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Gray-scale ultrasonography (US) is the first way of detecting focal liver lesions, but with lower specificity in establishing their etiology. Typical hemangiomas at US are hyperechoic, well defined masses, without peritumoral rim, without Doppler signal [1], but there exist also atypical forms (especially if the tumor is grafted on chronic liver diseaseCLD): heterogeneous and/or hypoechogenicity hemangiomas, or with hyperechoic rim. Preoperative US, although sometimes their etiology is difficult to establish as gray-scale US has low specificity in characterizing liver tumors [2]; in
such cases, complementary explorations like: liver scintigraphy, angioscintigraphy, contrast-enhanced CT and MR, or even invasive methods (puncture-biopsy, diagnostic laparoscopy) with histological examination, are mandatory. Although the typical aspect of hemangioma at US is of nodular hyperechoic, well defined mass, without peritumoral rim, without Doppler signal [1], there exist also atypical forms: heterogeneous and/or hypoechogenicity hemangiomas, or with hyperechoic rim [3].
The aims of our study were to establish in liver hemangiomas possible correlations between tumoral and liver echogenicity; tumoral size and presence of chronic liver diseases (CLD); presence of peritumoral rim- tumoral and liver echogenicity, tumoral size and presence of CLD.
II. MATERIAL AND METHODS
The study involved in the experiment group 270 patients (156 women, 114 men), aged 25-81 years, with the presumptive diagnosis of benign liver tumor masses, established by ambulatory US, hospitalized at the Emergency Hospital "Prof. Dr. Octavian Fodor" and 2nd Medical Clinic Cluj-Napoca between 2006-2015. There were found 352 liver masses in these 270 patients, 30 of them having concomitant other tumor tumors, and 52 being with multiple hemangiomas (hemangiomatosis).
The control group consisted of 60 patients (38 women, 22 men), aged 36-82 years with malignant hepatic tumors. Their diagnosis at admittance consisted of hepatocellular carcinoma (HCC) (12), metastasis (7), cholangiocarcinoma (3), hemangioma (2), hamartoma (1), tumor of unknown etiology (28) and the rest in other extra-hepatic pathologies.
Investigation of patients in this retrospective study was performed using ultrasonographs Logiq 7 (GE, USA), Si2000 Sonoline with transducers having 3,5MHz (for preoperative diagnosis) and 7,5MHz frequency (for intraoperative diagnosis), tomographic scintillation SPECT Orbiter Siemens camera, computed tomography (CT) and magnetic resonance imaging (MRI), along with clinical and biological examination.
All patients (both the experiment and the control group) underwent abdominal US examination in gray scale and color
3 S. Vlad and N.M. Roman (eds.), International Conference on Advancements of Medicine and Health Care through Technology; 12th - 15th October 2016, Cluj-Napoca, Romania, IFMBE Proceedings 59, DOI: 10.1007/978-3-319-52875-5_1
Doppler. Most of the patients (56%) underwent at least 2 types of imaging investigation in order to establish the final diagnosis. Planar liver scintigraphies and SPECT with sulphur-colloid (n=211), „in vivo” labeled-RBC scintigraphies (n=189) and liver angioscintigraphies (n=184) were performed. 72 patients underwent CT (1 native and 71 with contrast) and 28 MRI with contrast. Diagnostic laparoscopy was performed in 15 patients, surgical resection in 22, US-guided puncture-biopsies in 42 and histological examination in 69 patients. The final diagnosis was established based on the results of all these investigations corroborated with clinical and biological examinations.From the statistical point of view, in order to establish possible associations between echogenicity of the tumor and the liver, respectively tumor's size and the presence of liver diseases, we used the statistical software in order to obtain the Hi-square test and Fisher's exact test, coefficients of contingency and Cramer's coefficients; p values<0.05 were considered to have statistical significance. Estimation of possible association between the presence of hypo-/hyperechoic peritumoral rim and tumoral and liver echogenicity, tumoral size and the presence of CLD was done through the same tests and correlation coefficients mentioned above.
III. RESULTS
US parameters in the 270 patients finally diagnosed with hemangioma revealed the features shown in Table 1. There have been identified hemangiomas ranging in size from 0,3-24cm at US. Hemangiomas were located in the right lobe (298), left lobe (115), caudate lobe (4) and in both lobes (80).
As shown in Table 1, the presence of hyperechogenicity and homogeneous structure inside the tumor is not a universally valid criterion in the diagnosis of hemangioma. The typical image of well-defined (94.81% of cases), hyperechoic mass (81.48% of cases), without Doppler signal (54.07% of cases), was detected in most hemangiomas (Fig.1). Hypoechoic masses (Fig.2) associated with the presence of a heterogeneous structure and hyperechoic rim raised problems of differential diagnosis in 7 cases, requiring supplementary investigations. Out of all 274 cases with USpresumption of hemangiomas, 270 patients proved to have finally hemangiomas, 3 HCC (and coexistence with one hemangioma in one case), 1 cholangiocarcinoma and coexistence with metastases (from gastric carcinoid); in 21 cases it was not possible to differentiate US from other tumors (1 lipoma, 1 pheochromocytoma, 1 area of calcification, 3 metastases, 2 regenerative nodules, 2 focal nodular hyperplasias, 3 patchy areas of steatosis, 6 HCC, 2 hemangiosarcomas). Co-
existence with other masses was found in 30 (11.11%) patients: simple hepatic cysts (17), fatty-free areas (4), focal nodular hyperplasia (3), HCC (2), patchy areas of steatosis (2), hepatic hydatid cyst (1) and metastasis of gastric carcinoid (1).
Absence of Doppler signal (146/157), spotted presence (11/157) were identified in all hemangiomas located in the right lobe (157), the left lobe being difficult to explore due to artifacts produced by the cardiac cycle; in one case, exacerbated and tortuous vascularisation pattern (arterial and venous type) rose the suspicion of neoplasia, but puncture-biopsy confirmed the diagnosis of hemangioma.
There were identified multiple hemangiomas in 52 cases (19.25%), their increased echogenicity and multicentricity raising problems of differential diagnosis with liver metastases.
Table 2 US characteristics of hemangiomas grafted on normal liver and on different CLD
Hemangiomas on: normal liver steatosis+ NASH + chronic hepatitis (alcoholic+ viral) cirrhosis hyperechoic 126 45
NASH), 39 hypoechoic masses (with maximum percentage on: steatosis and NASH, followed by cirrhosis, normal liver, chronic hepatitis) and 5 isoechoic and 2 with mixed echogenicity (hypo- and hyperechoic) (Table 2).
When comparing echogenicity and echostructure of hemangiomas, we observed differences between the 2 groups of patients, namely those without liver disease and those with CLD. Also, the presence/absence of peritumoral and rim's echogenicity according to the size of hemangioma are shown in Table 3.
Diagnosis of hemangioma was suspected only in 93.70 % (253/270) cases of all patients with final diagnosis of hemangioma, the rest being diagnosed by US as: lipoma (1), metastasis (3), tumors of unknown etiology (5), regenerative nodule/HCC (1), steatosis, patchy steatosis (1), focal nodular hyperplasia (1), pheochromocytoma (1), benign tumor with arterial-venous shunt (1), malignancy (2), and in one case US did not detected any mass (isoechoic).
Table 3 Tumoral and rim's echogenicity according to the size of hemangioma
Hemangiomas: size≥2cm size<2cm
9
5 0 mixt 2 0 with hypoechoic rim 4 1 with hyperechoic rim 6 1
The presence of hypoechoic rim was described in 4/220 cases (0.018%) of histologically proven hemangiomas. The hyperechoic rim was present in 14.89% of the cases (representing 7/47 patients). There were no differences regarding the predominance of peritumoral hypoechoic rim in the two subgroups of hemangiomas grafted on normal liver and CLD (Table 4); the predominance of hyperechoic rim was observed in iso- and hypoechoic hemangiomas. The peritumoral rim depending on the size of the hemangioma was more commonly seen in hemangiomas ≥2 cm, but without any statistical significance.
Legend: NASH- nonalcoholic steatohepatitis
Of all 17 cavernous hemangiomas, US described 14 (82.35%) as such, two of them being thrombosed, and in one case as atypical cavernous hemangioma.
