C\J,0 -

■ >. 0 3 O < a« M0 T3 ' o ft to d ä oi :

« a xi a) ^ tu ^ • u 3 p

+J tM *H

s *

w a a a; xi f4

■H P g C- i a To * 3 ^ P a a n to a] m cO

>» tv P +J ^H u +J 3 a) «J a to o

U O £> X) m öS -H 3 3

a -* p cd 3 » PH U o -H v a - o

■H m a □ a js a >» -H C o P to +J +J a> v o a ft a P a E o o o co OJ 3 V B (J & U V a C a 3 o a £) J3 -H 03 a A

<S ft

p * ft * o y

P c H*—* a co to oj • ad

•H S CO -w S ' P P CJ «0 CO a 3 -H cfl >. o v > -H x; u 43 M •a ft c 3 a> flj E i-i 03 r_i E 4>

OJ

3 CO -H -H e

-44 WJ <*t w (3j P OJ rH * . t> CO CO

•» 3 4j ^^ oj >, <ü > «M a > «H x:

Ä o Q aj 0) cu E ■ %-t u IA ft u E OJ

ngismu

rienta

muse.

urbane

astric

> utan

eoi

ysema,

nal pa

throa

q to (H

co >*

•HO ptcflox:i-oj a CO CDO-H-HX) ft 4J C

x: co a) n M to u eg

4J ^ >>-H ft aj 3 E P O •H «j gS XJ CC ü ft o

i Ztr to u 01 3

+J to

□ ^ a ^ OJ -H

en cd tu

> P y . CU CM S CZ CO CM

Is uS +J

01 •> PtH ■P >, E I. d to o as

□ to

E t- a 0) -I

> p cj

fa CO Cu

ITS [>, 8S r-t CO

8S ^H ta m EM fc v -P OJ OJ P CM pu, Rl

CH

o 3

to CO

a 5g o —

&

ft.

R

3 O CO i-l to > 0> OJ

a

< < < Pu CM &«

CM CIH tM

euro IA

< < fa fa

o 0) -V • > U < •M O T3 • -p -p OJ fa ° ° r1

ftE^^- m -p H Cx o to cd > a 3cD

CM 4J CM -P

O CM •H CO

• HR Ä X CO

"SiS s s IA co co ta

X

5

• U) SJ1

UJ UJ

UJ ro

UJ UJ o Ö ro IS & z

o

E

o CD s > to CD > fe B CO > >o

r-> HU)

to . 1

n o o s 33

H r n c. T3 W cn O

o z

» • CD

2 n ♦

D

IT "p

> ■c

r k

> * c

? z i m

•

OS -J \JI UJ »— O

SO » > OS SJ1 h- ro »-- UJ UJ ON

^ ^ ro r— <x> o o h-

\J1 ro

SJI to

\ ^ Vjn vn \J1 Wl h- « « M M *-■ M H1

« ae SB s SE Z 5 »TJ =B M 91

f t-1 rt

r "r H r r C" Hi-

sg 1

ro H1

1

00 ffOOlBff et H t-t oremMWrtrro

a o o rt

P CO

> *~"i ^H^»I rt *-t

rt p. Q O rt rt 3 H Kb ct CD co Dg O

1

<+

H- M ♦^•O Ö so

^ *—. H< t— sji H g^co »-^l\) f CO

Co CD (—' t-fc Q > c ■< w

cn m CD a CD

OOd o i a

Hfc Q CO ftOX

(R CO O

cn v^ SJI O Kb

r>o o m— pi

Or >

Kb rt

»*. i»

o

oq cr 0 1 0 a H — CO

>

3 r r □ Kb t^ rt a rt rt .

