A HISTORY OF HYPERBARIC MEDICINE

Francis Wattel
Service d'Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare,
Hôpital Calmette, Centre Hospitalier et Universitaire, Lille, France

1. A HISTORICAL OVERVIEW

Hyperbaric Medicine goes back a long way, since its history derives from
the history of diving which dates back to ancient times.
The history of Hyperbaric Medicine has been closely linked with the
development of technology for underwater activities and the advance in
knowledge about the physical laws and physiological mechanisms of
breathing oxygen at pressures above atmospheric pressure.
Three periods can be distinguished:
a time for discoveries: from the Renaissance to the Age of
Enlightenment;
a time for hyperbaric therapy: from the middle of the 19th century to the
beginning of the 20th century;
the practice of Hyperbaric Medicine on a scientific basis: since the
second half of the 20th century.

1.1 A time for discoveries

Science and technical knowledge flourished from the very beginning of

the Renaissance.
These are the main areas of scientific progress: in 1644 Torricelli invents
the barometric tube; in 1653 Pascal confirms the variation of barometric
pressure with altitude and establishes the laws of hydrostatics; Boyle (1661)
and Mariotte (1676) both state the law relating the volume and pressure of

1
D. Mathieu (ed.), Handbook on Hyperbaric Medicine, 1–11.
© 2006 Springer. Printed in the Netherlands.
2 F. Wattel

an ideal gas; in 1755 Black discovers carbon dioxide; in 1775 Priestley

discovers oxygen; and in 1789 Lavoisier describes oxidation phenomena.
Diving activities had been limited to snorkelling, restricted in time by the
duration of apnoea and in space by poor underwater vision. However, from
the 16th century onwards, an enormous variety of ideas and projects
flourished, such as a breathing tube between diver and surface, which was
taken up by Leonardo da Vinci and, after some changes, by Borelli. In 1690
Edmund Halley suggested a system with a diving bell where the air was
changed by means of a leather pipe using the air contained in weighted
barrels sunk to the seabed. In London, at about the same time (1662),
Henshaw was the first to think of using atmospheric pressure as a therapeutic
modality. Denis Papin suggested using bellows to inject fresh air
continuously into the diving bell. In 1791, Smeaton, an English engineer in
charge of repairing bridge piers in Hexham, had the first chamber built in
cast steel and fed it with compressed air from a pump on a boat. This 18th
century-derived pressure chamber is still in use nowadays. During the same
period, Fréminet developed a full-pressure suit and helmet with compressed
air supplied through a pipe from bellows on the surface.

1.2 A time for hyperbaric therapy

The therapeutic use of hyperbaric oxygen (HBO) grew in France between

the middle of the 19th and the beginning of the 20th centuries. In 1834, Junod
described the beneficial effects of high-pressure oxygen on man. Pravaz in
Lyon, and Tabarie in Montpellier, both described the positive effects of
immersion in compressed air for various ailments. In 1876, Fontaine had a
mobile operating theatre built which Péan used for 27 operations. From 1860
onwards, an amazing number of centres were opened in Europe
(Amsterdam, Baden-Baden, Brussels, Haarlem, London, Malvern, Milan,
Moscow, Munich, Odessa, Stockholm, Vienna, among others); and the first
chamber was built in Canada, at Ashawa. The largest was built in 1927 in
Cleveland, USA, by Cunningham. This was 6 storeys high and comprised 72
rooms. It was a failure because patients were not selected on proper
scientific or clinical grounds.
Among all the people with an influence on the history of hyperbaric
medicine, the most famous is certainly Paul Bert. His work “La Pression
Barométrique” (1878) is universally known and is one of the foundations of
Hyperbaric Medicine. He studied the effects HBO, discovered its toxic
effects on living organisms and insisted on the risk of convulsions. He
concluded that to avoid harmful effects, oxygen should not be inhaled at a
concentration above 60% at 1 ata. The toxic effect of oxygen on the nervous
system was later to be named “Paul Bert effect”. Shortly afterwards, Lorrain
Smith in Edinburgh described the effects of oxygen on the lungs. At around
A History of Hyperbaric Medicine 3

the same time, in 1895, Haldane was carrying out an experiment on the
effects of carbon monoxide on oxygen tension, recommending as a result the
use of HBO for the treatment of carbon monoxide poisoning.