Out of 270 patients explored by US, we detected 52 cases of hemangiomatosis, 17 cavernous hemangiomas, 213 hyperechoic masses (being grafted in descending order on: chronic hepatitis, cirrhosis, and normal liver, steatosis and
Hi-square test of independence finds no association between tumor echogenicity and hypoechoic rim in patients with hemangiomas (χ2 =1.125 < 7.81, p=0.650); but it showed that there was only moderate association between hypoechoic rim and hyperechoic tumor in patients without hemangioma (p=0.004). Fisher 's exact test shows that there exists moderate association between hyperechoic rim and hypoechoic hemangiomas (Cramer coefficient=0.37, p=0.001) and between hyperechoic rim and isoechoic hemangiomas (p<0.05).
The association between the presence of the hypoechoic rim and hepatic echogenicity or tumor size is shown in Table 4.
Table 4 Correlation of hypo- and hyperechoic rim with hemangioma’s echogenicity and size, echogenicity of liver and presence of CLD
Criteria: hypoechoic rim hyperechoic rim
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hyperechoic 5/270 1/270
isoechoic 0 3/270
hypoecoic 0 3/270
mixt 0 0
Gejqigpkv{"qh"nkxgt
normal 4/270 5/270
increased 1/270 2/270
Uk|g"qh"jgocpikqoc
< 2cm 1/270 1/270
> 2cm 4/270 6/270
Rtgugpeg"qh"ENF
yes 3/270 4 no 2/270 3
Legend: CLD- chronic liver diseases
Fisher's exact test shows no association between liver echogenicity and hypoechoic rim (p=0.205) or hyperechoic rim (p=0.273) of hemangiomas. Fisher's exact test shows no association between hemangioma size and hypoechoic (p=0.659) or hyperechoic rim (p=0.427) of hemangiomas. Presence of steatosis/nonalcoholic steatohepatitis (NASH) in 69 images from our study revealed the following patterns of hemangiomas: hypo- (16/69 cases), isoechoic (2/69 cases) and heterogeneous (51/69 cases).
The association between the presence of the hyperechoic rim and tumoral size and the presence of CLD is shown in Table 4. Fisher's exact test shows no association between the presence of underlying CLD and hypoechoic (p=0.328) or hyperechoic (p=0,468) rim.Statistical parameters of the US method used in the diagnosis of hemangiomas are shown in Table 5.
Table 5 US sensitivity, specificity, positive and negative predictive laues in the diagnosis of hemangioma
US diagnosis of hemangioma: Presence of CLD Size of hemangioma No (n=155) Yes (n=115) <2cm (n=95) ≥2cm (n=175)
US alone established the diagnosis of hemangioma in 44% cases and US together with scintigraphic methods in 36% cases; other imaging and invasive techniques (contrast-enhanced-US, computed tomography, magnetic resonance, puncture-biopsy, diagnostic laparoscopy, histology) were necessary to corroborate with the previous methods in the rest of 20% patients. Figure 3 shows the methods used in corroboration, being both imaging and invasive, that contributed to the final diagnosis of hemangioma.
Fig.3 Imaging and invasive technics used in the diagnosis of hemangioma
The value of different US methods (pre- and intraoperatory), computed tomography (CT), magnetic resonance (MR), differ depending on etiology of the tumor. US represents the first method of detection of hemangiomas.
The issue of differential diagnosis of hyperechoic masses grafted on CLD is difficult, as far as it was shown that 1550% of focal lesions grafted on cirrhosis initially interpreted as hemangiomas, are actually HCC [4, 5]. The chance of preexistence of a vascular malformation (hemangioma) grafted on CLD is about 50%, but it is always necessary to corroborate with complementary methods (CT, MR, „in vivo” labeled-RBC SPECT) in order to exclude a HCC. Transformation of hypoechoic nodule in a hyperechoic mass can be explained by necrosis and interstitial fibrosis; in these cases is not possible to differentiate from a typical small hyperechoic hemangioma [6].
Literature mentioned the typical "low-flow" hemangioma in cases of hyperechoic well defined masses, without peritumoral rim, and the "high-flow" hemangioma, which are commonly hypoechoic and with atypical aspect in gray-scale US [7]. There have been described both qualitative and quantitative differences regarding the presence of Doppler signal in color and Power Doppler, being cited both lack and presence
of increased (especially peripheral, but also central) vascular signal, suggestive for the diagnosis of hemangioma [8].
Hemangioma occurs as hyperechoic masses, which sometimes presents central thrombi, cystic areas and intratumoral calcifications, due to the thrombotic formation in time, cystic degeneration and calcification, or intratumoral necrosis. These atypical features make difficult sometimes the differential diagnosis with malignant tumors [9, 10].
A special mention concerns the hemangiomas grafted on steatosis, showing various aspects of echogenicity (from hypo, to hyperechoic) and of CT density (hyperdense-native, isodense-arterial phase); in these cases MR and/or histological examination are mandatory, and sometimes fine needle aspiration biopsy is useful in order to clarify the diagnosis [9]. This might explain the 69 images from our study in patients with: steatosis/nonalcoholic steatohepatitis (NASH), which were hypo- (16/70 cases), isoechoic (2/70 cases) and heterogeneous (91,66% cases); cirrhosis with 3/21 hypo- and 18/21 hyperechoic hemangiomas; chronic viral and toxic hepatitis, with 3/30 hypo- and 27/30 hyperechoic masses.
The attempt to establish an association between the tumor's echogenicity and presence of CLD, or tumor size has not shown any statistical significance; we found a good correlation (p = 0.001) between hyperechoic rim and hypo- and isoechoic hemangiomas.
Spotted presence of Doppler signal was identified in 7% (11/157) of our cases, the rest of the masses in the right lobe being without vascular signal. The model of the spotted mixed type of vascularisation (both arterial and venous) was encountered also in literature, but in a greater proportion (14 %) [11].
US is able to detect, within the 40% cases with hyperechoic rim in literature (where differential diagnosis with metastases from insulinomas is required), atypical forms as solid tumors with hypoechoic areas and with the described features in periphery [12].
We could establish the diagnosis of atypical hemangiomas in 19 of our cases, that would qualify as: heterogeneous (n=7), having hypoechoic inhomogeneous structure, hyperechoic rim, and size of 2,7-9cm (average 4,51cm); hemangiomas with calcification (n=4) and multilocular cavernous hemangioma (n=8).
Corroboration of US with dynamic CT and „in vivo” labeled-RBC SPECT have shown a high sensitivity, specificity, and high diagnostic accuracy [13], similar to the data in our study.
Limits of the study were: the impossibility of follow-up in all focal lesions and histopatological documentation for all, and the varying experience of the examiner.
V. CONCLUSION
Classic criteria of hyperechoic, well defined tumor and without Doppler signal was found in 81.85% hemangiomas, US proved to have increased specificity for masses <2 cm (94.87%) and grafted on normal liver (94.12%). Hypo- and isoechoic hemangiomas moderately correlate with the presence of a hyperechoic rim. No statistical correlation was found between the underlying CLD and the hemangioma's echogenicity, nor with the presence of any tumoral rim.
Presence of hemangiomas grafted on CLD is a challenge for the physician, as it is important for the differential diagnosis with HCC or even metastases, especially when atypical hemangiomas are hypoechoic. A good correlation of US parameters with other imaging methods (scintigraphy, CES), in case of atypical features, can avoid liver biopsy and enables to establish a correct positive diagnosis.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest and there is no disagreement in this new approach of imaging assessment of hemangiomas.
STATEMENT OF HUMAN RIGHTS
The procedures were in accordance with the ethical standards of the responsible local and national committee on human experimentation and with Helsinki Declaration of 2000.
