B-ENT, 2007, 3, 217-230

A Historical Vignette“Be proud of yourself: you have a History!”

Dr Bonain, an ENT surgeon with an ocean background

J. Tainmont

Winston Churchill Avenue 172, Box 9, 1180 Brussels, Belgium

Key-words. Bonain's mixture; anaesthesia of the tympanic membrane; diphtheria of the larynx; naval surgeons; AlbertCalmette; Emile Moure; Emile Roux; Joseph O’Dwyer

Abstract. Dr Bonain, an ENT surgeon with an ocean background. Bonain’s liquid, otherwise known as Bonain’s mixtureor Bonain’s solution, is universally known and still in use. How many medicines can say the same after a hundred years?By contrast, Jules Aristide Bonain, a physician from Brittany, remains unknown. We pay a tribute to him in this paper,describing the origins of the famous solution, as well as Bonain's role in the treatment of diphtheria and his surprisingearly career as a naval surgeon, which led him to participate in France's colonial adventure at the turn of the 20th cen-tury.

Figure 1Portrait of Dr Bonain (1860-1934) from the “GalerieInternationale des Oto-rhino-laryngologistes” published in1908 in the “Revue hebdomadaire de laryngologie, d’otologieet de rhinologie du Docteur E.J. Moure” (with kind permissionfrom the Portmann Foundation). Figure 2

Dancing children in front of the waves” (1912) by LéonSpilliaert, a Belgian painter (1881-1946).

218 J. Tainmont

The Bonain family1

Bonain was born, lived and died inBrest on the edge of the ocean.Several members of his familyachieved fame in the navy or thecolonial army:– Timothée Lambert Bonain

(1799-1874), his grandfather,was a “cook and caterer” andthe first member of the familyto move to Brest from his hometown of Moliens.

– Aristide Prosper Bonain (1837-1887), his father, kept a draper’s shop in Brest.

– Jules Aristide Bonain (1860-1934), the subject of our paper,started out as a naval surgeon.He enlisted on the Bayardunder the flag of AdmiralCourbet, participating in thecampaigns of Annam, Tonkinand then Formosa. He was alsoin Madagascar. Later, heresigned from the navy andbecame an ENT surgeon.

– Marie Emma Bonain, hisdaughter, married CharlesMirguet, the future SurgeonGeneral of the navy.

– Georges Ernest Bonain, one ofhis younger brothers, wasSurgeon General of the navy.

– Erasme Alfred Bonain, acousin, was the “commander ofthe native guard”

– Adolphe Louis Bonain, anothercousin, was a Surgeon Major inthe colonial army.

Bonain and his colleagues2,3

“He was modest and unaffected.Since the death of his wife morethan 25 years previously, he hadbecome something of a recluse.His deep sorrow left in him abackground of sadness and bitter-ness that nothing could erase.”

(Funeral oration for Bonain byDr Lecouteur)

“Among the general public,Bonain’s reputation did not extendbeyond the Brest region: with themost complete devotion, a deliber-ate self-effacing manner andabsolute modesty, he put intopractice an incomparable love ofscience that kept him at a distancefrom all fashionable intercourse...That deliberately self-effacingmanner, so removed from noisyevents... his absolute unselfish-ness... an exquisite simplicity ofmanners...

He was a delightful talker whocharmed his listeners by his wordsfull of imagery, his clear diction,his clear common sense...

This was doubtless why, at atime when knowledge or evenability count for so little comparedto the ability to get oneself known,he was not considered for officialhonours. The Academy ofMedicine, which would have hon-oured itself by inviting him to joinits ranks, limited itself to makingrecords of the numerous papers headdressed to it about each of hisdiscoveries...”

(Funeral oration for Bonain byCaptain Rondeleux)

Even taking into account thecircumstances in which theseeulogies were given, Bonainwould not seem to have beena man obsessed with “public

relations”, a characteristic whichmakes him appealing to us.

Doctor Bonain Street

Jules Aristide Bonain was born inBrest (in the Finistère department)on 25 July 1860. He died there on28 December 1934. His home wasat 61 Traverse Street, at the cornerof Siam Street. Siam Street was anarrow but important road inBrest, as is shown by JacquesPrévert’s song:

Rappelle-toi BarbaraIl pleuvait sans cesse sur BrestEt je t’ai croisée rue de SiamTu souriais...

[Remember BarbaraThe rain fell unceasingly in BrestAnd I passed you on Siam StreetYou were smiling...]

Since 16 December 1968, Bresthas had a “Doctor Bonain Street”.However, it is a long way fromBonain’s former home, on the out-skirts of the old city in the old StMark commune, that was annexedto Brest as the “quartier du Bot” in1945.

Summary of Bonain’s career

• Bonain’s medical career beganin the national navy where,according to Moure, he served

Figure 3Siam Street in Brest, as Bonain knew it

Historical Vignette 219

from 1881 to 1890. Dr Lecouteurclaims that Bonain resigned hiscommission in 1892 only.

Between 1890 and 1892, whilestill in military service, he spe-cialised in ENT in Bordeauxunder Professor Moure.

