Midnight in Missouri

Just before the end of your shift you decide to look at a rash in the waiting room.  This 35 y.o. complains of an itchy rash and shoulder pain. What is it?

Our patient had cutis marmorata, the “skin bends”.

 He was a diving instructor at Mermet Springs which is a flooded quarry within two hours of St. Louis where many Midwestern divers go to train. The quarry contains numerous objects on the bottom including a 747.   Our patient had done numerous 30 ft dives ( although the depth is actually over 100 ft) and states he “came up fast “ three times.  He noted a rash and also pain in both shoulders about three hours after he got out of the water. Although it may seem strange to see someone with the bends at midnight in Missouri, decompression illness was actuallyfirst described in st louis in 1871 during the building of the Eads bridge when 30 were injured and 12 killed from decompression illness.  Alphonse Jaminet, the physician for the project described the illness in himself and this is the first recorded documentation of what would later be known as the “bends” because of a dance popular at the time called the Grecian bend where dancers would bend at the waist.  The illnessoccurred in workmen who were in caissons pressurized to keep the river water out while the pillars for the bridge were being built.  It wasn’t until 1900 that Leonard Hill showed decompression causes bubbles to occur in tissues if it does not occur slowly enough to allow the lungs to expel nitrogen 

The bends can cause strokes and MIs.  Most frequently it affects the shoulders as in our patient, the elbows and the knees.  It is often accompanied by marmorata, the marbling of the skin thought to be caused by an immune reaction to the nitrogen bubbles. The rash is evanescent but the joint pain can be disabling. The findings in divers with decompression illness are usually 60-70%   pain , 10-15%  have neuro symptoms like confusion , seizures or cord infarct, and 10-15% have skin rash. 


People at risk include divers who fly after diving, space walkers,  and obese people since fat absorbs more nitrogen into tissues during the dive. Astronauts abourd the space station prepare for space walks by sleeping in a chamber with low atmospheric pressure for 8 hours before their walk.

In our patient his condition was recognized by Luke. He was put on 100% oxygen  and he was sent to St Lukes for a hyperbaric treatment . He underwent three hours of decompression and had no sequelae. 


Alcott, Chris 1999 A brief history of diving and decompression illness. South Pacific Underwater Medicine Society Journal.  South Pacific Underwater Medicine Society.  29(2) .

ButlerWP Caisson disease during the construction of the Eads and Brooklyn Bridges: A review 2004. Undersea and Hyperbaric Medicine. 31 (4) 445-59.