REFERENCES
1.Badea R. Ficatul. In: Badea R, Mircea PA, Dudea S, Stamatian F (2000)Tratat de ultrasonografie clinică - vol.I Principii, abdomen, obstetrică şi ginecologie. Ed. Medicală Bucureşti:105-175
2.Harvey CJ, Albrecht T (2001) Ultrasound of focal liver lesions. Eur Radiol 11:1578–1593
3.Farrell MA, Charboneau JW, Reading CC (2000) Sonographic pathologiccorrelation of the hyperechoic border ofan atypical hepatic hemangioma. J Ultrasound Med 20:169–170
4.Repiso A., Gomez Rodriguez, R., Gonzales de Frutos C. et al. (2007) Angioma like liver lesions in patients with chronic liver disease. Rev. esp. enferm. dig. 99(5): 259-263
5.Caturelli E, Pompili M, Bartolucci F et al. (2001) Hemangiomalike Lesions in Chronic Liver Disease: Diagnostic Evaluationin Patients1.Radiology 220:337–342
6.Sheu JC, Chen DS, Sung JL et al. (1985) Hepatocellular carcinoma: US evolution in the early stage. Radiology 155:463–467
7.Galanski M. Jördens S, Weidemann (2008) Diagnose und Differentialdiagnose benigner Lebertumoren und tumorähnlicher Läsionen. Chirurg 79:707-721
8.Choi BI, Kim TK, Han JK et al. (1996) Power versus Conventional Color Doppler Sonography: Comparison In the Depiction of Vasculature in Liver Tumors. Radiology 200:55-58
9.Vilgrain V, Boulous L, Vullierme MP et al. (2000) Imaging of atypical hemangiomas of the liver with pathological correlation. Radiographics 20: 379–397
10.Shimizu S, Tadatoshi T, Kosuge T et al. (1992) Benign tumors of the liver resected because of a diagnosis of malignancy. Surg Gynecol Obstet 174:403-407
11.Bartolotta TV, Midiri M, Quaia E (2005) Liver haemangiomas undetermined at grey-scale ultrasound: contrast-enhancement patterns with SonoVue and pulse-inversion US. Eur Radiol 15:685–693
12.Moody A, Wilson S (1993) Atypical hepatic hemangiomas: a suggestive sonographic morphology. Radiology 188:413-417
13.Weimann A, Ringe B, Klempnauer J et al. (1997) Benign liver tumors: differential diagnosis and indications for surgery. World J Surg 21:983-990
Author: Ioana Grigorescu
Institute: 2nd Medical Department, „Iuliu Hatieganu” University of Medicine and Pharmacology Cluj-Napoca, Romania
Street: Clinicilor Str. 2-4
City: Cluj-Napoca
Country: Romania
E-mail: ioanaducagrigorescu@gmail.com
Impact of Spectralis Optical Coherence Tomography in the Clinical Practice
S.D. Nicoar
"Iuliu Ha ieganu" University of Medicine and Pharmacy/Ophthalmology, 8. V. Babes str., 400012, Cluj-Napoca, Romania
Optical Coherence Tomography (OCT) is a high resolution, non-invasive imaging method that started to be used in the clinical practice in 1990s. The first application of OCT technology was in the field of ophthalmology and the images resembled the histological sections of the retina. However, the pictures depict the result of the scanned tissues' optical properties, not the tissues themselves [1].
OCT concept developed at Massachusetts Institute of Technology, at the beginning of 1990s. The first commercial device was made by Carl Zeiss (Jena, Germany) in 1996. The first OCT applications referred to quantitative and qualitative information about the peripapillary area of the retina and the coronary arteries [2].
OCT uses light, as opposed to ultrasonic biomicroscopy (UBM) that uses ultrasounds, with the aim to visualize eye structures. Light speed is 1 million times higher than sound speed. By consequence, resolutions lower than 10 μ microns are obtained in the posterior pole of the eye with OCT technology. For many years, UBM offered resolutions in the range of 150 μ. By using high frequencies, resolutions of 20 μ are possible with UBM technology. The ultrasound waves used in UBM are markedly attenuated by the biological tissues and therefore, are limited to the examination of anterior eye structures [3].
OCT exam is very comfortable for the patient, as it does not require the direct contact with the eye.
A. Overview
II. DESCRIPTION OF THE DEVICE
Spectralis is a multimodal platform that uses the confocal laser technology, in order to obtain color and spectral optical coherence tomography (OCT) images of the eye structure. Two different laser wavelengths catch simultaneously, the OCT and the fundus image of the eye [3].
The principle of Spectral Domain OCT (SD-OCT) is based on the Fourier equation, as compared to Time Domain OCT (TD-OCT) that developed on the ground of interferometry. In TD-OCT, an interferometer measures sequentially, the delay of light echoes that are reflected by the retinal microstructures. In SD-OCT, a spectrometer evaluates simultaneously, the light reflected by retinal microstructures. In TD-OCT, 6 radial scans are performed, whereas in SD-OCT, 65.000 scans are made within an area of 6 mm diameter. Acquisition time is about 60 times faster with SD-OCT devices and the axial resolution varies between 3 - 7 μ, as compared to TD-OCT ( 10 -15 μ) [3].
Eye tracking function is used to neutralize the errors induced by involuntary eye movements. Spectralis is able to detect changes within 1 - 2 microns, at the depth of 289 microns, and it is able to filtrate and select the high resolution images, in order to identify the finest details. The auto re-scan function is very important for the patient's followup, as it places the subsequent scans precisely at the initial examination site. The deep layers can be examined with the enhanced-depth OCT function (EDI-OCT) [3].
B. Investigation possibilities
Spectralis offers the following imaging possibilities for the eye: spectral domain OCT (SD-OCT), infrared (IR), red free, fundus autofluorescence (FAF), confocal multicolor 3D, wide field (55˚), SD-OCT for the diagnosis and monitoring of glaucoma, anterior segment imaging [3].
C. Technical characteristics
Domain: Spectralis operates in the spectral domain OCT, based on the Fourier equation.
A super luminescent diode λ 870 nm acquires the images . IR light (λ 815 nm) allows the visualization of detailed images of the eye fundus.
A green laser (λ 518 nm) ensures the obtaining of confocal, 3D images of the retina, with multicolor technology.
A blue laser (λ 486 nm) is used for identifying fundus auto fluorescence (FAF) and obtaining the red free images. The blue light makes it possible to identify fundus auto fluorescence, based on the fluorescent properties of lipofuscin. With red free light, specific structures are visualized: nerve fiber layer, epiretinal membranes and retinal cysts.
The simultaneous, confocal, 3D collection of the imaging data with three different types of lasers (red, green and blue) allows to evaluate various retinal layers on a single image.
The device also offers the possibility to combine the above mentioned acquiring modalities, in various ways, according to the investigated retinal condition: IR and FAF, OCT and IR, OCT and FAF, OCT and red free, OCT and 3D multicolor confocal eye fundus examination [3].
D. Examination modules
Anterior segment: By the use of a high resolution 3D examination lens, images with 7 μ axial resolution and 30 μ lateral resolution can be obtained. The scanning depth in the tissue is of 1.9 mm.
Multicolor confocal 3D module: It allows the visualization of the 3D, color image of the eye fundus, simultaneously with the transverse section through the retina. Thus, different retinal structures are evaluated on one single image. Scanning with multiple laser wavelengths allows the detailed evaluation of the retinal structure: superficial, middle and deep retinal layers.
Wide field module: It makes possible to view the retinal periphery, by OCT and fundus image, using a non-contact, 55˚ lens. The high resolution visualization of the macula, optic nerve and retinal periphery is achieved in a single image. The scanning models are: radial 55˚ central and volume 55ºx25º (for the diabetic patients) /55ºx40º /25ºx5 º central.
Glaucoma module: It allows the complete analysis of glaucoma, with the evaluation of the neuro-retinal rim, retinal nerve fiber layer (RNFL) and asymmetry regarding the posterior pole and the ganglion cell layer.
The optic nerve head (ONH) analysis is made using the Bruch's membrane opening as the anatomical frontier for the rim. The neuro-retinal rim is measured between Bruch's membrane opening and the nearest point of the internal limiting membrane (ILM).
During scanning, the device lines up automatically, the fovea with the central axis of Bruch's membrane opening.
Future scans and sectors are placed exactly on the previous sites, which is very important for the accurate monitoring of the disease progression.
Various scans are available: 24˚ radial scan, circular scans with 3,5 mm/4,1 mm/4,6 mm diameter, volume scans of 30ºx25º/30ºx15º /15ºx15 º, circular scan of the RNFL at 12˚, with 768 analyzed points [3].
III. SPECTRALIS OCT IN THE DIAGNOSIS AND MONITORING OF MACULAR DISORDERS
Optical Coherence Tomography is widely used in the assessment and monitoring of macular diseases. We illustrate the contribution of Spectralis in the clinical practice with selected cases from our own experience. The patients were included in this study in accordance with the Helsinki Declaration of 1975, as revised in 2000 and 2008.
A. Age related Macular Degeneration (AMD)
AMD is one of the retinal conditions that benefited the most from the progress in of OCT technology. The main advantage of the OCT imaging is the quantification of the retinal thickness, allowing to monitor the anti-VEGF treatment efficacy in wet AMD. OCT is also able to identify the location of the fluid in neovascular AMD: intraretinal, subretinal or sub-Retinal Pigmented Epithelium (RPE) [4].