*~" ' *}

??S a a ^b X UJ ? -<

'*-' "-* *—' >-' ■^^■w^

?)S > ♦ ro > *«3 t» ^0 *-i c+ Q. CD • B O r+ 0 H- pr > a « - ** b >

*»1 H ^o1

> CO H

58 zn -< — ■ 3 C+ K- 0 OP ' 3 «3

ft

s ■ ^s P ►* c r-f, (B U1 Hi ff ro > O (- a M r UJ rt fil 8 3B

CD t-t, 1 c+ 6 O H CD o o K- D 1- I» H- H- fP "***. cn MI a ro t-t» CD cn»

8.3 <I P- rnpi x xzpi m o

CO m a*1 g «-1 w C

►1 o p •1 c+ & ro

n

ft c

B 1

CO (-»■

n co ■ s n

H

0 pr

O 0 a CD

rf* •i

1 B C COB- •a cr re

Pgnc? fl ? 0 D B O p o

O p fi co B S K h

ff? ty ^ |5 a o t»

C D •g g" B r? § eg & E ° S

OOP ro co < Ti B P i-n

*1 •<

(» V- D O H- O H- 3 fP O « Q. o* ro p- n co

ffl D 1 »d cr c+ ro "ÜR V) VI

Is • cr o Kb en O O 2 o

•d * £ D < Co fPil n a CL C+- D 0 D o> on CO CO CO p* n p- o P e+ H cn 0) <- a «• c+ H *< B C c+

co ro rf rt- r> M *? c o a o

m rt • f+'- 1- Co H- P"«< t- K n p- n CD (l 01 P 03 CO

3" ►*•< » r»- cr »i I-*

§ e <■? 0> t-* H- cn ro co cn H- CO t-»- -

P CD P P § & B 'S

S P rt i*

n) o in CO C K*

ro a i & p B ro H* ■g &

-i tn

§z a

!-■ o o 0 H- CO h-1 a H1 o O" H« H- H- co a co ro is a ll O rf D CD DP P Co - & ID n c cn CO < «•OS to S » C ET CO CO a *. H. t-t cn H CO c+ fB e* e « * n — C P" a co * a N f+ pr c* P ro O >-* CO n C •<

rt- ro CO P

(V CO

^ Mj

I e CD D «• 1

Co

,p - CO »-- «■ D to

•sj B -a O (» VJi H -a p- M •p- UJ H am mo I

5ii P

P »t CO c+ P- ro

•1 ( CO M B

( p ^/i ft fD i-l V*

ft (t»1 01 ro D B

m P o

t (D CJ i- cr t-9 <+ ►-*■ D P o g 9 g ? s? s3

^o5 if -4 > CD X 1— X PI (A

c «; c+ CT & cr & er C3- It cr H (-< fl> K- ►— H H ^ M M 1— CO q

CO (t H rt 0\ P Cb ON <b rp n OJ ro ro ro

w~t a T v/' >-• n Ul O H- CO UJ M H u> UJ UJ O 0 UJ

w> ro D a ►■*. D 8 rt • <-» 1

^ n ro p" n ro

§ s l/l m

1 IB ro t¥ CO H-

8 PI r-

cn D PI

O CD " D 3 ro

•I

PI -* n

l^5 UJ

ODD» CO

3" CO a> o p ro

> 0. O t- p* CO

it- »o a w crv;

t-t **i r+ "> & S c X pi

Z > 8? P

cr a c ro

& Kb ft M- rt - cr P Kb

ft H- o •• B cr a 0 rt t* o H- H. C *-a ro cr D P> D P 0 K* 7C P r- »wP H* Mj O 01 c+ D rt n C r* r+ ro j» (+n hff D B

CD m

*-* •I

g

CO cn

ro 1

n> p C D 0) p CO c* <* ft rt -

rt

*l *" 1 ro \0

ro 8 l\J SO

s

* o I H <-* -*

H r-t

to

K < 2 ÜJ or

E CO

•' O

10 E

fa 0 0 0

■P c

< cd

O -P 0 P P OJ a

■H O TJ 0 >H oj ■*-» -♦->

TJ <M <s c -iw H «j •" 3 0 u n m £ 1 1 D Ü <; CM TH ft)

