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Review

History of anaesthesia: early forms of local anaesthesia

Zimmer, Marguerite

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European Journal of Anaesthesiology: January 2014 - Volume 31 - Issue 1 - p 1-12
doi: 10.1097/EJA.0b013e328365ad7c
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Abstract

Introduction

The introduction of general anaesthesia in the 19th century was one of the most important events in medical history, but it is largely forgotten that the anaesthetic agents employed were also used topically. The knowledge that cold could induce a degree of numbness locally to aid surgical incision and dissection predated the discovery of general anaesthesia. One way of achieving this was through the latent heat of vaporisation of topical applications of volatile agents. Édouard Robin in 1851 developed a hypothesis to explain the differences that existed between the various routes of administration of these agents. He proposed that, depending on the dose, they could function as sedatives, anti-inflammatory agents or asphyxiant poisons. For topical application, he regarded a boiling point of 80°C as a threshold; greater than this meant that the latent heat of vaporisation was insufficient to adequately chill the tissue for a surgical incision. Any mechanism of action was dependent on an intrinsic local anaesthetic action. If the boiling point was lower than this, evaporation was too speedy to achieve an intrinsic local anaesthetic effect, and anaesthesia could only be obtained by cooling (local) or through inhalation (general).1

The list of substances used topically included chloroform, Dutch Oil (ethylene), vaporised ether, methylene, and finally, fumigations with carbonic acid gas. Some of these were used for their cooling effects, and some for their local anaesthetic properties.

Early use of cold

It was in 1807, during the battle of Eylau, that Napoleon's surgeon Dominique Larrey observed that applying snow or chilling a limb was very helpful when amputation was needed. This appears to have been forgotten until August 1836, when P. E. Barthélémy, a doctor from Saint-Ouen, presented his thesis ‘De la compression considérée comme moyen thérapeutique, et d’une nouvelle manière de l’exercer au moyen du caoutchouc’.2 He proposed that similar therapeutic benefit might be obtained by localised compression of a limb. Barthélémy patented the device he invented to achieve this in January 1838. Subsequently, Marie Maurice Gariel appropriated Barthélémy's ideas, and after failing to impress the French Academy of Medicine, he sent an article to the Academy of Sciences. This institution immediately nominated L-J.S. Thillaye, Jean-Louis Marie Poiseuille and Antoine-Constant Danyau as commissioners to report on Gariel's work, resulting in an award to him of 200 Francs. Not surprisingly, Barthélémy angrily claimed in a letter to the Academy of Sciences that his invention had precedence. His protests were relayed to the commission in 1851 and Danyau promised to visit Barthélémy's workplace, but failed to keep this promise. Barthélémy sent a new letter to the Academy of Sciences on 3 May 1852 where the whole affair is described. This letter has been preserved.3

The British interest

Around this time, in June 1842 in the UK, James Arnott,4 a surgeon from Brighton, suggested using cold or warm water drained from a reservoir into a bladder or a rubber bag, and then laying it on the skin (Fig. 1). This system allowed the tissue temperature to rise or fall in a uniform and constant manner. Arnott5 published further comments in The Lancet in 1848, concerning local insensibility induced by ice for operations that required a simple incision. Instrument makers such as Forster in Brighton and William Hooper in London were soon interested in Arnott's method. William Hooper marketed a device, the so-called ‘Hooper's Water cushion’.

Fig. 1
Fig. 1:
No captions available.

Arnott encountered considerable difficulty trying to convince French doctors of the advantages of his idea. In November 1849, he went to Paris and gave several demonstrations on local anaesthesia by cooling. A big abscess could be incised and ingrowing nails could be removed without the inconvenience and risk of chloroform inhalation. Freezing could, however, produce necrosis. To prevent this occurring, the application of cold mixtures was recommended only for a very short time. In January 1850, Auguste Nelaton6 employed Arnott's method with great success. At the Val-de-Grâce, refrigeration was used by the army surgeon Jean-Baptiste-Lucien Baudens7 to bring down the temperature of inflammatory lesions and traumatic injuries with suppuration, or when a pseudomembrane appeared on an amputated leg. Baudens had served in the Crimean war and had this experience behind him. He had learnt to add salt to cooled water to bring the temperature down further.8 For disorders of the eye, Édouard-Pierre-Marie Chassaignac obtained very good results from cooling for the treatment of cataracts.9