According to OCT imaging, the choroidal neovascular membranes (CNV) in wet AMD were classified into 3 types. In type 1 (occult neovascularization), CNV is located under the retinal pigmented epithelium (RPE), in type 2 (classic neovascularization), it is located above the RPE and in type 3, there is a retinal angiomatous proliferation (RAP). In large RPE detachments, breaks in the RPE layer can occur. The rupture of the RPE layer appears as a clearly demarcated region of RPE absence, adjacent to a region of RPE elevation. The reversed shadow effect is identified. Often, especially in type 2 CNVs, the interruption of the RPE layer is identified. In type 2 CNV, the neovascular membrane is located in the subretinal space and it penetrates through the RPE/Bruch's membrane complex. RAP is a rare form of wet AMD that originates in abnormal neovascular tissue from the deep retinal layers [5].
The response to anti-VEGF therapy is translated into the OCT imaging, by the diminishing/disappearance of the intra/sub-retinal fluid and by the decrease of the PEDs size and of the macular thickness [2].
Figure 1 presents the combined IR-OCT image of the retina in a patient with wet age related macular degeneration (AMD). The neurosensitive retina is detached by fluid (superior arrow) originating in a fibro-vascular membrane under it (inferior arrow). The retinal pigmented epithelium (RPE) layer is irregular and disrupted in the area of lesion. The fluid has no reflectivity (it appears black on the blackwhite image). This aspect corresponds to the classic neovascular membrane which responds better to anti-VEGF therapy, as opposed to occult membranes which are located under the RPE. OCT has a major role in locating precisely the neovascular membrane in relationship with the RPE and the neurosensory retina.
In figure 2, the retinal thickness map (RTM) in the same patient as in figure 1, is presented. The thickness of the macula is significantly increased in the macular area located infero-temporally from the fovea. This is signalized by white and red colors.
OCT is able to identify early stages of AMD, named drusen, as elevations and irregularities of the RPE line (figure 3).
B. Vitreo-macular interface disorders
Vitreo-macular interface disorders benefited from the advances in OCT technology, in terms of the diagnosis precision and surgical indication [3]. In figure 4, an advanced stage of vitreo-macular traction syndrome is presented. Along time, it led to the disorganization of the macular retina, which is dissected by liquid spaces and cysts. Therefore, the resistance of the retinal tissue is considerably diminished. In this situation, the dissection of the vitreomacular interface, in order to relieve the traction, is risky, as it may lead to the break and detachment of the retina.
Figure 5 depicts the fellow eye of the same patient. Obviously, the vitreo-macular traction is less advanced, but there are modifications of the retinal structures: the macular thickness is increased and a hole within the retina is identified. Surgery in this situation is indicated, in order to prevent the progression of the disease.
RTM proves the increased macular thickness and offers precise values for this parameter, within the macular area (figure 6).
Fig. 1. Classic form of neovascular AMD
Fig. 2 RTM map in a patient with classic form of neovascular AMD
Fig.3. Drusen
Fig. 4. Retinal disorganization following an advanced vitreo-macular interface syndrome
Fig. 5. Fellow eye in the same patient as in figure 3
Fig. 6. RTM for the same eye as in figure
C. Diabetic maculopathy
Diabetes is the main cause of visual impairment in the group of working age population. Maculopathy is the main cause of vision decrease in the diabetic patients. Progress in OCT technology allows early diagnosis and treatment of diabetic macular edema, which is crucial for vision preservation [6]. The main mechanism of macular edema caused by diabetes is represented by the microangiopathy at the level of the retinal capillaries [3,6]. Figure 7 presents intraretinal microaneurysms (hyperreflective dots) that leak, as proved by the non-reflective material (liquid) elevating the neuro-sensory retina.
The liquid within the neuro-sensory retina is responsible for the considerable macular thickening, as shown in figure 8 (the maximal macular thickness appears of 600 μ).
IV. CONCLUSIONS
Spectralis is a very useful tool in the diagnosis and monitoring of macular diseases. A super luminescent diode (λ
870 nm) is used to acquire the OCT images. The simultaneous, confocal, 3D collection of the imaging data with three different types of lasers (red, green and blue) allows to evaluate the structure of various retinal layers on a single image.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
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3.Duker JS, Waheed NK, Goldman DR (2014) Handbook of retinal OCT, Elsevier, London
4.Lim LS, Mitchell P, Seddon JM et al. (2012) Age-related macular degeneration. Lancet, 379: 1728–38
5.Talu SD, Talu S, Use of OCT Imaging in the Diagnosis and Monitoring of Age Related Macular Degeneration, in Age Related Macular Degeneration. The recent advances in basic research and clinical care (2012) Inn Tech, Rijeka, ed. Gui-Shuang Ying.
6.Menke M, Lala C, Framme C, Wolf S. The Ever-Evolving Role of Imaging in DME Management (2012) Retin Physician, 9 (4): 24-32.
Author: Simona Delia Nicoara
Institute: "Iuliu Hatieganu" University of Medicine and Pharmacy Street: 8, Victor Babes street, 400012
City: Cluj-Napoca
Country: Romania
Emai: simonanicoara1@gmail.com
Fig. 7. Diabetic macular edema
Fig. 8. Macular thickening in diabetes
Laparoscopic Repair of Morgagni Hernia – Transfascial Suturing with Extracorporeal Knotting
F. Graur1, 2, E. Moi 1, 2, N. Al-Momani2 and N. Al-Hajjar1, 2
1 University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
2 Regional Institute of Gastroenterology and Hepatology “Prof. O. Fodor”, Surgery Department, Cluj-Napoca, Romania
The three principal types of congenital diaphragmatic hernias are Bochdalek, hiatal and Morgagni’s, which is the rarest form. They were first described in medical literature in the early 18th century [1].
Generally, Morgagni's hernia, which is the topic of this case report, present early in life with respiratory symptoms. Adult presentations are less frequent, particularly symptomatic adult presentations [2]. Surgical repair is mandatory even in asymptomatic cases to avoid the risk of lifethreatening complications, such as bowel prolapse and subsequent strangulation [3, 4]. Laparoscopic repair is the procedure of choice in uncomplicated cases [5].
In this report we present a case of a greatly successful laparoscopic repair by transfascial suturing with extracorporeal knot tying technique.
II. CASE REPORT
A 67-year-old female patient, known with ischemic heart disease, presented to the outpatient clinics at our Institute, in April 2015, with symptoms of intestinal subocclusion. About one year ago she start complain of intermittent, vague epigastric pain, which was aggravated mainly by heavy meals and associated with nausea and vomiting. She
also noted that she’d lost 5 kg in the last 6 months. The patient reported no dysphagia, early satiety, dyspnea, sweating or palpitations. She denied any history of trauma as well.
Physical examination was unremarkable; her vital signs and lab tests were within normal limits. Cardiopulmonary and abdominal examinations were normal as well. Chest Xray was normal, thus we performed a thoracic CT-scan with oral contrast that showed an anteromedial, retrosternal diaphragmatic defect of approximately 45mm (LL).
Furthermore, the transverse colon and part of the omentum were herniated into the thoracic cavity, and so the patient was diagnosed with Morgagni’s Hernia. Routine preoperative investigations included complete blood count, liver function test, electrolytes levels, coagulation tests, ECG and an abdominal US, all of which were normal.
III. SURGICAL TECHNIQUE
The operation was performed under general anesthesia with endotracheal intubation, the patient was placed in a supine, 15 degrees, anti-Trendelenburg position and the lower limbs were in abduction. The operating surgeon stood between the patient’s legs and the assisting surgeon on his left.
A 2 cm supraumbilical skin incision was made, Veress needle was used to create a CO2 pneumoperitoneum of 1214 mmHg under a 1/min flow rate. Then a 10 mm optic trocar was introduced in a closed technique at the supraumbilical skin incision as a camera port. Throughout inspection of the intraabdominal space, a 6x7 cm anteromedial diaphragmatic defect was detected and the hernia sac was empty as the abdominal contents were spontaneously reduced by the time of the operation (Figure 1). After that a 10 mm and a 5 mm trocars were inserted under direct camera visualization in the right and left hipochondriums, respectively, at the midclavicular lines. Thereafter we dissected and excised the hernia sac and sectioned the falciform ligament by electrocautery. Next, we performed 5 interrupted (1-0 silk) sutures in a U-shape manner using a Reverdin needle; meaning that we started inserting the suture extra-
corporeally at a point on the skin going diagonally through the anterior abdominal wall and exiting at a point on the internal surface of the abdominal wall. Then we took the anterior edge of the defect and went back at another point alongside the first one on internal surface of the anterior abdominal wall but going out at the same point of skin entry (Figure 2).