4J • 3 -P J=

>j O «M P-—*

p to 0 a) p- -13 0 0 0 OJw 3 0 w aJ uS M

CJ -H M J3 •

«H > E P P <w ai 0 a aj TJ V4 CM IH JH CD r-t ■H ft CM J^ M <U O •Ö S -H £ ^

•C * C0 T3 P < * TJ M

0) -H • p CM a O 33 £ fa <M O n) CM

i CO

J= OJ < •p 10 • OJ 3 6M OJ U p TJ

J3 O -1 a TJ

TJ HUB o -^ a 03 TJ OJ

OJ

cd c >iH td

H 3^ J3 J2 M

a) -H 3 ,Q P -P O 10 CO

J-. OJ -H

fa > TJ

a E -H O CJ -p cd P M O O

r EH OJ ■ N

■p s OJ

CO ft QJ

M 0 3

fa TJ CO

J3 td X!

>»p" H >. CO C P> 3 -H -H O E

—J CO OJ > a M eu -H P> M td x fa ft OJ

u h- UJ

UJ < -J UJ

o Id V)

+3 CM

□ 0 0 ro -H

CO ■P CO

cd aj

0J ft-J- u E C O OJ ID UH h U J3 W M Qj 3 EH U TJ OJ B M

K aJ O

UJ X _l

< r-

■P ( 1 CM QJ QJ TJ

X) t-. Ql O to t>- TJ ÜJ l 0)

ro u s a? O 4> 0 0 *« H Q (M o a

m

0J

X»

QJ rH XI cd

EH

CJ

m CJ

XJ 1 1 TJ OJ

n D H x: x>

tu 0 cd r~\ P P

X) -M cd > 0 H to -P Oj

H

OJ H JD

CO

E-i

O

* Zh o o« X OUJ

en or

(A

a> OJ -P

H a 1 i-t

OJ E

(O OJ •p

2 g 1 -«H

in E

OJ CO

-* 3 t O

m

OJ -p

VO 3 0 *-t

B c«

a •H E

C

E

to (H x:

no

o Zlfl

in»-

SI — > in in

a OJ

-am CO ID 3 QJ C 3 0 - C O O OJ o3 O

■H -H 5 E <H tC co cj co oj oj n- M

-H W+J I0O-H D

3 ß 3 >> M X» >■ O CJ X! TJ OJ E a 0 jo ft a) -p to 0 a 3 E oj c £ O 3 CD 0J TJ 0J (J

tu -M

t*> CO C ft

5H CJ to

0 t CO 0 •H OJ "^ -H X P CO -M C CO OJ CO >>X< U gJ 10 3 tf ft fa 10 ft «

a a 0 -^ •H T3 to co a

a to a to 1 B) H •H O OJ OJ JO CD

•H p> a 3 to a oj co 0 •-* co 3 ^H E 01 > «kr-H O -P m--N at O)3-.OJCO>>J

a -MIMP 5 «i s« ^HJjtfC toB-H^M 'HOtOTJOJPTJft" 3ojjz:aj23ojEX fa a cj cd 0 0 E rn^—

« >. w -P 03 -^

s d -1^3 (4 «H O1

H AV •H 3 a P 0.-H

cf 1 •M- JD M

CO M 1 W O * Q* 3 -r4 0) C T-*

bß P N OJ 3 U 0) rH CO NH -H OJ H Oj -H-H d P

Ü TJ TJ 05 -P CO

•o C A. 9 c UH •> w ft CO P cd CO ■ -H

CO 3 OJ CO H OJ E J3 to u co to C 3-n a (D D 81 >, <to>eda-HÄrH

10 TJ

X ■> cd cd TJ -H a eo

TJ 0) 10 -H E q N tu -p OJ 3 >> j2 to co

H -p td >. to cd co f-t- x! bO M OJ TJ ft aj aj c a; E •J ft tfl E QJ

(3

O

* M * co a M to co -H td 3

a >: B •H CJ -P 03 P N <d x: P jz; N U CJD to w

T-t U «Ft >i -r-i 0 T ■ M a M

cd CJ 0

H ft co td CO -H

a >» co w TJ X OJ -P

■p * ft to a 0

J3 -H E

3 Cfl OJ

CO ft J3

M OJ > >> 0 p>

r-t -H

E P* OJ CO x; M a ho P *H

■H X Cfl (X tU ft

Q UJ

ui zt flE UJul UJ I >

x *o * u «!/)

o

1 0 cd

CM

M

3 CO

a 0 t*> ft a

CO

0) 1 -P M 3 3 a to

•rt M

E M X OJ -H

n-p u 1 <M a)