Making ice

To produce ice very quickly and in great quantity was difficult. The pharmacist Jean Baptiste Alphonse Chevallier and the French physician Jean-Louis Poiseuille suggested putting sodium sulphate and hydrochloric acid in the ice and water container.10 Chevallier had copied the procedure from the confectioner Fumet, (25 rue Helder, Paris), who had taken up one of the 28 formulae given by Walker, a pharmacist of the Radcliffe Hospital in Oxford in 1788 to Henry Cavendish. Mateo José Buenaventura Orfila found it easier to produce ice at a lower cost by mixing water, ammonium nitrate and hydrochloride salts.11 The process of dissolving ammonium nitrate in water is endothermic; it requires heat, which it takes from the surrounding water. The cooling water forms ice.

Following in Arnott's footsteps, on 14 August 1854, Walter Blundell,12 a London dentist, let a mixture of ice and salt melt in the bladder of a rabbit and then applied it to the gum of his patient. Not only was this helpful to cool an acute swelling of the gum or soothe an sensitive tooth, it also offered a safer alternative for tooth extraction at a time when general anaesthesia with ether or chloroform was considered dangerous. The same year Blundell published a booklet entitled ‘Painless tooth-extraction without chloroform, with observations on local anaesthesia by congelation in general surgery’.13 He patented his method in France (Fig. 2). Blundell thought that it was unjustified to inhale chloroform in dentistry. An extraction of a tooth should not expose the patient to risk of his life.

Fig. 2
Fig. 2:
No captions available.

In France, the use of cooling was introduced into dental surgery by J.B. George, in December 1856. George presented his apparatus to the Academy of Sciences and to the Academy of Medicine.14 It took only 3 to 5 min to anaesthetise a tooth. On 13 December 1856, the Perpetual Secretary of the Academy of Medicine nominated two commissaries, Jobert de Lamballe and Jean-Étienne-Victor Oudet, to examine George's invention. George claimed that he had been inspired by the research of Alfred Velpeau and completely ignored the work of Arnott and Blundell. George criticised the recipe of Orfila in which the temperature of the mixture fell as low as –12°C, something that interfered with the properties of the rubber bags. Finally, George published his leaflet ‘Étude sur l’anesthésie locale dans ses applications à l’art dentaire et moyen de supprimer la douleur dans l’extraction des dents aussi bien que dans l’odontalgie’.15 The concept spread widely and quickly; by the end of 1856, C.S. Putnam16 from New York (who in 1860 was the Editor of the ‘Revue odontotechnique franco-americaine’) had also invented an apparatus to anaesthetise teeth by applying cold (Fig. 3).

Fig. 3
Fig. 3:
No captions available.

Chloroform

Following reports of the success of inhaled chloroform, other routes of administration were tried. The first oral preparation was formulated by Louis Melsens, a Belgian chemist, in the laboratory of Jean-Baptiste Dumas in Paris. Nathalis Guillot in 1844 is credited with the first clinical use. He used it as a sedative in cases of hysteria and chorea. Joseph-Augustin Delioux de Savignac from the military hospital in Rochefort proved that a light anaesthetic state could be obtained by swallowing syrup containing 50 μg of chloroform. Most of the activity, however, was directed at topical preparations.