No knotting was made until all the sutures were in place, whilst the stitches were clamped with a grasper. The sutures were then manually tightened under videocamera visualization and tied at the subcutaneous level (Figure 3). A drainage tube was placed in the interhepatophrenic space. Postoperative evolution was uneventful and the patient was discharged on postoperative day one.
IV. DISCUSSION
Morgagni’s hernia was first described by GiovanniBattista Morgagni in 1761.[6] It is a rare type of congenital diaphragmatic hernias in which abdominal contents herniate into the thoracic cavity through a triangular retrosternal (anteromedial) diaphragmatic defect that results from failure of fusion of the pars costalis and pars sternalis of the septum transversum [7, 8].
Morgagni’s hernia is frequently found on the right (91%), most probably because the heart and pericardial attachment would impede its occurrence on the left [9]. A well-formed peritoneal sac is usually found containing the transverse colon and the omentum in most cases and to a lesser extent, the liver, stomach and the small intestine [7].
When the defect is relatively large, significant visceral herniation and intrathoracic compression would lead to respiratory distress, strangulation, or even cardiac tamponade presenting early in life, otherwise, patients usually remain asymptomatic until later in life and are usually diagnosed incidentally by chest X-ray [10]. Acute lifethreatening presentation is reported in adults as well, with strangulation and large bowel obstruction comprising most of the cases [11].
The gold standard for the diagnosis of diaphragmatic hernias is barium enema. A lateral CXR can demonstrate a gas pattern, haustrations and even the defect in the pericardiophrenic angle. CT scan and MRI may be needed in more vague cases to confirm the diagnosis [12]. Once the diagnosis is made, surgical repair is indispensable due to the risk of the life-threatening complications mentioned earlier [3, 4].
Generally, repair is performed through an abdominal or a thoracic approach. Laparotomy is more preferred in complicated cases with strangulation and intestinal obstruction, however, laparoscopic repair remains the optimal surgical approach in uncomplicated cases [5].
Fig. 1 - Intraoperatory aspect of Morgagni’s Hernia
Fig. 2 - Insertion of the stitches with the Reverdin needle
Fig. 3 - Stitches in place before knotting
Numerous successful laparoscopic techniques were described in the literature, varying mainly in terms of placing a mesh, primary repair of the defect, knotting and the discussion of whether to remove the sac or not.
Intraoperatively we detected a retrosternal defect of approximately 6 cm in diameter, thus we chose to perform a primary repair with nonabsorbable silk (1-0) sutures placed in a U shape manner using Reverdin needle in a transfascial extracorporeal knotting technique.
Rau [13], Huntington [14], Del Castilo [15] and Bortul [16] used polypropylene mesh prosthesis. Their decision is mostly advocated to the relatively larger defect dimensions (6), (4x9), (12x15), (6x10) cm respectively. There is no established limit regarding the indication of a mesh placement, but when the defect is larger than 20-30 cm2, a mesh placement is substantially preferred [17].
Kuster [18], Vinard [11] and Fernandez [19] reported successful laparoscopic primary repairs with running sutures, in contrast, Newman [20], Orita [21] and Angrisani [22] choose to perform laparoscopic primary repairs with separate sutures. We preferred to do separate sutures because we believe and as other authors note it that separate suturing helps to avoid tissue tearing. Furthermore, intracorporeal knotting is rather challenging because of the defect location in a plane parallel to the instruments, aside from the scanty tissue to which the defect is supposed be sutured to [23].
Whether to remove the sac or not is genuinely controversial, systematic studies entailing complication risk assessment are lacking. The most serious complication related to sac removal is fatal pneumopericardium moreover injuries of the mediastinal and pericardial pleura were reported as well [24]. However, other authors stated that sac excision is a crucial step that can decrease the risk of recurrence if performed with supreme level of precision and accuracy avoiding pleural or pericardial injuries [25].
Rau [13], Newman [20] and Fernandez [19] excised the sac with no complications or recurrences reported. In our experience we decided to defy the risks with careful, confined dissection and excision of the sac with which we came through successfully.
Laparoscopic repairs using staples were implemented as well, Smith [26] performed a primary repair while Bortul [16] used a mesh. Regarding recurrence after laparoscopic repair, a valid estimation is unobtainable due to the lack of follow up figures. Our experience is quite recent, therefore follow up data is still unavailable.
V. CONCLUSION
Laparoscopic repair with transfascial sutures and extracorporeal knot tying is a distinct, durable, easy and efficient approach for the management of Morgagni’s hernia. It offers a successful repair with less postoperative pain and hemorrhage, shorter hospital stay and recovery time, reduced risk of postoperative infections, rapid return to regular physical activity and overall it is cosmetically preferred. The transfascial suturing provides an easy, fast, durable and efficient repair of the defect without the need for a mesh placement. Likewise, the extracorporeal knotting is much easier to execute compared to intracorporeal knotting.
ACKNOWLEDGMENT
The authors are grateful for the financial support from the Romanian National Authority for Scientific Research UEFISCDI for project no. PN-II-RU-TE- 2014-4-0992 and Iuliu Hatieganu University of Medicine and Pharmacy, 3rd Department Of Surgery, Cluj-Napoca, Romania, internal grant no. 4945/14/08.03.2016.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
2.Loong TP,Kocher HM (2005) Clinical presentation and operative repair of hernia of Morgagni Postgrad Med J. 81: p. 41-4.
3.Pairolero P, Trastek V, Payne W (1989 ) Esophagus and diaphragmatic hernias.In: Schwartz SI, editor. Principles of surgery McGrawHil. New York. p. 1118 –1132.
4.Kimmelstiel FM, Holgersen LO, Hilfer C (1987) Retrosternal (Morgagni) hernia with small bowel obstruction secondary to a Richter's incarceration J Pediatr Surg. 22: p. 998-1000.
5.Pironi D, Palazzini G, Arcieri S et al. (2008) Laparoscopic diagnosis and treatment of diaphragmatic Morgagni hernia. Case report and review of the literature Ann Ital Chir. 79: p. 29-36.
6.Morgagni GB. In: Millar A CT, eds. Seats and Causes of Diseases.London 3: p. 1769:205.
7.Harris J, Super T, Kimura K (1993) Foramen of Morgagni hernia in identical twins: Is this an inheritable defect? Fed Surg. . p. 28:177-178.
8.Sinclair L,Klein L (1993) Congenital diaphragmatic hernia Morgagni Type Emerg Med J. p. 11:163-165.
9.Horton JD, Hofmann LJ, Hetz SP (2008) Presentation and management of Morgagni hernias in adults: a review of 298 cases Surg Endosc. 22: p. 1413-20.
10.Papia G, Gerstle J, Langer J (2004) Laparoscopic repair of Morgagni diaphragmatic hernia in children: technical challenges and results. Pediatric Endosurg Innovat Tech p. 8:245–249.
11.Vinard J, Palayodan A, Collomb P (1997) Emergency laparoscopic treatment of a strangulated Morgagni hernia. Eur J Coeliosurg. p. 1:35-40.
12.Wolloch Y, Grunebaum M, Glanz I et al. (1974) Symptomatic retrosternal (Morgagni) hernia Am J Surg. 127: p. 601-5.
13.Rau HG, Schardey HM, Lange V (1994) Laparoscopic repair of a Morgagni hernia Surg Endosc. 8: p. 1439-42.
14.Huntington TR (1996) Laparoscopic transabdominal preperitoneal repair of a hernia of Morgagni J Laparoendosc Surg. 6: p. 131-3.
15.Del Castillo D, Sanchez J, Hernandez M et al. (1998) Morgagni's hernia resolved by laparoscopic surgery J Laparoendosc Adv Surg Tech A. 8: p. 105-8.
16.Bortul M CL, Gheller P (1998) Laparoscopic repair of a Morgagni-Larrey hernia Laparoendosc Adv Surg Tech. p. 8(5):309-313.
18.Kuster GG, Kline LE, Garzo G (1992) Diaphragmatic hernia through the foramen of Morgagni: laparoscopic repair case report J Laparoendosc Surg. 2: p. 93-100.
19.Fernandez-Cebrian JM,De Oteyza JP (1996) Laparoscopic repair of hernia of foramen of Morgagni: a new case report J Laparoendosc Surg. 6: p. 61-4.
20.Newman L, 3rd, Eubanks S, Bridges WM, 2nd et al. (1995) Laparoscopic diagnosis and treatment of Morgagni hernia Surg Laparosc Endosc. 5: p. 27-31.
21.Orita M OM, Yamashita K, Morita N, Esato K. (1997) Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni Surg Endosc. p. 11(6):668-670.