In 1892, he resigned from theNavy. However, he took up hiscommission again during the FirstWorld War, serving as MédecinPrincipal.• From 15 November to31 December of 1892, he attendedthe lectures of the microbiologycourse at the Pasteur Institute inParis. The teacher was EmileRoux, one of Pasteur’s close col-leagues, and the demonstrator wasCharles Nicolle, a future NobelPrize winner (1928).

Two years previously, one ofBonain’s colleagues, anothermédecin de marine named AlbertCalmette, had followed the samecourse and he was so enthusiasticabout this training that he gave upthe Navy and devoted himselffrom that point onwards to Pasteurresearch (creating the BacillusCalmette-Guérin for tuberculosis,1924).• Unlike Calmette, Bonain took amore conventional road after mov-ing to the Pasteur Institute.However, this period doubtless

focused his attention on thedramatic consequences of diph-theria, to the reduction of whichhe was to dedicate much of hislater life. The high mortality rateassociated with diphtheria spurredhim on to learn, practise, defendand propagate an American intu-bation method which he eventaught in the Parisian hospitals forchildren at the request of Dr EmileRoux. • In 1892 also, Bonain opened afree private ENT practice, whichhe maintained until the creation ofthe ENT department at the civilhospital of Brest in 1896.

As an assistant surgeon at thecivil hospital of Brest, he createdthe ENT department, which hecontinued to lead until 1925.

He was appointed President ofthe French ENT society in 1907.

Training for naval surgeons inBrest: the Maritime Hospital4

A gigantic Maritime Hospital wasbuilt in Brest at the beginning ofthe 19th century (1200 beds). Itwent into use in 1834. It broughttogether theatres for dissections,museums of normal and patho-logical anatomy, lecture halls,botanic gardens, and a naturalscience museum. Physicians,surgeons and military pharmacistswere trained there.

However, this “School of NavalHealth” accommodated manystudents of various kinds. Themajority could look forward to a

Figure 4The Military Harbour and the impressive buildings of theMaritime Hospital.

Figure 5Two views of the Maritime Hospital of Brest

220 J. Tainmont

future only as auxiliaries in thehealth service prior to a move intoprivate practice.

At this time, the colonial adven-ture also provided openings fornaval surgeons, and tropical dis-

eases were a specialism of navalmedicine (Calmette). That situa-tion was a leftover of the OldRegime, when the military healthservices trained their own staff.Their training schools weredistinct from the faculties ofmedicine and they did not leadto a university qualification.

When Bonain was in the Navy,from 1880 to 1890 (or 1892),radical changes were made totraining for naval surgeons: thedoctorate became a requirementfor the practice of medicine. Theschool of Brest was “down-graded” to an associated trainingestablishment in 1890. From thenon, it concentrated solely onpreparing students for the entranceexamination for the Bordeauxschool of naval health, which wasnow the only fully-fledged traininginstitution. In academic terms, itwas dependent on the Bordeauxfaculty of medicine, and thereforeallowed students to obtain thenecessary university qualifications.

However, we believe thatBonain was a product of the oldtraining arrangements and wastherefore not required to train atthe school of naval health ofBordeaux. It would appear that theonly thing he did in Bordeaux wasto follow the ENT lessons givenby Moure.

Bonain’s two naval campaignsas a naval surgeon

• The campaign of China

As a young medical auxiliary,Bonain sailed on the Bayard. Thisbattleship sailed in the seas ofChina under the flag of AdmiralCourbet. In 1883, the future admi-ral was in charge of the naval divi-sion in Tonkin. He contributed tothe establishment of the Frenchprotectorate on Annam (treaty ofHué in 1883) and to the conquestof Tonkin. The admiral died in1885 on the Bayard. Bonain wasprobably on board at the time.

Figure 6Amédée Courbet was appointed to thehead of the China Seas squadron in 1883.In August, Courbet blockaded Hué beforeattacking it and taking its citadel. Heforced the emperor of Annam to makepeace (treaty of Hué, August 1883). Hethen occupied a part of the Tonkin delta.In March 1884, he was promoted to therank of Vice-Admiral, in which capacityhe directed the operations targetingChina. In February 1885 he had a part ofthe Chinese fleet destroyed by his torpedoboats. (Ten years earlier, Courbet hadorganized a course about torpedoes andthe new weapon fascinated him.) Finallyhe landed in Formosa (Figure 8) andconquered Ke-Lung (asterisk), a citylocated in the northern part of the island,and Makoung (arrow), a harbour on thewestern coast of Penghou, one of theprincipal islands of the Pescadores. Atlast, in May 1885, he subjected the wholeof these islands, which form an archipel-ago to the west of Formosa.But Courbet fell victim to an infectiousdisease and died on board his flagship, theBayard, in Makoung harbour on 11 June1885. A naval officer, Pierre Loti, who wassigned up on the Triomphante, anothership in the squadron, described the deathof the admiral in a few moving pages inhis “Propos d’exil” [Words on exile] (seebelow).

Figure 7The Bayard was a battleship built for service in distant seas. It was built, launched, andfitted out in Brest shipyard. In June 1883, it was sent to Indochina with Bonain on boardas a medical auxiliary.