Having heard that Pernot,17 a dentist from Limoges, extracted teeth without pain by rubbing the gum with a stupefying substance, James Young Simpson, the discoverer of chloroform anaesthesia, carried out his own experiments on small animals. Amongst the substances he investigated were the vapours of various ethers, carbon bisulphide, benzene, aconite, methyl iodide and aldehyde. Finally, Simpson proved that chloroform could produce local paralysis when applied on a region of the skin. It was absorbed by the skin and acted directly on superficial muscle and nervous tissue. A hand, immersed in a jar containing vapours of chloroform, was anaesthetised deeper than with the other agents tried. He recorded his investigations in several essays published in February 1848.18

Simpson's essays had an impact in France when, on 13 August 1848, Jacques Joseph Moreau applied chloroform locally to treat lumbago.19 Other applications were then sought throughout Europe for a variety of conditions. Paul Hervier and Bretin20 in Lyon, and H. Fricaud21 in Sémur en Brionnais tried it for neuralgia. Fulgence Fiévet de Jeumont,22 an aide-major of the 3rd Bataillon de la Garde Mobile, applied it in cases of sciatic neuritis, gastralgia, uterine pain due to cancer or in a poultice for paronychia or strangulated hernia. Fiévet mixed chloroform with oil of cajeput, made from the leaves of the Melaleuca trees, found in Malaya and Indonesia. In 1854, the chemist Louis Figuier built an apparatus to vaporise topical chloroform, but, when tested at the Lariboisière hospital, the local anaesthesia was not wholly effective.23 Two years later, in 1856, Giovanni Ruspini, a pharmacist from Bergamo (Italy), prepared chloroform for the first time as a gel, a much more practical formulation.24 It proved so convenient that Bouron des Clayes, a physician from Créteil, (106 Grand-rue), carried it around in a suitcase to treat cystitis, gout, lumbago, gallstone crisis, sciatic neuritis, stiff necks and postoperative wound pain. Gelatinous chloroform ointments became a universal remedy.

Topical application of Dutch liquid

Chloroform was not the only agent used in topical experiments. François-Amilcar Aran was influenced greatly by François-Achille Longet, Marie-Jean-Pierre Flourens, Ernst von Bibra and Emil Harless’ experience with the action of anaesthetic agents on the nerves. He thought that Dutch Liquid or Dutch Oil (ethylene) would prove a better local anaesthetic. It had the advantage of being less irritable to the skin than chloroform.25,26 Aran treated lead poisoning and acute rheumatic fever with Dutch Oil, the anaesthetic having been manufactured by the pharmacist Louis Mialhe. Aran went on to prove that the more an anaesthetic vapour evaporated from the skin, the less its local anaesthetic action would be. Dutch Liquid was less volatile than chloroform, and was, therefore, superior topically. Chloroform, being less volatile than ether, was a more effective local anaesthetic than various ethers. He also experimented with local applications of ‘ether chlorhydrique chloré’ (ethyl chloride) prepared by the chemist Émile Rousseau, which gave excellent results in articular disorders, especially Bouillaud's disease, acute rheumatic fever with carditis. As ethyl chloride is a vapour at room temperature, its success was probably due to chilling from the latent heat of vaporisation rather than an intrinsic local anaesthetic effect. Although most of the applications discussed are historical, the principal used here is the same as that of the football physiotherapist who carries an aerosol in his bag to treat injuries.

In 1864, the Parisian chemist Émile George,27 suggested that amyl hydrate, a tertiary amyl alcohol, in the form of a spray might be useful in short operations (Fig. 4). Amyl hydrate was inexpensive and easily available in the USA. It could be sprayed on the eyes, the gums, the anal mucous membranes or used for lachrymal fistulae and ingrowing nails. By all accounts, insensibility was complete, so if this was as simple and effective as was claimed, it is not clear why uptake was not widespread.

Fig. 4
Fig. 4:
No captions available.

