The first death from chloroform in France occurred in 1848, several months after Hannah Greener died in England. The French Government ordered judicial and medical inquiries. The Academy of Medicine set up a special commission which arrived at contentious conclusions. The patient, a healthy 35-year-old woman, needed surgery for an abscess that had formed around a foreign body resulting from a riding accident. Within a minute of inhaling from a gauze pad onto which 20 drops of chloroform had been poured, she exclaimed‘I am choking’, turned pale and died despite two hours of attempted resuscitation (involving insufflation of air into the airways) [7]. Malgaigne, who had presented his studies on ether anesthesia to the Academy one year earlier, led the inquiry. The Commission included Antoine Jobert (de Lamballe) (who had given the first ether anesthetic in Paris on December 15 1846), Alfred Velpeau (an adept enthusiast of surgical anesthesia), and Frédéric Blandin (author of a lengthy academic study on the effects of ether in 1847). Of the 13 Commissioners 7 were surgeons and the remainder veterinarians, pharmacists and chemists.

Malgaigne presented the Commission’s findings to the Academy in October 1848. They questioned the details of the report written by the surgeon who had conducted the anesthesia and operation, focussing on the dose of chloroform and the delay to the moment of death. They noted that the woman said‘I am choking’, indicating in Malgaigne’s view that the chloroform had not started to work. They suggested therefore that the sudden death was, without doubt, due to anxiety, or to a gas embolism (gas was found in the blood vessels at autopsy). Finally, the death was attributed to asphyxia (as Simpson had suggested for Hannah Greener). Other deaths occurred subsequently, but such cases were rare, being less than a dozen in one year out of several hundred chloroform anesthetics. Concerning the overall safety of chloroform, Malgaigne noted that ‘one could not set up rules starting from exceptions. It was only necessary therefore to introduce certain precautions to avoid asphyxia’.

This conclusion was not unanimously accepted, some members of the Commission noting that sudden deaths had occurred in animals as well as in humans. Blaming chloroform might mean abandoning general anesthesia itself, despite the successes with ether. Velpeau hoped that ‘for the honour of chloroform’ the real cause of the deaths would be found. Jules Guérin (1801–1886) supplied the most virulent criticism, saying that to deny chloroform as the cause of death ran contrary to the facts and would render the Academy responsible for future accidents. He suggested a research program to establish the contributions of dose, setting, delay of action, and supply, through a program of animal experiments. This program had been preceded by intensive research on many animals (mostly dogs, but also including rabbits, chickens, birds and frogs) conducted by chemists, veterinarians, and surgeons, including some members of the Commission. Guérin himself had studied the effects of chloroform on dogs, rabbits and frogs. However, Malgaigne remained content with clinical experience alone and thereby began a bitter dispute in which he denied the fact that Guérin had experimented on anesthetics. Further, he insinuated that Guerin had previously referred to ‘non-existent results’, inferring that Guérin was a liar. Guerin made no immediate response to this accusation but went on the attack the following day.

The confrontation had nothing to do with the anesthetic question. The real reason was a quarrel beginning ten years earlier. Both were surgeons, members of the Academy, and directors of medical journals’and their dispute had only been resolved a few months previously. In his journal, Guérin had reported on tenotomies for correction of club foot and spinal deformations. Of 750 operations, he described 650 cures or improvements. Thinking these results to be too good to be true, Malgaigne had attacked Guérin who then sued Malgaigne for defamation. Guérin won this case, but Malgaigne, having pursued the matter legally, attracted public attention by his eloquence. Guérin then asked for, and won the right for a Commission to judge the results of his new cases occurring during the following 3 months. The Commission judged that the results were consistent with those that Guérin had previously reported, and the Commission noted ‘Mr Guérin had brought honour to science and to humanity’. (Fig. 28.2)

During the following days, Guérin threw down the gauntlet declaring ‘In deference to all I had to refrain previously from rising to this provocation. However, now you will no doubt be ready to provide the satisfaction that is normal among persons of honour’. Malgaigne refused the invitation to duel but also refused to withdraw his accusations.