Historical Vignette 221

• The Madagascar campaign

At the end of the 19th century, theFrench also wanted to put theirclaim to Madagascar into effect.The first expeditionary corps con-sisting of 2500 men, and includingBonain, was sent to the regionfrom 1883 to 1886. However, itclashed with the Malayans on theisland, the Hovas, who seizedpower with support from theEnglish. In 1885, however, thoseHovas were forced to sign a treatyunder which the entire island wasplaced under French protection.The Queen of Madagascar refusedto comply with the treaty andGeneral Duchesne was appointedin 1894 to lead the Madagascarexpeditionary corps (Bonain had

resigned in the meantime).Tananarive was seized in 1895.This time, the Queen was forcedto submit and sign a new protec-torate treaty.

Three of Bonain’s colleagues:Albert Calmette, Victor Segalen,Pierre Loti

Bonain’s career as a naval surgeonmay be compared to the careers ofsome of his colleagues to high-light the differences betweenthem. These three figures arecertainly more famous thanhe. Calmette achieved fame inmedical research, and the twoothers in literature.• Albert Calmette (1863-1933)was three years younger than

Bonain. He was also trained at theBrest school of naval medicineand served at the same time asBonain in Admiral Courbet’ssquadron during the China cam-paign from 1883 to 1885.

The year 1890 marked a turningpoint in his career: he was givenpermission to follow the course atthe Pasteur Institute under thedirection of Dr Roux. From thismoment, the future course ofCalmette’s career was settled: hebecame an immunologist, winningfame in different domains, andparticularly in the area of tubercu-losis (with the Bacillus Calmette-Guérin). He was appointed amember of the Academy ofMedicine.• Victor Segalen was a naval sur-geon who was much younger thanBonain (1878-1919). He was also

Figure 8Formosa island; a map from a dictionary of 1900 (Larousse)

Figure 9The Queen of Madagascar, RanavalonaIII, who reigned from 1883 to 1895during the two French campaigns.

222 J. Tainmont

a student at the new associatedschool of medicine of Brest,before moving on to the Bordeauxschool of naval health (see above).However, his main claim to fameis as a writer, a romantic poet parexcellence, but also an archaeolo-gist and a sinologist. He wasfound dead in the Huelgoat forestin Brittany, with a copy of Hamletat his side. He is the author of LesStèles, in which he evokes China,and of Les Immémoriaux, inwhich he describes the arrival ofthe missionaries in Polynesia(Segalen stayed also in Tahiti,where he collected Gauguin’sfinal paintings).• Of the four naval officers listedhere, Pierre Loti (1850-1923) wasthe only one who was not a navalsurgeon. He enlisted at the Brestnaval school at the age of 17, andreached the rank of captain in1906. His real name was Viaud,but his naval colleagues gave himthe name of an Indian flower “theloti”, because of his timidity.

In 1885, we find him serving asa sub-lieutenant (enseigne de vais-seau) in the squadron of Admiral

Courbet, whose death off Formosahe described in his Propos d’exil:

A bord de la Triomphante, rade deMakoung, vendredi 12 juin 1885.C’était hier à sept heures du soir,- pendant que nous étions à tabledînant assez gaiement – on enten-dit un canot accoster le bord, etles timoniers dirent qu’il venait duBayard avec une lettre pour lecommandant. Alors il y eut uneminute de curiosité impatiente,car ce devait être une communica-tion grave: la paix signée ou laguerre reprise? ... Non, rien detout cela, mais une chose sombreet imprévue: l’amiral étaitmourant à cette heure même. Cecanot faisait le tour des bâtimentsde l’escadre pour le dire... (PierreLoti, Propos d’exil, Calman-Levy,Paris, 1887)

[On board the Triomphante,Makoung Harbour, Friday,12 June 1885.

It was yesterday at seven in theevening - while we were sittingdown to eat in a rather cheerfulmood – that we heard a small boatcoming alongside. The helmsman

Figure 13Caricature of a naval surgeon (4)

C’est une bell’ professionQue celle de médecinAvec beaucoup de potionsOn rend tous les hommes sainsOn leur flanq’ de la quinineça leur donne bonne mine

[To be a physician.It’s a nice profession.With all sorts of potionsWe get all the men fighting fit We give them quinineFor a better complexion.]

Figure 10Albert Calmette

Figure 12Pierre Loti

Figure 11Victor Segalen

Historical Vignette 223

said that it was from the Bayardwith a letter for the captain. Therewas a minute of impatient curiosi-ty, because it was probably a seri-ous message: had the peace treatybeen signed or the war resumed?No, it was none of these things,but something sombre and unex-pected: the admiral was dying atthis very moment. That boat sailedaround the ships of the squadronto announce the news...]

(Pierre Loti, Propos d’exil,Calman-Levy, Paris, 1887)

Disillusioned with his career asa naval surgeon, Bonain changescourse3

Mais cette navigation active quepratiquaient la plupart desnavires de la flotte s’accompag-nait d’un terrain pathologiquetrop peu varié aux yeux deBonain, et poussé par le désir des’instruire, il se trouva rapidementenfermé dans le dilemme posé audébut de la carrière des jeunesmédecins de son époque: ou biensuivre le tour d’embarquement oùl’on courrait la chance de s’attir-er la faveur des futurs grands

chefs de la marine, ou bien s’ori-enter vers le professorat, plusfavorable à sa formation intel-lectuelle.