Topical application of sulphuric ether spray

The first volatile anaesthetic agent was sulphuric ether, and as early as 28 February 1842, Vigier d’Amfreville in Calvados, Normandy, suggested giving a continual irrigation with sulphuric ether for the reduction of a strangulated hernia or as a direct application on a tumour.28 He claimed that his technique was successful, and the mechanism of action was probably cooling, but the method was forgotten. Other uses concerned the treatment of pain, and this was of interest to Jules Roux. On 27 November 1848, he presented his classification of surgical pain into three categories:29 the pain of the operation itself; the pain following the operation; and the pain appearing during the period of healing. The discovery of anaesthesia had of course resolved the first point; nevertheless, pain remained a problem after the operation. Roux proposed to treat the wound in question with liquid ether, applied over 5, 10 or 15 min. This could be done directly on the wound with a sponge with threads of old linen or, if necessary, with a syringe. He applied the physiological theories published by François-Achille Longet30 earlier in 1847. Longet had proved that a nerve exposed to ether vapour or ether in its liquid form became insensible. After 12 or 15 min, axonal transmission was completely suspended. On 2 December 1848, at Cherbourg Hospital, Roux31 locally applied a sponge impregnated with sulphuric ether to the inflamed wound of a patient, who continued to inhale chloroform from the apparatus that Roux had invented. He concluded that the topical etherisation of traumatised tissues considerably diminished pain.

In 1854, the surgical instrument maker Louis Mathieu built an apparatus with a small ether irrigator for the physician Alphonse Guérard. This apparatus could project a stream of ether vapour onto the skin to facilitate excision of sebaceous cysts, ingrowing nails and other forms of minor surgery. It can still be seen at the Musée de l’Hôpital maritime de Rochefort.32 Several accounts of the use of Guérard's apparatus are provided by Charles Richet.33 He thought that sulphuric ether was the best local anaesthetic, as it did not irritate the skin and its evaporation was very prompt.

Sulphuric ether was also put to use to create a new branch of medical therapeutics. The vapour was added to the sulphurous mineral water of Pierrefonds-les-Bains and sprayed into the respiratory rooms. The first tests were performed in 1856 by Jean Sales-Girons,34 a physician and inspector of the water springs from Pierrefonds-les-Bains. Very soon the spas at Biarritz, Arcachon and Trouville had water respiratory rooms, but they were only open two or three months of the year. This problem was solved by the invention of portable apparati to be used at home and built in 1862 by Jules Charrière, a surgical instrument maker, for the spraying of medical liquids to treat pulmonary diseases (Fig. 5).

Fig. 5
Fig. 5:
No captions available.

Another apparatus was built by William Krohne, the London surgical instrument maker. Émile Siègle, an otorhinolaryngologist from Stuttgart, took out a patent for a modification of this apparatus on 7 April 1864. It allowed the spraying of liquids and was tested with rectified sulphuric ether. It was used in cases of angina, pharyngitis, laryngeal abscesses, pneumonia and tuberculosis, but its freezing power was not enough to make it useful in surgical procedures. Siègle modified the device by surrounding the ether pipe with a mixture of ice and salt, cooling sufficiently to allow him to extract teeth or to prick the skin without pain. The best known apparatus was that of Benjamin Ward Richardson (Fig. 6). Richardson's ether spray was used for the first time on 11 December 1865 for the extraction of an upper incisor.35 Richardson drew his inspiration from the device of Siègle and added a system of bellows (built by Andrew Clarke) to the apparatus. In 30 s, the temperature of the spray reached −4°C. A witness to its use, William Waite,36 noted that the extraction of teeth was painless. On April 1866, Leonard W. Sedgwick described an amputation of a breast at St Mary's Hospital in London with the help of Richardson's apparatus.37 Richardson's device was used in hospitals for oophorectomy, phimosis, a Caesarean section, amputation of a finger, lumbago, spraying on the spinal column in chorea and other diverse indications. To make it more efficient at freezing Richardson's spray was modified by the addition of a pump, by the student Stapfer and surgical instrument makers Émile Galante and Robert and Collin.

Fig. 6
Fig. 6:
No captions available.

Other devices for anaesthesia with an ether spray appeared; one was the apparatus of Guerard-Mathieu,38 and in Montpellier, Charles Gensollen39 and F. Martin40 (Fig. 7) designed an apparatus to speed the freezing effect of ether. It had two pipes emerging from a cylinder curved around a glass bottle, and it was possible to obtain a spray at –16°C or –17°C. The device was used successfully by Garimond at the Hospital Saint-Éloi, in Montpellier, by Léon Labbé for extraction of teeth and by Frédéric-Étienne Bouisson for an amputation of the leg.