1.3 Practicing Hyperbaric Medicine on a scientific basis

1.3.1 Over recent decades, progress has taken many directions

The increased number of experiments on the animal model, for instance,

has brought about an improved understanding of the effects and
physiological consequences of HBO: its capacity to increase oxygen
delivery to the tissues, its effects on vascularisation and on anaerobic
bacteria, its activity as a means of defence against infection and its
contribution to wound healing.
The indications for HBO have been determined more precisely, as much
for critical conditions as for long-term or chronic disease, and listing only
those which have been validated by clinically controlled research following
the criteria of Evidence Based Medicine (EBM).
There has been emphasis on increased safety and improved care for
patients in hyperbaric chambers, including those who are critically ill and
requiring continuous intensive care.
Lastly, the necessary means of education have been brought into play to
promote the development of Hyperbaric Medicine as a speciality.
Looking back, progress has not been linear: the 1950’s marked the
pioneering decade. During the next 20 years, Hyperbaric Medicine
underwent an intense phase of development: over 60 indications were listed.
Between 1980 and 1994, there was a phase during which the usefulness of
HBO underwent doubt and suspicion. The last decade (1994 - 2004) has
been a phase of rigorous scientific.
Who’s who in the development of HBO?
The first real scientifically based therapeutic approaches were made by
Boerema in Amsterdam (1959) in the field of cardiac surgery with the
asystolic heart, and Brummelkamp (1961) in the increasingly frequent
treatment of gas gangrene. Since then the contribution of the Dutch school
has been central in research on infections causing soft tissue necrosis, and
their treatment by HBO. Ledingham in Britain, and Jacobson in the USA,
were also among the pioneers of HBO.
It is worth noting that in different countries physicians in various fields
of medicine and surgery were intent from the start in making progress in
Hyperbaric Medicine.
In France, following the suggestion of L. Barthélémy from the Toulon
naval Medical Institute, intensivists were the first to introduce HBO.
4 F. Wattel

M. Goulon, A. Larcan, J.M. Mantz, Ph. Ohresser, C. Voisin, L. Lareng and

J. Ducailar contributed to determining the indications of HBO for critically
ill patients.
In the United States, the influence of surgery can be found from the start,
including G. Hart and M. Strauss (indications for HBO in traumatology and
plastic surgery); J. C. Davis and T. K. Hunt (problem wounds and HBO) and
R. E. Marx (mandibular osteonecrosis and HBO).
In Italy, it was mostly anaesthetists/intensivists who took charge of HBO
from the start including A. Gasparetto, A. Gismondi, A. Sparachia and
others. In Spain, Internal Medicine specialists initiated Hyperbaric Medicine,
including J. Desola who has done excellent work in coordinating centres
there.
Where research on diving accidents is concerned, it is mostly those
countries with a strong tradition of diving for military purposes which have
made the greatest contribution to establishing diving profiles and
recompression tables. These tables have quickly been used for treating
recreational diving accidents.

1.3.2 What are the reference institutions for Diving and Hyperbaric
Medicine?

On the one hand, there are the national and European scientific societies;
and on the other, there is the European Committee for Hyperbaric Medicine
(ECHM).
- The Scientific Societies
Their duties are to promote knowledge in the fields of Diving and
Hyperbaric Medicine, organize scientific meetings and annual conferences
and publish study reports. Among the oldest are the “Société de Physiologie
et de Médecine Sub-Aquatiques et Hyperbares de Langue Française”
(MEDSUBHYP), along with the two Italian societies, one created by the
National Society for Anaesthesia and Intensive Care (SIAARTI), and the
other specifically geared towards Hyperbaric Medicine (SIMSI). German
(GTUM) and Dutch (NVD) societies are more involved with Diving
Medicine. The Swiss society (SUHMS) and the British Hyperbaric
Association (BHA) are involved in both aspects, whereas in Spain this role
is taken by the Coordination Committee of Hyperbaric Centres. However,
before 1989 there was not much cohesion between the various European
countries. There was also a lot of activity in communist Eastern Europe; but
we did not know much about that since even the Proceedings of the Moscow
meeting of the International College on Hyperbaric Medicine (ICHM) in
1981 appeared only in the Russian language.
The European Undersea Biomedical Society (EUBS) was founded in
1965. The main goal of the EUBS was diving and underwater medicine. In
1993, the EUBS changed its name to European Undersea and Baromedical
A History of Hyperbaric Medicine 5