[But the navigation actually prac-tised by most of the ships of thefleet gave rise to pathological con-ditions that Bonain found to be toolimited in range. Motivated by thedesire to learn, he found himselftrapped in the dilemma thatmarked the early careers of theyoung physicians of his time: toengage in the round of appoint-ments which gave people a chanceof gaining the favours of the topNavy brass of the future, or toconcentrate on a teaching profes-sion that would be more propi-tious to intellectual development.]

(Funeral oration for Bonain byCommander Rondeleux)

So apart from a few unusualmoments during France’s coloni-sation campaign in the Far East,Bonain was probably weary of theroutine aspects of day-to-daymedicine. The caricature below(Figure 13) shows the monoto-nous reality. So Bonain opted foran entirely new specialism: otorhi-

nolaryngology. Professor Moureof Bordeaux was its supreme per-sonification.

Unfortunately, naval medicinehad no need of this branch of medicine. A process resembling adivorce was set in motion...

Three of Bonain’s teachers:Emile Moure, Emile Roux,Joseph O’Dwyer5,6

• Emile Moure (1855-1914) wasthe founding father of ENT as aspecialism in France. At the out-set, he trained in Paris under thelaryngologist Fauvel and theotologist Jules Ladreit de Charrière,a physician at the Deaf-MutesInstitute. After this training(which Sebileau thought waspoor), Moure went abroad beforeestablishing a practice inBordeaux, where his talent was toachieve its full potential. He rapid-ly mastered the lighting instru-ments available and acquired lesscumbersome instruments. Last butnot least, he was the first to prac-tice the three branches of his pro-fession in conjunction and so hewas the one to establish otorhino-

Figure 14Emile Moure

Figure 15Emile Roux

Figure 16Joseph O’Dwyer

224 J. Tainmont

laryngology, even before the exis-tence of ENT specialists!

His work took three directions:1. In 1880, he founded the Revue

mensuelle de Laryngologie,d’Otologie et de Rhinologie inBordeaux.

2. In 1882, he established theSociété Française d’Otologie etde Laryngologie, which wasexpanded to include rhinologyin 1892, when the society wasrenamed the Société Françaised’Otologie, de Laryngologie etde Rhinologie.

3. Faced with the absence of offi-cial recognition for ENT in thefaculties of medicine, he set upshops as an independentteacher, taking Bonain underhis wing from 1890 until 1892.Later, Moure received officialrecognition and was appointedchargé de cours [fellow].Finally, in 1913, Moure becameFrance’s first ENT professor.

• Emile Roux (1853-1933) wasan immediate associate of LouisPasteur, with whom he researchedrabies from 1881 onwards. Hetaught microbiology at the PasteurInstitute in Paris. His studentsincluded Calmette and Bonainattended his classes.

It was in 1891 that Roux beganto develop the anti-diphtheria

serum that was to establish hisheroic stature in the medical pro-fession of Europe.

In 1904, he succeeded Pasteuras the head of the Pasteur Institute.

• Joseph O’Dwyer (1841-1898)practised at the FoundlingHospital of New York establishedby the Sisters of Charity of the StVincent de Paul order, the firstinstitution of that type in theUnited States. Here, from 1880 to1885, he studied a laryngeal intu-bation method that he used forchildren suffering from diphthe-ria. He devised tubes with a formthat kept them in place, and instru-ments for their introduction andwithdrawal. Bonain correspondedwith O’Dwyer by letter.

The discovery of the serumreduced the number of casesrequiring intubation, except forthe regions where this immunisa-tion was not possible. This pro-longed the use of the tubes untilthe mid-20th century.

The civil hospital of Brest from1896 to 19257,8

At that time, the civil hospice ofBrest consisted essentially of thehospital of the “Traverse Street”.Later, the Delcourt-Poncheletretirement home was added.

At the same time, the MaritimeHospital, a military hospital, wasalso in place.

The “Traverse Street” hospitalwas destroyed during the bom-bardment of 1941.

The retirement home was par-tially destroyed by the alliedbombings of 1944, as was a largepart of the city of Brest.

Principal communications ofBonain before the French ENTSociety and other publications9

Bonain’s mixtureNotes sur un nouveau procédéd’anesthésie locale pour opérersur la membrane et la caisse dutympan (1898)

De l’emploi du mentho-phénolcocaïné en ORL (1899)

Bonain A. Note au sujet del’anesthésique local employé enORL sous la dénomination «liq-uide de Bonain». Ann Mal OreilLaryngol. 33:216, 1907

Diphtheria of the larynxContribution au traitement de ladiphtérie du larynx (1893)

Résultats de l’intubation dularynx par la méthode d’ O’Dwyer(1894)

Tubes longs et tubes courtspour l’intubation du larynx dansle croup pseudo-membraneux(1896)