Fig. 7
Fig. 7:
No captions available.

Another apparatus for spraying ether specifically into the mouth or on the skin was patented by Otto Moecke in Leipzig in 1881. The surface of this device was so cold that tissue samples placed on it could be sectioned by the microtome for histological study. A comparison of his apparatus with the device presented at the Société de Biologie by Raphaël Blanchard41 in the name of Ladislas Lesser, in June 1882, shows that they are identical. The technique was to apply two plates to the skin of a finger, arm or on an inguinal swelling, and to cool them very quickly with a spray of ether. Lesser performed various amputations, tonsillectomy and extraction of teeth with success but its employment was limited to operations involving mucous membranes, pharyngeal and laryngeal procedures.

Methylene vaporisers

By 1875 the vogue for local anaesthesia with ether or a mixture of ice and salt had wained, and their use became exceptional. In 1878, following the precepts of the chemist Isidore Pierre, fellow chemists Camille Vincent and Delachanal studied the density and the coefficient of expansion of the methylene chlorides. In 1880, their attention had settled on the properties of a mixture of gaseous methylene chloride and alcohol, for which Vincent had to invent an apparatus in which the gas could be stored. In November 1884, he patented a new vaporiser to deliver the freezing mixture. It was used in surgery by Georges Maurice Debove42 to anaesthetise superficial nerves and was sold by Henri Galante and Sons in Paris. The system was used in dental surgery by Victor Galippe, but the great intensity of cold produced made its use in dental surgery difficult. Charles Bailly from Chambly found that by pouring a mixture of methylene chloride and ether onto cotton and silk plugs, he could arrest surgical bleeding effectively. This was also used in acute sciatica, lumbago, incision of abscesses, scarification and cauterisation. The results obtained in dental surgery were presented by Dunogier43 from Bergerac at the First International Dental Congress in Paris, in 1889.

Mastering the projection of cold was very difficult. The obstruction of the filter or aperture of the devices used for the spraying of anaesthetic liquids became a major challenge for instrument makers.

Kelene or ethylene chloride vaporisers

Kelene or ethylene chloride very quickly superseded methylene chloride. It was prepared by the manufacturer Gilliard, Monnet and Cartier and the chemical society Les Usines du Rhône. By 1890, the chemist P. Monnet from Lyon was storing ethylene chloride in glass tubes. In this form it was used for the first time in the Lyon hospitals in October 1890 by Louis-Auguste Rougier to treat shingles. The liquid was heated by the surgeon's hand. He had only to break the tube and the contents evaporated. An alternative and better known apparatus was the device of the pharmacist Dr Bengué.44 Unfortunately this was impractical in dental surgery because it had a fixed straight nozzle that did not permit spraying of the gums of superior molars. This problem was resolved by Georges Goddé in November 1893 and only a month later, by Émile Guilmeth; both patented new devices, respectively called the Cryogène (Fig. 8) and the Coryleur. Goddé and Guilmeth based their systems on Bengué's but with a new design of the nozzle that improved precision of the jet.

Fig. 8
Fig. 8:
No captions available.

If methylene chloride spray chilled too severely and ethylene chloride evaporated too quickly, then perhaps there was an advantage in combining them. An apparatus with a mixture of both chlorides emerged in 1892, when G. Joubert and Cie, populariser of the Coryl-coryleur, presented their new device at the Brussels Congress. The dentist Jules D’Argent used it in January 1893, and in French, Belgian and Dutch hospitals, it was used for the incision of abscesses, whitlows, lumbago and other conditions.45 One of the inconveniences of the Coryl-coryleur was the necessity to maintain the temperature of kelene at −20°C or −25°C. Higher ambient temperatures made this more difficult and was probably responsible for the Coryl-coryleur's failings.