22.Angrisani L, Lorenzo M, Santoro T et al. (2000) Hernia of foramen of Morgagni in adult: case report of laparoscopic repair JSLS. 4: p. 177-81.
23.Mallick MS,Alqahtani A (2009) Laparoscopic-assisted repair of Morgagni hernia in children J Pediatr Surg. 44: p. 1621-4.
24.Pokorny WJ, McGill CW, Harberg FJ (1984) Morgagni hernias during infancy: presentation and associated anomalies J Pediatr Surg. 19: p. 394-7.
25.Shah RS, Sharma PC, Bhandarkar DS (2015) Laparoscopic repair of Morgagni’s hernia: An innovative Approach Departments of Paediatric Surgery, and Minimal Access Surgery, P. D. Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, Maharashtra, India.
26.Smith J,Ghani A (1995) Morgagni hernia: incidental repair during laparoscopic cholecystectomy J Laparoendosc Surg. 5: p. 123-5.
Author: Emil Mois
Institute: University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
Street: Str. Victor Babeş Nr. 8, 400012 Cluj-Napoca
City: Cluj-Napoca
Country: Romania
Email: dr_emil_mois@yahoo.com
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PART I EARLY YEARS 1585-1607
CHAPTER I
1585-1590
The birth of Armand Jean du Plessis de Richelieu—The position of his family—His great-uncles—His grandfather and grandmother—His father, François de Richelieu, Grand Provost of Henry III.—His mother and her family—His godfathers—The death of his father.
In the year 1585, when Elizabeth of England was at the height of her power, when Mary of Scotland lay in prison within two years of her death, when Philip of Spain was beginning to dream of the Invincible Armada, when Henry of Guise and the League were triumphing in France, the future dominator of European politics was born.
Armand Jean du Plessis, third and youngest son of François du Plessis, Seigneur de Richelieu, was an infant of no great importance. Even his birthplace, for a long time, was not known with any certainty.
His family was noble, but not of the higher nobility which governed provinces, commanded armies, and glittered at Court. He belonged to that race of French country gentlemen which led a strenuous life in the sixteenth century, either for good or evil—perhaps mostly for evil. They were generally poor, proud, and greedy. If, by fair means
or foul, they could capture a rich wife of their own station, so much the better; if not, they readily sacrificed birth for money, and bestowed an old name, coat and sword, rough manners and ruinous walls, on some heiress of the bourgeoisie. When the resource of marriage failed, such a gentleman would turn himself into a mercenary soldier, Catholic or Huguenot, or creep into Court employment in the shadow of some great noble of his province; or failing such honest means, he might clap on a mask and take to highway robbery, rich travellers being better worth pillaging than the peasants who hid in their hovels as his horse’s heavy hoofs clanked by. Sometimes Religion herself, or the false Duessa who personified her in those days, might help a needy gentleman to a livelihood. There was many an abbot who had never been a monk; and there were lucky families—that of Du Plessis, for instance—who possessed a bishopric as provision for a younger son.
The Du Plessis were an old family of Poitou. In that ancient and famous province they had held several fiefs so far back as the early thirteenth century; but they were a wandering, fighting race, without strong attachment, it seems, to their native soil. One of them is said to have gone to England in the suite of Guy de Lusignan, and to have married a noble English wife. Another journeyed to Cyprus with the same distinguished patron. In the Hundred Years War, two Du Plessis brothers were found fighting on opposite sides, French and English. Pierre, the elder, head of the less distinguished branch of the family, was a robber of Church property as well as a traitor to the national cause; but in the way of morals there was not much to choose between him and his brother Sauvage, the patriot, in favour of whom their father threatened to disinherit him.
Sauvage was a man of strong, acquisitive character, and everything prospered in his hands, though he began his career by carrying off a younger brother’s wife. It was his son, Geoffroy, who laid the real foundation of future greatness by his marriage with Perrine Clérembault, of a good old family, whose brother was Seigneur of Richelieu. Louis de Clérembault, who held a post in the Court of Charles VII, left his fortune and estates to François du Plessis, his sister’s son. The young man not only succeeded to the
fortified château of Richelieu and a good position in his native province, but also to a connexion with the Court which lasted into the reign of Louis XI, and which helped him to lift his family a step higher by marrying his own son, François, to the daughter of Guyon Le Roy, of Chavigny, in the Forest of Fontevrault, a distinguished courtier, and Vice-Admiral of France under François I. This François du Plessis de Richelieu was great-grandfather to the famous Cardinal.
An ecclesiastical turn—for the sake of gain rather than of godliness—was given to the family by its relationship with that “true prelate of the Renaissance,” Jacques Le Roy, uncle of Madame de Richelieu. He was successively Abbot of Villeloing, Cluny, and St. Florent-de-Saumur, and Archbishop of Bourges, and in him the bad sixteenth-century alliance between the Church and the world, the consequence of royal nomination to benefices, might be seen at its most flourishing point.
He chose three out of his five Richelieu great-nephews to follow in his footsteps. Two of them rose to be abbot and bishop; the other, Antoine, took the vows as a monk at Saumur against his will, and after a short religious life varied by floggings and other punishments for rebellion, unfrocked himself and ran away to the wars. Known throughout his military life as “the Monk,” he was a cruel and ferocious soldier. With his brother François, a man of very different type, he first saw service in the Italian campaigns under the Maréchal de Montluc. Both brothers returned to Poitou towards 1560, and both took the Catholic side in the religious civil war which raged for years in the miserable western provinces of France, where Protestantism, from various causes, had taken a firm hold. Attached to the Guise faction, the brothers became special partisans of the Duc de Montpensier, the King’s lieutenant in Poitou and their own near neighbour at the Château de Champigny. His army swept the province with fire and sword, and among his many fierce and adventurous followers François and Antoine du Plessis-Richelieu led the way.
The former, however, seems to have been an honest soldier rather than a bloodthirsty demon. He, nicknamed “le Sage” and regretted as “un fort brave gentilhomme,” lost his life in an expedition against
the English, who had occupied Le Havre. Le Moine survived his brother some years, and his fame as a fighter became worth a post at Court and a knightly order. With an ever-growing reputation for vice and violence, he was killed in a street brawl in Paris—“mort symbolisante à sa vie,” says the chronicler l’Estoile. His most characteristic exploit, and the most startling among many, was the single-handed massacre of a hundred Huguenots who had taken refuge in a church near Poitiers. Antoine de Richelieu “amused himself” by shooting down these poor defenceless creatures in cold blood.
So much for the Cardinal’s great-uncles. His grandfather, Louis du Plessis, Seigneur de Richelieu, the eldest of the family, died a young man, but not before he had helped on its fortunes by a marriage profitable in dignity, if not in coin. The heir of Richelieu was of a quieter spirit than his brothers. He entered the household of a fine old noble—Antoine de Rochechouart, seneschal of Toulouse, distinguished for valour in the reigns of Louis XII and François I—as lieutenant of his bodyguard; and very shortly married his master’s daughter, thus distantly connecting his famous grandson with one of the noblest old ducal families in France, from which sprang Madame de Montespan and her brilliant brothers and sisters, the Duc de Vivonne, Madame de Thianges, and the learned Abbess of Fontevrault. His Rochechouart grandmother was the one precious link between Cardinal de Richelieu and the higher nobility.
M. de Rochechouart was poor, probably extravagant, and his daughter Françoise, whom tradition makes neither young, pretty, nor amiable, seems to have lived in a sort of dependence on the great Dame Anne de Polignac, dowager of La Rochefoucauld, at Verteuil, where Charles V was royally entertained in 1539. These circumstances may account for the mésalliance which Mademoiselle de Rochechouart certainly made in marrying Louis du Plessis. Her interest gained him the Court appointment of échanson, or chief butler, to Henry II. But he was neither clever nor prudent, and his widow was left with five young children, very little money, a sharp, proud temper, and a deep discontent with her lot in life.
She settled herself at Richelieu, then only a small castle on an island in the river Mable, in the heart of a country terribly disturbed by civil war, and commanded, from the neighbouring hills, by the strongholds of unfriendly neighbours. Here she brought up her children, of whom the second son, François, was the father of Cardinal de Richelieu.
The story goes that a tragic event made François lord of Richelieu. There was a feud, centuries old, between the Du Plessis in their moated castle and the family of Mausson, perched upon the hill. The quarrel had been in abeyance during the peaceable, absentee life of Louis du Plessis, but when his proud widow, with her haughty, passionate boys, took up her abode at Richelieu, it broke out again furiously. Louis, the eldest son, was just growing into manhood, an officer in the Duc de Montpensier’s guards, when he fell out with the Sieur de Mausson over that ancient bone of contention, a seat in church.