Intubation pour croup d’unenfant de sept mois avec séjour de

Figure 17Civil and religious staff of the civil home of Brest in 1912

Figure 18Bonain’s signature (Collection of the Portmann Foundation)

Historical Vignette 225

390 heures en neuf reprises dansl’espace de 22 jours du tube dansle larynx. Guérison (1898)

Traité de l’intubation du larynxchez l’enfant et l’adulte. EditionAlcan 1902

Sténose cicatricielle duvestibule du larynx consécutive àun lupus. Dilatation par l’intuba-tion et résection des replis ary-téno-épiglottiques (1905)

La fixation des tubes d’O’Dwyerdans le larynx par le procédé dePolverini et Isonni (1911)

NosePolypes muqueux et sarcome desfosses nasales (1895)

Des troubles causés par lesvégétations adénoïdes chez lesadolescents et les adultes (1897)

EarConsidérations sur l’ostéo-périos-tite mastoïdienne suite d’otitemoyenne (1897)

Traitement de l’otite moyennefongueuse (1900)

Deux observations intéres-santes de complicationsendocrâniennes d’otite moyennesuppurée (1904)

Deux points de pratiqueotologique (1905)

Danger des interventionsincomplètes dans les suppurationsmastoïdiennes (1906)

L’Oreille et ses maladies.Edition Doin, Paris 1933

N.B. The titles ending with theyear between brackets ( ) are tothe papers delivered at the FrenchENT Society.

Bonain’s mixture9

• 1898 paperThe formula of the famous mix-ture was established after differenttrials made by Bonain.The first formula contained mostphenol: 2 g to 50 cg of mentholand cocaine chlorohydrate.Although that mixture “never hadthe least unfortunate conse-quence”, Bonain admitted that thecaustic action of phenol wassometimes rather pronounced andthat the whitish appearance givento the tympanic membrane and theswelling of its cutaneous sur-roundings “concealed the detailsof the tympanic membrane and thesharpness of its outlines” or pro-voked “a swelling of the auditorycanal, definitely preventing asatisfactory view of the tympanicmembrane”. Moreover, after para-centesis, he observed “somedelays in the cicatrisation of theincisions, sometimes of a fewweeks”.

To prevent this caustic action,Bonain reduced the proportion ofphenol successively: to 2 g of phe-nol per 1 g of menthol andcocaine, and finally to 1 g of eachcomponent, the definitive formu-

la. In 1898 however, Bonain hadused the last formula in only 3cases out of 28.

In addition to paracentesis,Bonain conducted operations onthe tympanic cavity in the follow-ing manner: he added 3 drops ofcocaine chlorohydrate of a 10 per-cent solution that was injectedthrough the opening of the para-centesis using a Hartmann cannu-la mounted on a syringe. In thisway, he achieved the destructionof synechiae, the mobilisation ofossicles or their withdrawal, or theablation of the whole of the tym-panic membrane!

Before incising the tympanicmembrane, Bonain took care to“withdraw the piece of cottonsoaked with the anaesthetic andnext to remove what might remainof the anaesthetic on the mem-brane or in the ear canal with abrush well soaked with boiledwater”.

Bonain thought that the firstformula, the one containing mostphenol, had its own indications:“the curettage of the fungi of thetympanic membrane, the anaes-thesia of the hypertrophied lingualtonsil for the purposes of gal-vanocautery, and finally the palpa-tion of vegetations in tuberculouslarynx”.

• 1899 paperBonain explains the liquid natureof the mixture by reference to achemical reaction between thecrystals of menthol and of phenicacid: “menthyl phenate is formed,acting as a solvent in the presenceof equal quantities of menthol andphenol, or with larger quantities ofphenol; cocaine dissolves easily init”.

Bonain details the indicationsfor the two formulae: formula I,the one usually used today, with 1

Figure 19“Yellow Flask and Mortar” (1909), byLéon Spilliaert, Belgian painter.

226 J. Tainmont

g of each ingredient (the anaes-thetic formula) and formula II (thecaustic and anaesthetic formula)with 1 g of phenic acid “pure andsnowy” and 0.5 g of menthol andcocaine.

1. EarUsually, formula I (the anaestheticformula) was used for:- circumscribed or diffuse exter-

nal otitis: application for10 minutes of a wick soakedwith the mixture; then afterlocal incisions and anotherwick soaked with phenosalyl1/100;

- paracentesis for acute middleear otitis;

- chronic suppurating middle earotitis with fungi in the tympaniccavity: use of the mixturebefore cauterisation with zincchloride 1/10;

- closing of eardrum perfora-tions: anaesthesia of the bor-ders, and then cauterisationwith trichloracetic acid.

Figure 20At the top, a set of O’Dwyer tubes.At the bottom left, forceps for introducing the tubesAt the bottom right, forceps for removing the tubes(From Lannois: Précis des maladies de l’oreille,du nez, du pharynx et du larynx. TestutCollection, Doin, Paris; 1908).