On 28 October 1895, Bertrand Bourdallé (a pharmacist) and Charles Berthemet (a banker) invented a chloromethylene vaporiser that could be used with methylene bromide. Émile Sauvez46 found that this apparatus of Bourdallé had advantages, and he presented it to the International Congress of Medicine in Moscow in 1897. The bottles could be filled by the surgeons with the help of a choridemethyliser can, creating a saving of 35% of the anaesthetic agent. Anaesthesia was complete after 15 or 20 s and analgesia was effective for 20 or 40 s, a period of time that permitted the extraction of a tooth or the incision of an abscess.

Carbonic acid vapour

Discovered by the Flemish chemist Jan Baptist Van Helmont in 1648, carbonic acid gas (carbon dioxide) was investigated by Robert Boyle and Jean Bernouilli in 1696, then by Stephan Hales, Joseph Black (1757), Henry Cavendish and finally by Joseph Priestley in 1771. It could be produced by pouring small quantities of hydrochloric acid or sulphuric acid onto pieces of marble or chalk in water. It was Antoine Laurent de Lavoisier who, in 1776, described its composition and gave it the name carbonic acid. Priestley recommended its use in continuous putrid fever. According to Albert Le Play,47 the physicians of the end of the 18th century, Mathew Dobson,48 William Falconer, John Ewart from Bath, William Hey of Leeds and Thomas Percival49 employed carbonic acid gas baths in the treatment of ulcers, cancers and various wounds.

Jan Ingenhousz was a Dutch physiologist, biologist and chemist who followed Priestley's research and corresponded with Henry Cavendish. He must also have known Thomas Beddoes, who established the first institute for pneumatic medicine in Bristol, England. Ingenhousz asked Beddoes to apply a preparation of Cantharis, or Spanish fly, to the skin of his left hand. This was irritant to the skin and made it blister. Having found that the vesicle formed was particularly painful in contact with air, Beddoes knotted a bladder filled with carbonic acid gas over his finger. Pain immediately ceased, but insensibility continued only while the finger was kept in the bladder. On contact with air, the pain reappeared. After learning of this experiment, John Ewart50 immediately tried to find a more appropriate application. A bladder filled with carbonic acid gas and applied to an ulcerous cancer of the breast stopped the sharp ache experienced by the patient. Nevertheless, the method was quickly forgotten, probably because the effect of local anaesthesia was so short. Some 62 years later, François-Anthime-Eugène Follin51 translated Ewart's observation into the Archives Générales de Médecine, where he reported in detail the method used.

To separate production and application of the gas, and to generally facilitate the process, the problem of storage had to be resolved. Humphry Davy, who was employed by Beddoes at his Pneumatic Institute, had been the first to show that it was possible to liquefy gases by submitting them to a pressure of 36 atm at 0°C. Accordingly, in 1834, Adrien Jean-Pierre Thilorier52 manufactured a pressurised container of liquid carbon dioxide. He had found that when directing a carbonic acid gas spray from a gas flask, the bottle quickly filled with a powdery, fleecy white substance that clung to its inner surfaces. This process was further improved 10 years later, in 1844 and 1845, by F. Donny and J. Mareska.

Applications in the medical world

In 1834, Benedetto Mojon, a physician of Genova, suggested that fumigation with carbonic acid vapour would regulate the periods in amenorrhoea.53 The treatment needed a double piped flask with one-third filled with white marble powder on which he gradually poured sulphuric acid. Carbonic acid vapour escaped quickly from a nozzle placed in the vagina. Pain disappeared instantly. James Young Simpson applied Mojon's technique in 1856, to diseases of the womb. Although he was credited for the technique, Adam Raciborski54 claimed precedence for his friend Mojon. In his book, Raciborski55 reports Mojon's experiences up to 1844. On the 29 September 1856, Follin applied Mojon's technique to cancers of the womb and to treat abscesses. Diffusing into the capillary vessels, carbonic acid gas produced superficial tissue asphyxia and an analgesic state.