OJ CO CM

CO

aj * -P M

C CO •H tfl

B (H a OJ *t-t

> f> 0 0J Cw a) fa (0 CM

a 0 "0

a 1 • a w u

■P OJ 3 ^H -> +J m

•P 3 60 0 c c 1- a j aj -H ai ^

CJ E *> 0 p in IM 0)

C O

p CM

■P

OJ OJ O

P « < ed

to 1 TJ J-. a 3 O CO CJ to cy M a CO QJ -H

in CM 5 H Cd CM

1 IH

• 3 d w ^ •H bC E M a

OJ -H

OJ P 0 . 5 CM ed

5 Cd CM

M • O

CO > M

XJ M a>

m -p 1 CM

OJ cd

— 1- oz OUJ

P

°! m fa

P CM •P

<M

O s IA CO

p (M • < 0 • in ik,

p «M • < 0 ,* ir\ fa

•P OJ CM O

8S P <M • < in • j- fa

P> CM

C OJ Q -H > O Jtf -H •H CO TJ

j-

1- >-_ Z <Q uj -2

< 2 o: _ 0-

P O *H in Q »O CO

CO •» -m

V CO CO IP. _ - ■ "* CD p -p ■ H <H M b

fa ■P <ü

ft-i 0 0

R-5

< fa -P <M

8

<

P ^^ CM T)

0

8 S

< < < fa fa fa ■p p P»

CX> LT> O

CO CO

•p +> CM CM

00 O •—\ ITS

< TJ • 0

fa O

p CM . s

O x u-\

< 0,

M n OJ 0 Ä OP P> 1 i-t CO O -H P td

r-i a) ft 0 a) 0 5 3 -H a

U CO

0 OJ • p> > -p U -H CM

E'o p >>t~- 10 q

ago M e p

1 «Z

J z° fa*

J as

J SB

Ul r- <

OJ IT\

OJ

> CO

CVJ

OJ

OJ

OJ

m r-i

rn in

ON

rH

-31

in

OJ

m

UA

CO

rrt

UJ S < Z

J

U

• OS

• 2

• a

<

a Q

0

Pi

Q

DJ

Ü

Q

U

0-

lb

as:

1

en t-

O <

X CO < s CO < 3 3 s s n

§ « CO O -5T JT --7

^f «

• VI \^i ro r-1 »' *-

CD •r- *- *-

\J1

z o

tö 5 > co s CD > Cd R >o

5?

p

k > 50

>

O

So

C3

n >

p j-

p

* Crt

!

H

O

VI

C\

.CD

vn

*- VD

VJl

f o H

~^ *- Wi

r- *- >

SB « 55 c n << c et

to

SB 2 >0

a •0

Is -tr

ip oToD o O 1-0 Q. r*

>

ft

2 et- o

H" p POVi-i p M ff P VI O O e+ Pf

ff >-ft ^» ^t H P M H e+ e* e+ O CD O ' •v DP-

> H

H v* H

8Ä0D

•■* et r+ et- • •

W CO

cm o cx> o O ^ »-o O-rt c+

> >

a et

>

■4

O l-t a et

>

??? hg hrj *4

> > >

mrnifl non m — m o>z Zm» mr -<

et

»*) v> • o >

et et . l-t

ft

^8

?

2>

•

ET o c 1-1 DB

tj 8> o f ID o rf to ►» I»

£ " £ CD O C C 1 rt

f-tj Bj hg

ß 3 2

c§ " £ Dl P

i n cn

E et CD *i

P

a.