Figure 22The scene takes place at the Bretonneau Hospital in Paris, in1904. It was painted by Dr Georges Chicotot, himself a physi-cian radiologist and radiotherapist, as was the custom in thosedays (he represented himself in front, at the far left). Dr Josias,sitting in front of the child, has the tube-holder in his righthand. With his left hand, he is holding the base of the tongueand guiding the tube, as in Figure 20 (picture 1). On the right-hand side of the painting, a houseman (“interne”) is preparingthe injection of the anti-diphtheric serum (the vaccine wouldbe perfected in 1923 only). This painting is very didactic, verysmooth. We see a certain resemblance to the “Coca-Colastyle” of the 1960s. It does not provide any suggestion of thedramatic nature of the intervention, with the child looking likea docile doll. (Available at:www.bium.univ-paris5.fr/histmed/medica/1904.htm).

Figure 21The illustration shows the introduction of the tube using for-ceps but directed by the finger that works the epiglottis andfinally positions the tube. (From Aubry, in Lamariey, ORLInfantile. Masson, Paris; 1956).

Historical Vignette 227

Formula II was also tried withgood results;

- the after-effects of a curedchronic middle ear otitis: thiscase was already presented inthe preceding year (1898) forthe section of synechiae,mobilisation of ossicles, ossi-culectomy and myringectomy.2. Nasal Fossae

Formula I was also used most here(anaesthesia alone):- puncture of the maxillary sinus

through the inferior meatus;- galvano-cauterisation of the

nasal septum in cases of epis-taxis or tissue granulation(turbinates?);

- anaesthesia of the borders andof the internal side of the nos-trils (application must belonger, about 10 minutes).3. Pharynx and larynx

Formula I was also used mosthere; clearly, it is more efficientthan simple cocaine (anaesthesiaonly):- galvanocauterisation of lym-

phoid granulations of the poste-rior wall of the oropharynx;

- galvanocauterisation of thehypertrophied lingual tonsil;

- galvanocauterisation of theinfiltrated epiglottis and ary-tenoid protuberances;

- dysphagia of ulcerated tubercu-losis of pharynx or larynx(sometimes effective for severaldays).

Formula II (anaesthesia + cauteri-sation) was used for tuberculousulcerations and vegetations of thelarynx. However, the larynx alsohad to be swabbed with a dilutedsolution of cocaine.

Bonain and the fight againstcroup9,10

• In 1855, Reybard from Lyonmade a report concerning the

catheterisation of the larynx forcroup before the French Academyof Medicine.• In 1858, Eugène Bouchut pre-sented 7 cases of croup before thesame Academy. He treated themwith intubation of the larynx, butwithout success. He placed ametallic tube permitting the pas-sage of air and the expulsion ofthe false membranes, but thesetubes were large, rigid, and cylin-drical and they ulcerated the larynx. The Academy rejectedBouchut’s tubes and favoured tracheotomy. This was a majorobstacle to intubation untilBonain’s intervention.• From 1866 onwards, in Vienna,Jozeph Weinlechner (1829-1906)tried to improve Bouchut’smethod by using tubes invulcanite with different diameters:(“Ueber den Katheterismus desLarynx” in Jb Kinderheilk.1871;4:69-77).• In 1885, Joseph O’Dwyer fromNew York published “Two cases ofcroup treated by tubage of theglottis” in N Y Med J. 1885;42:146-151. This method spreadrapidly through the world as anapproach for the treatment ofcroup and of laryngeal stenosis.It was at this point that Bonainstarted to defend, teach and spreadthe method in France.

In 1886, the same O’Dwyerwas the first to conduct a partialcordectomy on paralysed vocalcords through an endo-laryngealroute, introducing an endo-laryn-geal tube made of rubber for tenmonths.

Over a period of 17 years, from1894 until 1911, Bonain presenteda series of papers to the FrenchENT Society about the treatmentof croup and particularly intuba-tion:

• C’est avec regret qu’il faut con-stater le peu de faveur dont a jouijusqu’à présent dans notre payscette précieuse ressource de l’artde guérir... Encore sous le coup dela condamnation jadis prononcéepar l’Académie de Médecine, l’in-tubation reste peu connue cheznous.

[“We must regret that this pre-cious resource of the art of medi-cine has enjoyed such little favourin our country... Intubation, whichstill suffers from the condemna-tion once pronounced by theAcademy of Medicine, remainslittle known here.”]• Bonain recalled the work andthe thinking of O’Dwyer: “If, inmy practice, a tracheotomy forcroup had resulted in only onecure in ten, I would probablynever have considered laryngealintubation.”• Bonain contacted the Americanby letter and obtained his originaltubes:

O’Dwyer lui-même, avant d’ar-river à un tube lui donnant satis-faction, a bien étudié et expéri-menté une dizaine de modèles dif-férents...

J’ai reçu... la boîte que me fai-sait adresser de New-York M. leDr O’Dwyer à qui j’avaisdemandé quelques renseigne-ments au sujet des derniers per-fectionnements apportés à saméthode... Ceux (les tubes) deNew York sont légèrement pluslongs (que ceux qu’on fabrique àParis) et d’un calibre intérieur unpeu plus grand; très légèrementincurvés en arrière au lieu d’êtrerectilignes, ils présentent un ren-flement plus accentué à leur partiemoyenne; leur tête enfin, légère-ment plus petite, diffère sensible-ment de forme... Ils n’ont pas étérejetés et n’ont nullement entravél’alimentation des enfants...