The Academy, wishing to end this affair quickly, voted on 6 February 1849, to accept the conclusions of a new report about chloroform. The conclusions were identical to those of the first report, adding that rules could not be established ‘on the basis of exceptions’. Chloroform was thus reinstated although, on 24 January 1849 in Lyon, another fatal accident was immediately reported in the journal, L’Union Médicale, with the objective of persuading the Commission to alter its conclusions.. After this latest accident, the surgeons of Lyon completely abandoned the use of chloroform, however they remained at odds with most other French surgeons who, as in England, used it successfully over much of the nineteenth century.

Based on the work of Paul Bert (1833–1886), the use of nitrous oxide increased in the latter half of the nineteenth century, with ethyl chloride appearing at the end of the century. In 1908, the Parisian surgeon, Louis Ombrédanne (1871–1956) described his ether inhaler. It was a modification of Clover’s inhaler, which he criticised “….as these are not provided with means of admission of fresh air, they rapidly produce cyanosis if one does not constantly raise the mask from the face.” Ombrédanne’s ether inhaler allowed the regulated admission of fresh air, and soon became the most commonly used apparatus in France, displacing the use of chloroform. It also became the usual means of anesthesia in many countries around the world, particularly Latin America.

Several other developments took place. Intravenous anesthesia, first used by Cyprien Oré (1828–1889) with chloral hydrate in 1872, was adopted from 1935 with the arrival of barbiturate compounds from Germany. Henri Laborit (1914–1995) described ‘re-inforced anesthesia’ using other compounds, notably neuroleptics, antihistamines and morphine-like compounds, which had the ability to ‘produce anesthetic states without using anesthetics’. His work also included the discovery of gamma hydroxybutyrate and its anesthetic effects.

Local anesthesia was largely the surgeons’ domain. It started with simple infiltration (Paul Reclus 1847–1914), followed by nerve trunk blocks introduced by Victor Pauchet (1869–1936) and his pupil Gaston Labat (1876–1934). Finally, Théodore Tuffier (1857–1929) followed in the path of the German August Bier (1851–1949), and popularised spinal block. This new technique appeared shortly before caudal epidural anesthesia, which was discovered independently by Fernand Cathelin (1873–1945) and Jean Athanase Sicard (1872–1929) in1901.

In the late 1940s, Daniel Bovet (1907–1992) at the Institut Pasteur synthesized new muscle relaxants, used in clinical practice by Pierre Huguenard (1924–2006). Powerful opioids were discovered by the Belgian Paul Jansen (1926–2003) in 1961, and were tested by his fellow countryman Georges de Castro (1918–1990), who also worked in France.

Anesthesia in France was based almost entirely on the use of the Ombrédanne ether inhaler well into the twentieth century. The context of the times slowed professional progress. At the end of World War II, the French hospital system was essentially an antiquated nineteenth century structure. Doctors, surgeons and anesthetists were employed part-time, working on a voluntary basis in the mornings and earning their living in private practice in the afternoon. Surgeons reigned supreme and guarded their privileges.

In 1946, a dedicated anesthetist, Ernest Kern (who had obtained his Diploma in Anesthetics in England) reflected the stagnation pervading the medical services, in his book,Mes Quatre Vies [8]. He described several anecdotes that followed his return to France after the Libération:

– After asking for some modern anesthetic equipment, the director of a clinic replied ‘we have used the Ombrédanne inhaler in France for 100 years to everyone’s satisfaction. I do not see why we should change now to expensive foreign techniques. If you want other equipment you just have to bring it in yourself’.

– For one anesthetic he recalled ‘I did not have curare available at the time and so used cyclopropane (which was at that time very expensive). This achieved perfect muscle relaxation and the surgeon thought the anesthesia was excellent. With total disdain the operating theatre sister threw me two 100 franc coins (the sum usually given to the theatre porter for giving the anesthetic). But this anesthetic had cost me five times as much…’

– In 1946, Kern presented a lecture to the Société Française d’Anesthésie et d’Analgésie (SFAA) on controlled respiration during thiopental and curare anesthesia. Afterwards, the President, surgeon Pierre Fredet (1870–1946), observed ‘God caused man to breathe and God alone has the right to take away breathing. I challenge any man and any anesthetist to have this right; that would be sacrilege’.