Both families attended the village church of Braye, on the forest slope close by. In those days, and long afterwards, the chief gentleman in the parish had rights over the church quite as jealously guarded as any other of his feudal privileges. He sat with his family high up in the choir. He ordered the hour of mass, and the curé did not venture to begin before he arrived. The congregation followed his lead throughout. When he was absent, his servants sat in his place and insolently demanded the honours due to him. His coat of arms was hung up for all to see. If he died, the bells chimed unceasingly for forty days, and the church was hung with black velvet for a year and a day.
It appears that the Sieur de Mausson and the young Seigneur de Richelieu both demanded honours which could not be paid to both. The young man, pushed on by his mother, made an angry resistance to the Mausson claims. His neighbour, by way of settling the question, lay in wait for Louis and murdered him.
Madame de Richelieu thought of nothing but revenge. Her younger son, François, was page to King Charles IX.: she sent for him, and he lived at Richelieu, mother and son with one object, one
intention, till the watched-for time came. Then one day, when Mausson was fording the river, François and his men rushed out from the shadow of the willows. They had set a cunning trap for the enemy, a cart-wheel hidden under water, and while his restive horse was plunging, they fell upon him and killed him. So ended the feud between Mausson and Richelieu, still a lingering tradition in the valley of the Mable.
There was not much justice in those days, but it appears that François was obliged to fly the country. He wandered as far as Poland, where Henry of Anjou was playing at being King, and shared in the adventures of that most worthless of the Valois when he ran away with the Polish crown jewels and travelled round by Austria and Venice to succeed Charles IX on the throne of France.
François de Richelieu became Henry’s trusted servant. Certainly there was nothing of the mignon about him. Very tall, thin, solemn and dismal, his looks were suitable to his dreary but necessary office —first Provost of the King’s house, then Grand Provost of France, charged with arresting malefactors and presiding over their punishment. He was known at Court as “Tristan l’Hermite,” so that he must have struck his contemporaries as resembling, not in his office alone, the famous Provost of Louis XI.
François de Richelieu was affianced in early youth, before the Mausson affair drove him abroad, to Suzanne de la Porte, who belonged by birth to the higher bourgeoisie of his native province. Circumstances brought about this marriage, to which one cannot imagine that the proud Françoise de Rochechouart gave a very willing consent.
The family of La Porte, highly respectable, and clever with all the Poitevin shrewdness, possessed estates in Poitou and elsewhere. François de la Porte, the Cardinal’s maternal grandfather, was a brilliant scholar at the University of Poitiers, only second in fame to that of Paris, and first in Europe for the study of Roman law in the original spirit; keen, solid, logical, practical.
François de la Porte became a learned and distinguished advocate in the law-courts of Paris, but did not lose interest in his
own province and his neighbours there. He appears to have been specially concerned with the affairs of Louis de Richelieu, who, according to Tallemant, was not only very poor, but “embrouilla furieusement sa maison,” and left his family in real distress. M. de la Porte made himself very useful to Dame Françoise de Richelieu, no doubt partly as to the management of her more distant property, difficult enough in those desperate times, and satisfied the vanity with which his contemporaries credit him by marrying his daughter to her son. The exact date of the marriage does not seem to be known.
As Grand Provost, François de Richelieu had a house in Paris, in the Rue du Bouloy, and all probabilities point to the fact of his son Armand having been born there. He was certainly baptized in Paris, though not till eight months after his birth, the delay being caused partly by his extreme delicacy, partly by the long and dangerous journey from Poitou which had to be made by his grandmother, who was present at the church of Saint-Eustache as one of his sponsors.
The others were two Marshals of France, Armand de GontautBiron and Jean d’Aumont; each of whom gave the child a name. Both these gallant soldiers are celebrated by Voltaire in the Henriade:
“D’Aumont, qui sous cinq Rois avoit porté les armes; Biron, dont le seul nom repandoit les alarmes....”
Both were intimate friends of the Grand Provost, and joined him later in placing their swords at the command of Henry IV.
The name of François de Richelieu is frequently to be met with in the documents of Henry III.’s reign. He received the highest honour Royalty could bestow, the Order of the Holy Spirit. The King’s personal safety depended largely on him, and allowing for the general corruption of the time, he seems to have performed his duties, often secret and mysterious, with honesty, loyalty, and courage. On that wild day in 1588, when the Duc de Guise had been welcomed by Paris with mad enthusiasm, when the streets were
chained and barricaded against the King’s troops, and Henry was escaping from his “ungrateful city,” it was the Grand Provost who checked the pursuers at the Porte de la Conférence. Old writers say that the gate took its name from that circumstance, and tell how “François de Richelieu, Grand Prévôt de France, père du Cardinal de même nom, arrêta les Parisiens qui vouloient suivre le Roi, pour tâcher de le surprendre.”
Luckily for his own fame, this “wise officer” was not an active agent in the murder of the Duc de Guise at Blois, a few months later. But he was sent to the Hôtel de Ville to arrest those dignified citizens whom the King suspected of being concerned in the Guise conspiracy. And in the following summer he performed his last duty towards Henry III. by arresting the miserable monk, Jacques Clément, whom the Duchesse de Montpensier, sister of Guise, had persuaded to earn his salvation by murdering the King, “enemy of the Catholic religion.”
In the confusion that followed Henry’s death, the wise “Tristan” did not trust himself to the faction of the Guises. With other Catholic nobles, and in spite of family traditions, he turned to the one man in whose hands he saw safety for France and himself, the Protestant Henry of Navarre. That clever Prince received him cordially and confirmed him in his appointments. So it came to pass that the nephew of “the Monk” reddened his sword with Catholic blood at Arques and at Ivry, and followed his new King, still as Grand Provost of France, to the camp before Paris. There his career was cut short by a fever in the summer of 1590, at the age of forty-two.
CHAPTER II
1590-1595
Friends and relations—The household at Richelieu— Country life in Poitou.
Whether the widow of François de Richelieu was in faminestricken Paris during the siege—one of those afflicted ladies to whom the good-natured and politic Henry sent provisions first, passports later, that they might escape from the city—or whether she had already, her husband being so strongly in opposition to the ruling powers there, removed herself and her five children into the country it seems impossible to know.
She was not without influential friends in Paris; the more useful, perhaps, because they were not in the fighting line. Her father lived in the Rue Hautefeuille, near the Church of St. André-des-Arcs, in the heart of the Latin quarter; the old turrets of his house still remain. He was divided from the Rue du Bouloy, on the north side of the river beyond the Louvre, by two bridges, the Island, and a labyrinth of dirty, narrow, dangerous streets. There may well have been a gulf fixed, during those horrible months of the siege, between the old advocate and his daughter.
But Amador de la Porte, his younger son, and Denys Bouthillier, his head clerk and future successor, were not likely to let Suzanne and her children suffer any unnecessary privation. Both were strong and brilliant men, worthy members of that bourgeoisie which was the pride and life of Paris. Amador, some years younger than his sister, was apparently too restless to settle down in his father’s profession. But François de la Porte had been very useful, as advocate, to the Order of Malta. They rewarded him by receiving Amador as a Knight of the Order, without a too close inquiry into his proofs of nobility. His foot once on the ladder, Amador rose to be Commander, then Grand
Prior of France, and by his nephew’s favour held several important governments.
These two men, Amador de la Porte and Denys Bouthillier, were constant friends and guardians of the Richelieu children. Bouthillier and his sons were devoted to the Cardinal throughout his career, to their very great advantage. Claude, the eldest, made an enormous fortune as surintendant des finances under Louis XIII., and his son Léon, Comte de Chavigny, was a minister under both Richelieu and Mazarin. Sébastien and Victor rose high in the Church. Denys became private secretary to Queen Marie de Médicis, and was created Baron de Rancé; he was the father of Armand Jean de Rancé, the famous Abbot of La Trappe.
Through the Cardinal’s other La Porte uncle, of whom, personally, not much is known, the old advocate’s family stepped up into something like equality with the highest in the kingdom. His son, Charles, a bold, eccentric creature, attached himself from the first to the fortunes of his cousin, Armand de Richelieu, and by this means became a Marshal of France and Duc de la Meilleraye. He was one of the Cardinal’s most trusted aides-de-camp, and later on, a conspicuous figure in Paris during the troubles of the Fronde.