5

O S

i»

co C

E? B

> et

)£ 3

o mm ° S <Im mm»

m a

CD

a < « o p o i- H- 5 -p- 5 P m co ^ a to N et C a Co co N

i H*< -r p ff m *o to ti a H- p CO CO D to t* ►- co O » B p » to * w

Pfl CO 5 P D o ff -j n D o> ps o <

■ft P ß C ET«< to H Q D) o n CD H* f-1- ►*■ ►* B O O 0) *. C 0

a> a P * ro co 01

ff co a a er« ä a c ff *< o 5 « •a er ä ro pa (->• o fr o ^*ö ") D K «< C ED p- n <- DJ ft 0) jo ff a ff p c*- 0Q P CL b S P H- H- ff *< Cü {D ff 3 p 01 CD

O P *• co »d n £H «. p P- CO ff ff

P P CD B * r+ a

N P »0 H-- P P ff ff P CD "» CD

n P* ff m et

0 < O ff r+*ö W D ö D & 3 * H* et Cf ff h* t- et pr et O P P P P p H et CD et fcr I CTH-h ff 1— ff H- co b p >1 ff o ff 0 (S >-t P

C ft H .tr-1 U* O ff

ff CD b p ff n O ff ff

< P " C 0 S O D H c n n H" CO < O et (5 C B f. p t- to D et CO O (R fö t* M-

0,00 P E

m co co 6 - O a. to

Co

ff a CD pr H- O

if D a a

Es 1 B O B ♦-*• H* H- to o O

C □ CD CD

1" n CD

wtn

11 i;

ff-J

8 U a ro

S H t- D tt C 0 et

to

- B ro H" P

.rt

CD cn

-a

P-

co

Ui o ra rt a

<-» ON

P

H

m D

ff P a r~ a UJ

37? . O C

H- ff

8^ a

LiO

g to Lg

H n ro

g er

m

UJ

Ü3

er o H rf

*-

> CD xr r x m IA

O ff X H* t( ft < «1 o in c B * 1

H- »1 & t+ n FF ff B o . "

ro < <l (3

P r*- - ff rt> tn »^ CD • v\

O P >B D &s et c P 3 1 er n «-( po »

" S ^ ^-•O to

tl rf p m et 0) r* Ui 0 O P

et

O r? C P ►j et a ff

P i-o et to *- i r-

ro

m

e m

> m

m -* o

O Hl D P

a M rt

to ft rt to

r> H rt> O C

rt «1 et

PS br) ff* P> c m < et

CD

O n n

M> D

HtltD P H- X <<

(D fj »ö n p ff e+

•ü l 0 H-W a B ö S H to

P> < & "5 O 0 P rf D i-l •< & M »

*1

ff t» Bp

to a St H rt o o ff c

**i rf et - 0

ff rt EI

a 1

1 et

2 *ö S Cl ff>< 0 •• r-

1

s f

ro -3 —*ro o ro

>- f+ *- tu ■c- ro

ro ro ro 4^ ^ 2

* CO CVJ & * « o

OJ

in

et < Z ÜJ cc

Free ascent from

85 ft.

to 50 ft.

with insufficient

exhalation.

Dropped to 100

ft and then rose

to 85 ft.

again

where became

unconscious.

Did not exhale

from 110 ft.

to

100 ft

. Slow

exhalation all

the way up

.

X-ray evidence

of pre-existing

right lower lobe

lesion (cyst?)

u c <u c > 0 •*

o ii 01 D ^ u a £■ >,

0. 0 d * **

X 0 ■p Ü -M a * >>

w a!

■H >, t- M (U a! P E to >M

£ P. Autopsy:

aeroembolism due

to entrapped air

space

u

UJ

UJ < -1 UJ o O UJ in

Two recurrences,

both treated on

table U, hemoptysis

later

in u

X_J er m <

t-

Table U

(to 180

ft.)

m

0)

o

%

m

ft> cd

at

at H

H

OJ

a Standard

decom-

pression

from

l65 ft.