Society in order also to include clinical Hyperbaric Medicine. This meant the
start of a very fruitful cooperation and even integration between Diving and
Hyperbaric Medicine. The same developments were seen in the USA, where
the Undersea Medical Society (UMS), founded in 1967, changed its name to
the Undersea and Hyperbaric Medical Society (UHMS) in 1986.
- The ECHM
The European Committee is not a learned society but an organization for
the promotion of Undersea and Hyperbaric Medicine on a European scale. It
is recorded that “during an informal and friendly discussion between some
distinguished gentlemen involved in Hyperbaric and Diving Medicine, the
necessity of founding a committee to improve the level of quality and
acknowledgement of Hyperbaric Medicine emerged in February 1989 in
Milan, Italy”. The next step was a first informal meeting between the above-
mentioned gentlemen (the founding members) in Lille, in November of the
same year. The founding members (D. J. Bakker, J. Desola, A. Marroni, D.
Mathieu, G. Oriani, P. Pelaia, J. Schmütz, F. Wattel (elected President) and
J. Wendling) decided to act as the Executive Board of the Committee. The
first plenary meeting (with representatives of all European countries) was
held in Amsterdam in August 1990. This occurred during a joint meeting
between the ICHM, the UHMS and the EUBS, the first in history. The
official founding, according to all necessary rules and regulations, of the
European Committee took place in Milan in 1991.
The goals for the Committee were defined as:
x Studying and defining common indications for hyperbaric therapy,
research and therapy protocols, common standards for therapeutic and
technical procedures, equipment and personnel, cost-benefit and cost-
effectiveness criteria.
x Acting as a representative body for the European health authorities of
the European Community (EC) in Brussels (Belgium).
x Promoting further cooperation among existing scientific organisations
involved in the field of Diving and Hyperbaric Medicine like Divers
Alert Network (DAN); Confédération Mondiale des Activités
Subaquatiques (CMAS); the European Diving Technical Committee
(EDTC); the UHMS, which acts as an international society although it
is American; the Japanese Undersea and Hyperbaric Medicine
Society; the South Pacific Underwater Medical Society; and the South
African Undersea and Hyperbaric Medical Society.
One of its main activities is the organization of European Consensus
Conferences and Workshops. Four workshops and seven Consensus
Conference have been organized over ten years. The last one took place in
Lille in December 2004 in order to review all the documents and literature
published since the first Conference in 1994. The ECHM list of accepted
6 F. Wattel

indications was up-dated, and guidelines for organization, safety, education

and research in Hyperbaric Medicine were issued, for the next 10 years.

2. STATE OF THE ART IN HYPERBARIC MEDICINE

The main aspects defining hyperbaric medicine today deal with

indications, design and safety requirements for HBO chambers and medical
equipment, staff training and continuing education requirements and
research protocols.

2.1 Current justified indications for HBO

An agreement was reached on indications during the Consensus

Conference which was held by the ECHM in Lille in September, 1994, and
updated 10 years later in Lille in December, 2004. To be deemed acceptable,
an indication had to be based on experimental and clinical studies carried out
with strict methodology and producing significant positive results.
In fact, one of the ways of assessing the efficiency of HBO is by referring
to the best data available from basic research, animal studies with control
groups and human studies following EBM procedures. This approach
involves: prospective, controlled, randomized clinical studies; quantified
results; collection of results through the Cochrane collaboration; and meta-
analysis of the various clinical studies.
The Jury issued its recommendations using a three-grade scale according
to the strength with which each recommendation has been evaluated.
Type 1 - Strongly Recommended: the Jury considers the implementation
of the recommendation of critical importance for final outcome
for the patient/quality of practice/future specific knowledge.
Type 2 - Recommended: the Jury considers the implementation of the
recommendation as positively affecting final outcome for the
patient/quality of practice/future specific knowledge.
Type 3 - Optional: the Jury considers the implementation of the
recommendation as optional.
The Jury also reported the level of evidence supporting the
recommendations.
Level A - recommendation supported by level 1 evidence (at least 2
concordant, large, double-blind, controlled randomized studies
with little or no methodological bias).
Level B - recommendation supported by level 2 evidence (double-blind
controlled, randomized studies but with methodological
flaws; studies with only small samples, or only a single study).
A History of Hyperbaric Medicine 7

Level C - recommendation supported only by level 3 evidence

(consensus opinion of experts).