228 J. Tainmont

[“O’Dwyer himself, beforefinding a tube that fully satisfiedhim, studied and tested a dozendifferent models...

I received... the box sent to meby Doctor O’Dwyer from NewYork. I had asked him for someinformation about the latestimprovements made to hismethod... The tubes from NewYork are a little longer than thosemade in Paris and their interiordiameter is slightly larger; theyare slightly curved on the backinstead of being straight, theyhave a more accentuated bulge inthe middle section; finally, thehead is slightly smaller and theshape is quite different... Theywere not rejected and did not pre-vent the feeding of the children atall...”]• Bonain also made an extensivestudy of the international literatureand he concluded that the successrate for tracheotomy was 10% to20%, whereas the success rate forintubation was 20% to 30%, andsometimes 40%.

He described the benefits ofintubation: it was less traumatic,appropriate for children less thantwo years of age, simpler andmore rapid (this last benefit wascontested by some). Intubation didnot necessitate anaesthesia in chil-dren. In addition, it preventedlaryngeal stenosis, and the tubescould remain in place for a longtime.• From a technical point of view,Bonain recommended long tubes.To prevent their accidental expul-sion, he advocated fixation with atranscutaneous thread through thethyro-hyoid membrane and fixedto the skin of the neck with agauze compress.• Other than intubation (and tra-cheotomy), and before the serum(and later the vaccine), treatment

for croup was rather poor: Bonainused an antiseptic recommendedby Loeffler himself: injections ofterebenthene.

He concluded: Tôt ou tard lavaccination, l’emploi de sérumthérapeutique ou de sérum anti-toxique, viendra peut-être trancherla question du traitement de ladiphtérie. Malgré ces précieusesconquêtes, il faudra néanmoinssouvent encore, intervenir contrele danger d’asphyxie résultant dela sténose du larynx atteint dediphtérie.

[“Sooner or later, vaccination,or the use of a therapeutic serumor antitoxic serum, will perhapsresolve the issue of treatment fordiphtheria. In spite of these pre-cious victories, it will be oftennecessary to intervene against thedanger of asphyxia resulting fromthe stenosis of the larynx afflictedby diphtheria.”]

Bonain’s work on otology(1933)11,12

The work presents some peculiarities: for example, 50% ofthe work is devoted to theoreticalor administrative discussion. Therest of the book is dedicated, as isusual, to the clinical signs of thediseases and of their treatment. • The emphasis on theoreticalconcepts is a reflection ofBonain’s wish to bring hearinginto the field of physics and physiology. He also wished toenrich otological knowledge byreference to the history of thinkingabout the auditory system, phylo-genesis and the embryogenesis ofthe ear.

Il a consacré les dix dernièresannées de sa vie à des recherchestrès avancées sur la physiologiede l’audition, études abstraites...et qui l’obligèrent à se perfection-

ner dans la connaissance desmathématiques, de la hautephysique... des vibrations... et toutce qui concerne l’acoustique.

[“He devoted the last ten yearsof his life to very advancedresearch dealing with thephysiology of hearing, abstractstudies ... that forced him to learnmore about the science of mathe-matics, and advanced physics...vibrations and everything con-cerning acoustics.”]

(Funeral oration for Bonain byDr Lecouteur)

For instance, the part of thebook devoted to acoustics dealtwith:

Vibratory energyThe vibration of ponderable

bodies Acoustic waves or progressive

vibratory waves The propagation of acoustic

wavesWavelength Harmonics

Figure 23Frontispiece of Bonain’s book

Historical Vignette 229

Acoustic resonanceStationary wavesThe vibration of membranes

• The administrative componentof the work possibly betrayed theinitial military component ofBonain’s career and his wish toinclude in his work the official andsocial components of hearing. Hecovered the testing of normalhearing using a watch, speech andtuning forks. He also covered simulation, and dissimulationthrough the cochleo-palpebralreflex; the conditions of admissionto the military service in cases ofwhispered voice (“aphonic lan-guage”), spoken voice and shout-ed voice (“commander’s voice”).It is not possible to be more mili-tary... Next came the determina-tion of the percentage of invalidityand the study of the relationsbetween the ear and accidents atwork.

Bonain’s book was also a reflec-tion of its time:• In 1933, Helmhotz’s resonatortheory had had its time but VonBekesy’s will still a long way off.Bonain was was one of those who

attempted, as well as they could,to elaborate a new physiology ofhearing.

Indeed, the book contains some“naïvetés” that reflect the period:for instance, the arrival of thesound wave in the vestibulethrough the stapes seemed absurdto him: Cette théorie a le grosdéfaut de faire aboutir les ondesau vestibule où elles n’ont aucunebesogne utile à remplir. Elles s’yheurtent immédiatement àl’utricule...Normalement lesondes acoustiques traversent enpartie le segment postérieur dutympan ainsi que la logepostérieure de la caisse etpénètrent par la membrane de lafenêtre ronde dans la rampe tym-panique du limaçon... Cette voieque nous nommerons la voie aéro-tympanique est certainement cellequi doit posséder le meilleur ren-dement.