(170 ft

. fo

r 1*

0 min.)

To 220 ft

death be-

tween 165

and 220

ft.

(2

minutes)

o

>Zr-

low tncr

t-

a ■H E

O

a

E

a

E

a

E

CO M

g x:

no

a •H E

CU

a

E

OJ 1

Q ZVJ

«? in»-

in in

CO QJ □ CO

3 a O -H

o ft CO a -p 0 to U QJ a s=. ^ u C

hest pain,

paralysis,

anesthesia

Headache,

paresis

paresthesla,

visual disturb-

ance, con-

vulsions,

unconsciousness

Chest pain on

ascent, Uncon-

sciousness,

convulsions,

hemophysis,?

mediastinal

emphysema

■a 3 CO CO -H D

flj x> ft M O 3 0 -P a co

CO CO 0) a CO 10

3 a 0 0 CJ CO CO .H

§1 0 a a 0

Ci 0

o UJ

UJ ZflC tr UJUJ UJ X> x5o 5 <_>

«in

O

to 0)

-p 3 a

E

OJ Few minutes

after sur-

facing

to 0)

■p 3 □

•M E

m During

ascent an

d few minutes

after sur-

facing

ä CM H 3 CO

p

0) u OS

>M M

' 3 CO

<

— h- <->z

< Q

■P

CO fa.

p lM

o < H fa.

< o •

IM ' < •P T3 CM • O

< O 0 • to

p CM • < O ■ l/> CQ

> -JC5

(/I UJZ

t I Z <D UJ —ui U oD in UJUJ

*|£

< fai p TJ CM o

o O 00 18

ft.

B.A.

50 ft.

B.A.

(goo

d)

< m

IM C C

CO w

Limb pains

after

treating

embolism case

on table 3

- Water work

previously.

< m

-p -a CM O

O CO ÖC

l8 ft.

B.A.

50 ft.

B.A.

(good)

in < a.

In o P a

s 4J 10 C M

M x>

U T3 0

a^s^—■ t>*

3! hi J SB

a.

■J

B5

u

E

M9

< a 0J OJ

H

t-

00

in

CO

m

r-

CO 0J

UJ

1 Z

tn

Ü

< ^ Q.

J 3:

5£ < 23 < s « £ 5

o 2 * t— cc 0 vo 1,

0s- 0\ ON ON CT> o\ (J\ ON o z • 1

VO CO -J ON vn *r UJ tu H o

to 3= 2C sc CD

> w CO W

-<c

IT. c = f-) (X _ _ c=

' J - ■ Z * J * * s i

50 * r

F C5 7=

Z

5C

r h •D

n z

i m

1 H

a

1

> 1

1 \o ,_, t-1 H< ■ai H UJ VJl *-

< 5 *-

r-1

o ro a.

l\3 ro VJl

> m

—j ■P" tJ\ ■f^ •F- -J ON *r

z z z •0 *a Z Z *B Z

h r i-i EC tu r P" ba "f

z>

B Cn re '»tCD

f+ < C TJ

3 o re re >

O C 1 CO -H ft CD CO 0 1 v; re c:

re K"

CO l-1 VJl •o ( UP it P r1

1 P CO ft 3 t-o H- re r+ cr rt 3 is! > •-t < re 3 ro o re cr

ct O •- *i H- ro M i O D O H- •« c «; c co ft- p

mm (yi

& ■ cr no n M cr m— m

s **3 <-t CD O ft 1-^ 3 1 H- o> z r-1 i re et res ^ H

> ^ »< PC CO • O P tn zm tn w • 00 ■«. p e+ Cir-

8 o M, CO W -< o o re p > & n w

s —' ^-> (—

* ^-\o 3 --~v/i 3 .—*\_n Vl VJ1

> —J 0\ UJ \jn

■ -i * * H

? mn

€3 B c? VD -i

t3 a r+ Zn

a h-l

a 01 K-' -* §

p > ►* p T? P h- > CD ' £ CO rt- <g 3S cn O o c+ O i rr o O O B 3" «-, o cr V re t-1 re re *-*, CD O