Table 1. Accepted indications for HBO therapy (7th ECHM Consensus Conference, Lille,
2004)
CONDITION ACCEPTED
Level of Evidence
A B C
Type I
CO poisoning X
Crush syndrome X
Prevention of osteoradionecrosis after dental extraction X
Osteoradionecrosis (mandible) X
Soft tissue radionecrosis (cystitis) X
Decompression accident X
Gas embolism X
Anaerobic or mixed bacterial anaerobic infections X
Type II
Diabetic foot lesion X
Compromised skin graft and musculocutaneous flap X
Osteoradionecrosis (other bones) X
Radio-induced proctitis/enteritis X
Radio-induced lesions of soft tissues X
Surgery and implant in irradiated tissue (prophylaxis) X
Sudden deafness X
Ischemic ulcer X
Refractory chronic osteomyelitis X
Neuroblastoma Stage IV X
Type III
Post anoxic encephalopathy X
Larynx radionecrosis X
Radio-induced CNS lesion X
Post-vascular procedure reperfusion syndrome X
Limb reimplantation X
Burns >20 % of surface area and 2nd degree X
Acute ischemic ophthalmological disorders X
Selected non-healing wounds secondary to inflammatory X
processes
Pneumatosis cystoides intestinalis X

2.2 Hyperbaric equipment

Over the last decades, efforts regarding equipment have dwelt on safety
and reliability. The rules and regulations enforced on manufacturers and
users are stringent, particularly regarding fire hazards. Further progress has
been made through the medicalisation of chambers: there is more room,
and entry is made easier by rectangular doors. Nowadays, intensive care can
be provided just as efficiently in a hyperbaric chamber as in an ICU.
8 F. Wattel

- A therapeutic hyperbaric chamber shall be considered as a medical device

according to the European Council Directive 93/42 “Medical Products”.
- The performance, testing and safety requirements of new therapeutic
multiplace chamber systems shall conform with the new European norm
prEN 14931 CEN TF 127. All new chambers will be CE marked. Existing
chambers should strive to reach the same safety levels as required by that
norm.
- Quality assurance should be implemented in hyperbaric centres.
- Approval of medical devices for hyperbaric use is a worldwide problem.
With a few exceptions, there is a lack of CE marked medical devices for use
in the hyperbaric chamber. A risk evaluation according to the European
norm ISO 14971 should be performed before bringing medical equipment
into the chamber. Publishing and sharing experience and information on risk
analyses between European HBO centres are recommended. The
manufacturers shall be encouraged to extend the CE approval of their
medical devices for hyperbaric use.
The range of indications for HBO has led to the idea of equipment
functionality. To avoid treating a patient in critical condition and an out-
patient in the same chamber, it is useful to have a series of chambers linked
together with airlocks. One chamber is kept for emergency and intensive
care indications, another for programmed therapy of chronic diseases.
Lastly, there are chambers with specific equipment for performing function
testing for divers, hyperbaric workers or patients requiring HBO.
- The Jury strongly recommends that the European Code of Good Practice
for Hyperbaric Oxygen Therapy (ECGP) be the minimum requirement to be
fulfilled by European hyperbaric centres, as it was established by strong
consensus between internationally recognized European experts.
- The operations must be conducted under standard operation procedures
described in a specific manual. Each hyperbaric centre must develop
emergency procedures in the same way. The staff must review these
regularly, and should be trained in these procedures.

2.3 Staff training

2.3.1 Physicians

Medical professionals in Hyperbaric Medicine, whether physicians or

paramedical staff, require specific training. Medical training in this field
began over ten years ago in some European countries, but varying
approaches were made regarding training contents, organization, duration,
diplomas and their recognition.
A History of Hyperbaric Medicine 9

Aware of this disparity, fruitful cooperation between the Training and

Education Committee of the ECHM and the Medical Committee of the
EDTC has led to the drawing up of a proposal for common objectives, which
will provide guidelines for harmonizing training between the different
countries in Europe, and which could gain official recognition. It is within
the duties of the European College of Baromedicine to make this possible.
Requirements include :
- a curriculum drawn up for different categories of hyperbaric personnel,
describing the levels of competence according to profession,
- a core curriculum of modular teaching, applicable to all hyperbaric
personnel (medical and non-medical),
- education based on a modular system obtainable in different teaching
institutions throughout Europe, with mutual recognition of core standards,
and with a system of credits based on minimum duration and emphasis of
teaching elements. Entry criteria for the education of hyperbaric medical
personnel will depend on the competency ultimately required for the
professional category.
- the European College of Baromedicine, as supported by the ECHM, should
provide validation and accreditation for education and training in European
countries.