[This theory has the great draw-back that the waves end up at thevestibule, where they have nothinguseful to do. There, they collidedirectly with the utricle...Normally, the acoustic waves passin part through the posterior seg-

ment of the tympanic membraneand also through the posterior partof the tympanic cavity, and pene-trate through the membrane of thefenestra rotunda into the scalatympani of the cochlea... We callthis the ‘the aero-tympanic route’,and it is certainly the one that ismost efficient.”]• Elsewhere, we see the outlinesof the near future: Sourdille’soperation for otosclerosis, thepresence of the very first operativemicroscopes used by Holmgren,the precursors of the futureaudiometers like R. Foy’s “acou-metric inductor” (Figure 24) ...

For us, who know how the storycontinues, the latest advancesdescribed in Bonain’s final workare an intimation of the rapidadvances to be made later. Theyare the timid glimmer of a light-house stationed at the borderof the known scientific world(Figure 25).

They are another Finis Terraefacing the Ocean of the Unknown.

References

1. Foucher J. Famille Bonain, familytree by Jean Foucher, archivist of thecity of Brest (1970s). Archives de laville de Brest, métropole océane,1 rue des Archives, 29200 Brest. Mailto: sonia.guivarch@brest-metropole-oceane.fr.

2. Les obsèques de M. le docteur BonainDiscours de M. le docteur Lecouteur.La Dépêche de Brest. January 1 1935.Archives municipales et communau-taires de la ville de Brest, 1 rue desArchives, 29200 Brest. Mail to:sonia.guivarch@brest-metropole-oceane.fr.

3. Les obsèques de M. le docteur BonainDiscours du Commandant Rondeleux.La Dépêche de Brest. January 2 1934.Archives municipales et communau-taires de la ville de Brest, 1 rue desArchives, 29200 Brest. Mail to:sonia.guivarch@brest-metropole-oceane.fr.

Figure 24Foy’s acoumetric inductor was able “to detect the malingerers,the exaggerators, to bring to the fore the sensibility of thesense organs faced with a sound of a determined intensitycorresponding to the medium tone, to establish a precisediagnosis distinguishing between organic deafness andpsychogenic deafness, to distinguish between perceptive deaf-ness and conductive deafness”.(This figure is from Bonain’s book. The instrument is alsopresent in the catalogue of the Museum of Natural History ofLille12).

230 J. Tainmont

4. Le CHU de Brest et la mer. In:Pulsations, le journal du CHU. 10,Septembre 1997. Available at:www.chu-brest.fr.

5. Legent F. La naissance de l’Oto-rhino- laryngologie en France.BIUM, Medic. Available at: www.bium.univ-paris5.fr/histmed/medica/1904.htm).

6. Legent F. Les débuts de la SociétéFrançaise d’Oto-rhino-laryngologie.BIUM Medic. Available at:www.bium.univ-paris5.fr.

7. Les hospice civils de Brest des orig-ines à la fin du 19ème siècle. In:Pulsations, le journal du CHU. 33,Juillet 2003. Available at: www.chu-brest.fr.

8. Les hospice civils de Brest de la fin du19ème siècle à 1945. In: Pulsations, lejournal du CHU. 34, Octobre 2003.Available at: www.chu-brest.fr.

9. Bulletins et mémoires de la sociétéfrançaise d’otologie, de laryngologieet de rhinologie (1886-1913). BIUM,

Medic. Available at: www.bium.univ-paris5.fr.

10. Gelfand C. Dr Joseph O’Dwyer andhis intubation tube. Caduceus1987;3,2 (Summer, 1987):1-35.

11. Bonain A. L’Oreille et ses Maladies,Doin, Paris, 1933

12. La mesure de l’homme, instruments ettests du Musée d’histoire naturelle deLille. Somogy Art Editions, Paris-Lille, Musée d’histoire naturelle deLille; 2002.

Additional references

– Pecker J, Avril J-L, Faivre J. La santéen Bretagne. Hervas, Paris; 1992.

– Service Historique de la Défense,Département Marine, BP 166-00468Armées. Available at: www.servicehis-t o r i q u e . s g a . d e f e n s e . g o u v . f r(Concerning the military career ofJules Aristide Bonain) cote CCT 4èmemoderne 370/4.

– Service Historique de la Défense,Département Marine, Brest, BP 46-29240 Brest Armées. Available at:www.servicehistorique.marine.defense.gouv.fr (Concerning the military careerof Jules Aristide Bonain).

Acknowledgements

I wish to thank Odile Bazerque, thesecretary of the Portmann Foundationof Bordeaux, who was kind enough tosupply me with the portrait and thesignature of Dr Bonain, which wereobtained during patient research inthe publications of Professor Moure.

Many thanks also to SoniaGuivarch, assistant for the conserva-tion of the Heritage of Brest. Sheobtained for me copies of the news-paper “La Dépêche” of Brest contain-ing the orations pronounced atDr Bonain’s funeral.

Figure 25“The lighthouse” (1909), by Léon Spilliaert, Belgian painter