o-i m &' cr o

rt D O ►n 3 c >> C c

1 ft ^4 CO □ r1

l-t CD p p TO ^ CD 8 c+

»1 r+ O D

M rt R <m za

P ft re to

O >-% re P c& G re

*i n i

i

p. O" CO M 5 H C SO p, a rr >o D en < rt- < ^ r < p. < < *o C H- C P D

n pr re p co CO H- re ** r& a i- a y*<< p £ c re c **■ t— e+ 1 sr ^< O 3 3 C eg c CD 3- H- h" n en 2S£ CD N v. ^ g cr P *i n p •

b p p %r p re D P 3 D o *o 3 co re pi p

Hi H^l n p P *Ö & c 5 -! rr ra

cr 1/1 Ul

rt ao n n c o N c* p <r tj. H- r+ C en p o c3 C0 -< -- C o> »1 [0 p tt c* (» ■< It H3 (D rt C

P O *< en 0 W ^< 3 C ft £ O

5 * PJ B- H ^ 3 ^ «< Q n t» »1 to re co re <^- re TJ Z

p < (x p <+ O h* w n r+ fi s D to n i— re & p •~i —i V)

T & ?5 p n H- en ►* CO H- H- co 3 f- b 3 S> ö h~ P ►* *• CD 3 a

a " « o p p re P o o> t— CO CG s n >. c ^ to O C/> Z n> c N- B" c+ a MJ i *. a, re en rt C CO o p p B I C P re P CD o D ^- CO t-H I. I- cr -^ ►I B n- 0) o re P o

cr i 4

rr 3 cn P 2 O

cr M ro u> h*

O t ro o H H C 1— x to *1 \ 3 3 cr mo X to ro

3 D o c CO

>o o -tz * m o

P H z rt H Ö ^^ (_i »O 3 ►O 2 E? D p o P fl) p —0 ON 1 0 s 3 o H &■ c o- cr cr UJ vp re re cr >

H tn T m «t 09 X ro re s re re re i? ED re co re re r~ x

m UJ r- UJ UJ O Q

D 3 0 0 t3 3

t— tn

V) m O c m r > m

m -H n

it r+ p < cr p, p »a to p ä

1 t- K ►* 0 I- C i ^B 1 c m re n >-i rt re p

ft re (D D 3 M>n a cr n M QtOH-tncotof^

3tD D r+t-r+3 p •-♦i re en co re a re p H H- cr H. 3 to re D C O tt 0 0 *< ■x & ft p a n ft c ^ c+ a CO P r+H3 H» tf O m

C u 1 c n ~^^t— re M < i— p co £ n D 0 t— re d re 2C»-- copnpner > P <& *J P ►-! to ?THJ[!

c+ <: D P M, rt to CO *< O 7 << r- p ft r* t-2 - 3 3 «: ^

C to rt a ft s rr re H* o n tn p c re r— CD *i

rr & o p

a 2 a co a. c* 1 c D ft CO *< f+ **•"'

h- UJ _j Lu u> UJ Cc UJ ro 2 \D V ( J- u^ ro UJ

o 5 C\J •"• fe- rn t-

rn * CO w m«8 j-

Ov . ON rr>4« hH »>•

en

< 2

a» E 3 tD ID

-rH GQ

O +J

B -P a) m 5 ajs In «H « V = TJ d a

E- ID

u >- bJ

bJ < bJ

o UJ CO

O 2 U a u 3 41 O

P 0-* •8 «H

03 4) g a to to to O 03 L0

•H 41 01 rn to a i-

r-4 LO CL. LO 3 3 £ 41 > O 0 f-l □ T> a xi O CJ 41 09 O to 05 P

UJ X -I CX CD <

1-

m 4)