Improving delivery of carbonic acid gas

The administration of carbonic acid gas was improved with a new apparatus invented and patented in October 1856 by the Mondollot Brothers of Paris, who, for their endeavours, received the medal of Merit and a medal of honour at the World Fair of Vienna in 1873 (Fig. 9). Their apparatus produced a great quantity of gas, but due to its size, its use was limited to the hospitals where it was housed. One of these was the Maison Royale de Santé du Faubourg Saint-Denis in Paris, where Jean-Nicolas Demarquay and Frédéric-Clément-Constant-Gustave Monod decided to use the Mondollot Brothers’ apparatus for cancers of the breast and carcinoma of the womb.56 The so-called ‘apparatus of Demarquay’ was in reality that of the Mondollot Brothers, in cylindrical form, equipped with a manometer for the measurement of atmospheric pressure. It could contain 5 or 6 l of gas and was less brittle than earthenware or glass instruments.57 Very soon the method was used to treat other diseases. Paul Broca58 and his colleagues injected carbonic acid gas into the bladder to soothe neuralgic pain of the urinary tract. Anaesthesia was effective for approximately 24 h.

Fig. 9
Fig. 9:
No captions available.

At the Hospital La Charité, the pharmacist Mathurin-Joseph Fordos59 manufactured a smaller apparatus (Fig. 10) made with thick glass, of 1 l capacity, which was similar to Simpson's vaginal injector.60 Fordos’ apparatus was presented to the Academy of Medicine on 24 November 1857 and was sold by the instrument maker Charrière. Both François-Anthime-Eugène Follin and François-Amilcar Aran used it in their hospital practice.

Fig. 10
Fig. 10:
No captions available.

The price of the Mondollot Brothers’ apparatus, its dimensions and the high working pressures that had to be mastered made it necessary to build a simpler, less dangerous device. This came from Constantin Paul, who adapted a pipe holder constructed by Charrière to the soda water apparatus of Briet.61 The great advantage of this was that it offered a vaginal douche that could be used at home. This had gynaecological and obstetric applications; Constantin Paul recommended it not only for dysmenorrhoea, congested uterus, itch, vaginal spasms, menstrual pain and ulceration but also to stimulate delivery. This apparatus saw several years of use.

In 1867, Jules Roger62 studied the different effects of carbonic acid gas on mucous membranes like ocular, nasal, buccal, stomach, bladder or vaginal membranes. Carbonic acid gas in the eyes produced watering. On the nasal membrane, the effect was described as ‘like a belch from drinking sparkling wine’. In the mouth, there was no anaesthetic effect. In the stomach, carbonic acid gas anesthetised the extremity of the nerves and made digestion much easier. It also stopped vomiting.

In his thesis ‘De l’anesthésie locale par la pulvérisation de l’éther et description d’un nouveau pulvérisateur par le gaz acide carbonique’, Albert Le Play63 gives a description of another vaporiser, which was built by Mathieu, an instrument maker. Le Play thought that it would be possible to lower the temperature and improve sedation by combining ether and carbonic acid gas. Unfortunately Le Play's apparatus did not give the expected results. At Bicêtre, on 4 August 1866, an anaesthetic given with Le Play's apparatus by the surgeon Paul Jules Tillaux for a tenotomy was shortlived.

On 3 May 1881, Augustin-Louis Boulanger invented and patented yet another new apparatus (Fig. 11). It could be used both at home and in the hospital and made visiting very expensive spas unnecessary. This was of benefit to the working class and farming community, who tended not to frequent such places. Its major inconvenience was that it had become so accessible that it could now be used without the control of the physician.

Fig. 11
Fig. 11:
No captions available.

Conclusion

By the end of the 19th century, surgeons and physicians had several methods of producing local anaesthesia at their disposal. Their popularity came and went in a series of medical fashions, and despite all the claims made for the various techniques, they were to be almost completely replaced by the introduction of cocaine.

Acknowledgements relating to this article

Assistance with the review: I am grateful to David Wilkinson for his extensive editorial revision.

Financial support and sponsorship: none.

Conflicts of interest: none.

Presentation: none.

Comment from the Editor: this review is part of a ‘History of anaesthesia’ series that is edited by Dr David Wilkinson.

References

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