2.3.2 Paramedical staff

To this day, France, under the aegis of the Ministry of Work, is the only
country where a certificate of capacity for working in hyperbaric conditions
is compulsory for paramedical professionals. This certificate bears various
indications depending on the person’s profession, and different categories
depending on the pressure authorized.
A programme for the education and training of non-medical hyperbaric
personnel has now been developed by an association of non-medical
professionals (for example EBASS) in collaboration with the ECHM.

2.4 Research

During recent decades, many studies have been carried out both on
professional and recreational diving medicine. Oil exploitation in the North
Sea has provided a stimulus to teams working in Aberdeen, NUTEC
scientists in Trondheim and COMEX in Marseille. The world-wide
development of recreational diving has generated an increase in the number
of studies on diving capacities and therapy procedures for decompression
accidents. In the meantime, there has been an increase in the number of
fundamental and clinical studies, wherever possible prospective, controlled
and multi-centre.
10 F. Wattel

In 2001, updating the report J. Schmutz presented at the First Consensus

Conference in Lille in 1994, D. Mathieu drew up a status report of research,
by analyzing the Medline database for the years between 1996 and 2000. He
reported that the mean annual number of publications remained constant,
research teams were few, but their number remained the same; that there was
a large proportion of experimental studies, but this was decreasing; and that
there was a great increase in clinical research. He also noted the appearance
of prospective, randomized, controlled and in some cases double-blind
studies.
Comparing the type of publications referenced in the Medline database
between 1996 and 2000 in the fields of Hyperbaric Medicine, Intensive Care
and Surgery produced the following results: the number of publications
varied between 1 and 20 with regard to Intensive Care, and between 1 and
300 with regard to Surgery. Clinical studies were about the same in the three
fields; but the proportion of prospective randomized controlled studies, equal
in Hyperbaric Medicine and Intensive Care, was half that amount in Surgery.
This leads us to the conclusion that hyperbaric physicians are developing
high quality and pertinent clinical research.
As for research networks, it is to be noted that many studies are carried
out by local teams in temporary collaboration with local laboratories. This
explains why experimental studies are a majority; but it is in itself a
handicap for clinical research because each centre will have only a few cases
of the rarer diseases. The answer to this problem is the development of
multi-centre research networks.
Still, the experimental research performed in the last few years has
provided an understanding of the mechanical effects of HBO, offering new
perspectives. These concern the ischemia-reperfusion phenomenon, and the
effects of HBO on the leukocyte/endothelium interaction, inflammatory
reactions, defence mechanisms against oxidization and apoptosis, as well as
the impact of HBO on auto-immune diseases.
The Action B14 of the COST programme is an appropriate vehicle to
promote clinical research in Hyperbaric Medicine. Launched in 1998, it
involves 18 European countries. Its activities are based on working groups
guided by a steering committee, led by D. Mathieu. Among other projects,
methodology guidelines for research and a code of good practice for
Hyperbaric Medicine have been developed. Various clinical research
protocols involving multiple centres have been defined and initiated: sudden
deafness, femoral head necrosis, diabetic foot lesions, glioblastoma
radiosensitivity, bone regeneration in irradiated bones. A website “Oxynet”
ensures coordination (www.oxynet.org).
A History of Hyperbaric Medicine 11

3. CONCLUSION

On June 19th, 1997 a first careful attempt was done to compare the
European Committee indications with those of the HBO Committee of the
UHMS. Not only indications were discussed but also recommended
protocols, pressures and threshold treatment levels. The conclusion was that
similarities were far greater than differences, and that in the future the two
tables should be harmonized. Conditions not on both lists were to be
evaluated to resolve differences as soon as possible. It was also planned to
include the levels of recommendation for the ECHM indications as in the
HBO Therapy UHMS Committee Report. A joint meeting took place during
the Annual Meeting of the UHMS in Sydney in 2004; but a lot more work is
required, involving both the UHMS Committee and the ECHM .
At the beginning of the 3rd millennium, Hyperbaric Medicine appears to
be a grown-up field of medicine world-wide with its own approved and
accepted methods of evaluation of the efficacy and cost-effectiveness of
therapy following EBM methods. For Hyperbaric Medicine to gain complete
recognition as such, ethical and ecological considerations must be paramount
in clinical practice, research and training. For this, imagination and creativity
are more than ever a necessity.