1

m

I a> H

1

m 41 H

1

i

> 41 41

a f 4i jo ^ P EH e) si

41

1

p So. m 4) • o o -*

1 • 41 in 41 U 41 -p Li 10 41 r| 3 (14l tD rH XI O □ iQ 41 XI « ii «o g K p«

En CC t4 J- 3 PIOEH

cn 41

r-t

■3

a>

|

Q

IOUJ c/>ce *-

a ■H s

H

(VI

l-t

41 P 3 a -H B

r-4

CO

41

1 ft

ro B

n

3

O

ff- to

3 a

■H

CO V

+->

□ O -H

o Z V)

S

p H ■* <° O Q 0) 3 4) «XI to CJ to V •HSO > 3 o «m

Xl H O to « g «IV

>, 3 «I -H O N -P O -P H J* -H O OJ 3

I a

« o CO «L «V n 4i it n 41 X! 3 10 a M) p 4i i-l -H -H 5 .p N M a <H h M a 3 U> rl Ott (ITI O p p -O t.

«r t a a 41 o a o a 3 •> o » i-l i-4 <0 una to >> O a H -H o a to

ill

■O

a T4 a «-. 0

•H o M H

it

xi P

:» .j ID 03 -H

«1 -H o to •H H 41 41 . >- 3 □ S. f 41 -P 1-1 P V

■p ■ H O » 09 -H ta 41 3

ftf 41 tj S3 O

•a a ■■ to

0 3 » d «•HO "»to - OS

CJ Pia 8 41- -H -r4 B 41 3 41 a OOP 41 ÖPPC04laTtoto

jjlif sSif W*Jffl4)J3t)S*J

03 LO

s « a 03 03

O 3 o o

■H -H 03 O

a cj o c O 3

d ■H a

LO i-l 41 «J

■C Si p to 41 01 41

S3-

a -^ -s ■H to a QUO tl£iH B

-P 0J 3 ID CO 0) <M 0) nj & n H a 3 o 3 < Ot t) Pki

i

aj S cö «H a) tu a eo x: to -H a> 3<o -C * cd aj at -P O C CO b to MJ (0 3 (U TH -. ftj CO CO V OJ U CO Jd t- t. J2 U ft) 0 a cu o a b a» p, > ä <H ft a

Q UJ <r

bJ ZbJ CC üJ>

xsu 5 to « —

Q

a o -o

• 3 to u +» 41 3 tM «4i a

o a a b a H 01 -H 41 i-l

ti a « tj P 03 "*H 0) < eg LA d «H

a o

• -p P 0 0-1 41

V o m OJ to

1

* tM

| a a O CO Pi a

v>

3 a

a o

■p

p LA a OJ 41

y

S3

•a a •H

h 41 •P 5

0) +5

0) C ■H

c ä E *H

3 CU CO

CO v ■

0 to •H Qfi ■ Li a

01 1-1

41 «H «9 h 0) «-I

I — ►- uz ULU < o

Pi u p.

ft ft p,

ft ft Pi

ft p.

ft

■p tM

ON Ol

u Pt

ft

Pi

52 tnu —

Z <bJ UJ — o UObJ tft bio:

-

t- lO < 0.

o — _J t- M

a.* a!

►i

85

j

as

hi as

a +^

a o -H u o as B5

UJ

< H LA

OJ LA

CM CM

OJ LA

en CM

o

LA

OJ

1A

LA

i— LA

t—

-3-

"ct 2"

o m ON

NO LA LA

LA OJ

"ON

UJ

5 z

H d 3,

OS

so

d a Ct.

J

5

D

X to 5

St 3 < <t < X CO < <: s

2 o Is-

H OJ rn LA 1-

*J3 t CD

if & ■ H-

O

t o

-p-.pr.p-.p- -P"u> u> U) oj ü; UJ oj UJ u u) rg rut\3 ro ro ro ro ■P-UJ ro K- o \o CD-J i^ui rw ro H O SO CO-3 CTWJI -P-UJ