In the autumn of 1590, if not sooner, a family of women and children was established at the Château de Richelieu. There were Dame Françoise de Rochechouart, widow of the Seigneur Louis, and her daughter, also a widow, Françoise du Plessis, Madame de Marconnay. There were Suzanne de la Porte, widow of the Grand Provost, and her five children; Françoise, a girl of twelve—who married first the Seigneur de Beauvau, secondly, René de Vignerot, Seigneur du Pont-de-Courlay, and was the mother of the Cardinal’s favourite niece, Madame de Combalet, afterwards created Duchesse d’Aiguillon; Henry, a well-known courtier of Louis XIII.’s young days; Alphonse, at this time intended for the Bishopric of Luçon; Armand Jean, the political genius, now a delicate, feverish atom of five years old; Nicole, who married the Marquis de Maillé-Brézé, and whose daughter, Claire Clémence, became the wife of the great Condé.
The head of this household, according to immemorial French custom, was the grandmother, Françoise de Rochechouart. Her rule, no doubt, was severe, and there are evidences that her daughter-inlaw, a woman of gentler type, suffered under it. The hard old aristocrat who had condescended in her marriage with Louis du Plessis was scornful of the bourgeoise mother of her grandchildren. She was soured too by the losses and troubles of her life. Probably Suzanne brought from Paris the habits of a civilisation that did not suit that rough old home, that “ancient house of stone, roofed with slates,” strongly fortified with walls and moats as useful now as in the time of the English wars, when they were new. In 1590, the civil wars were by no means at an end. The province, devastated for years by Catholics and Huguenots flying at each other’s throats, now suffered equally in the struggle between Henry IV. and the League. Poitiers took the latter side, and for three years, from 1591 to 1594, the King’s army besieged it in vain. All the neighbouring country, including the valley of the Mable, was ruined and unsafe. A band of ruffian soldiers sacked the small town of Faye-la-Vineuse, on the hills overlooking Richelieu. No wonder if the gentle Suzanne, “loyal lady” and tender mother, was kept sleepless by burning horizons as often as by her little Armand, shivering with fever in the unwholesome mists of that river valley.
Her anxieties indeed were many; for though Dame Françoise might be mistress of the house, all the business connected with her children and her inheritance devolved on her. And the Richelieu affairs were in an embarrassed state. The Grand Provost had left heavy debts behind him. There was the management of various small estates and châteaux in Poitou, which by some means or other had become possessions of the family: one of these was Mausson, name of ill-omen, which had been taken in exchange for an estate in Picardy, part of the dowry of Suzanne de la Porte.
She was an excellent woman of business, with hereditary instincts of law and order. All her tact and capacity, directed by strong affection, were devoted to the interests of her children. The words she wrote to Armand, years later, when he was Bishop of Luçon, seem to have been the key-note of her life:
“L’inquiétude que j’ai me tue et je vois bien que je n’aurai jamais de joie que lorsque, vous sachant tous heureux, je serai en paradis.”
With such a mother, and with an indulgent aunt in Madame de Marconnay—in spite of a fierce grandmother, barred gates and alarms of war—the children’s life at Richelieu need not have been unhappy. Indeed it was not so, if one may judge by the Cardinal’s recollections of it, and his constant devotion to the old place where most of his childhood was spent. After all, the family was on the winning side. France was growing tired of the League, attracted by the sunny, accommodating patriotism of Henry IV. If the harvests of Poitou were destroyed, woods cut down, villages burnt and pillaged, it was often, odd as this may sound, the work of friends, and in the intervals of these stormy visits of robber bands, country life went on cheerfully.
The strong old manor nestled snugly on the islet in the river-bed, something after the fashion of Chenonceaux in Touraine or Bazouges in Anjou. On the border of these two provinces and of Poitou, the country round Richelieu had something of the character of all three. The rich fertility of Touraine, the vineyards and gardens, though not unknown here, soon gave way to the forests and marshes of the wilder provinces. But Richelieu had its park and its avenues, leading from the high road which ran south from Chinon and Champigny into Poitou. By this road came all the travellers, all the visitors: Amador de la Porte, the beloved uncle, with news from Paris; Jacques du Plessis, the great-uncle, the non-resident Bishop of Luçon, with his eye on a young successor; or, less welcome to the heads of the family, the Duc de Montpensier, the feudal neighbour, with his pack of wolf-hounds and swaggering troop of guards and followers. One may fancy, even then, that the dark eyes of Armand watched the owner of Champigny, scarred from the wars, without much friendliness.
There are signs that the family at Richelieu was on kindly terms with its neighbours of lower estate. The curé of Braye, M. Yver, who said mass often in the chapel of the château, was an intimate friend. There was no oppression of the peasants, who lived round about in their low, mud-floored, one-roomed cottages, and eked out their poor
harvest by catching game in the forest or fishing in the river All through the western provinces, indeed, then and for long afterwards, seigneur and peasant lived well together; the contrary was the exception. And the contrary came to pass, in great measure, through the action of the founder of absolute monarchy, the boy who ran about hand in hand with his mother at Richelieu.
In the meanwhile, Dame Suzanne befriended and doctored the people, knew them all by name, visited them, gossiped with them. She and her children witnessed their marriages, were sponsors at the baptism of their babes; a few years later, in 1618, the old registers of Braye bear witness that the infant son of young Henry du Plessis was named at the font, in the chapel at Richelieu, by two “poor orphans,” assisted by “ten other poor persons.” The gates of the château were open to any humble neighbours who suffered in the wars; the kitchen supplied them with food, sometimes not too plentiful even there; and holy-days found the courtyard full of peasants playing their bagpipes, dancing their quaint provincial dances, singing the songs of Poitou. Thus masters and servants alike managed to forget the hardships and terrors of the time.
Among scenes like these the Cardinal’s early childhood was spent, and to his dying day, with all France at his feet, he loved that corner of Poitou. It must be added that the traditions of Richelieu itself, supported by many writers of the seventeenth century, declare that he was born there. When Mademoiselle de Montpensier, in 1637, paid her visit to Madame d’Aiguillon at the magnificent palace into which the Cardinal had transformed the little stronghold of his fathers, and found some of the rooms inconceivably small and mean, compared with the stately exterior, it was explained to her that the Cardinal had ordered Le Mercier, his architect, to preserve unaltered that part of the old building where his parents had lived and where he was born. The witnesses on the same side are too many to quote. On the other hand, Richelieu himself declared on more than one occasion that he was born in Paris, a Parisian, a native of the city which always had his heart; and his enemies dwelt strongly on the same fact, treating the Poitevin theory as an outcome of that immense pride and vanity which encouraged the Cardinal’s
worshippers to represent his family and their possessions as older and greater than they really were; feudal magnates of centuries, instead of country gentlemen with their fortune to seek.
CHAPTER III
1595-1607
The University of Paris—The College of Navarre—The Marquis du Chillou—A change of prospect—A student of theology—The Abbé de Richelieu at Rome—His consecration
Before Armand de Richelieu was eleven years old, his uncle Amador, who was among the first to recognize the boy’s brilliant gifts, carried him off to Paris and placed him at the University It was the family intention that Armand should carve out his living in a career of arms. The eldest brother, Henry, the seigneur of Richelieu, was to marry, and to cut a figure at Court. Being a charming and agreeable young fellow, he was likely to succeed in this line. Alphonse was a saint, and a born ecclesiastic; his future needed no arrangement; the see of Luçon was waiting for him. After the death of the great-uncle, Jacques du Plessis, in 1592, the revenues of the diocese were taken over by a titular bishop—no other than M. Yver, curé of Braye and chaplain at Richelieu—a worthy warming-pan who paid the largest portion to Madame de Richelieu, and wasted as little as possible on the cathedral and the diocese. The canons rebelled and complained most unreasonably, we are told; but Henry IV. had confirmed Henry III.’s grant of the bishopric to the Richelieu family, and the Chapter could obtain no redress. They had to wait till Alphonse was of age to be consecrated.
It was the right thing for every young Frenchman, of every rank, whatever his future walk in life might be, to go through his course at one of the universities. A king’s son might be found on the Paris benches, listening to the same lecture with the clever son of a tradesman or even a peasant from a remote province. The poor students were quite as numerous as the rich; they filled the high houses and crowded the narrow streets of the famous Pays Latin;
they “lived as they could,” and their character as a community did not alter much in the course of centuries.
When Armand de Richelieu was first entered at the College of Navarre, where “the great Henry” had studied before him, the University was at a low ebb, both as to professors and students. The wars of the League, the fighting in the streets, the horrors of the siege, had driven most decent people away from Paris, while armies of vagabonds and fugitives took possession of the city, even of that “city within a city,” which the University had been ever since the time when Philippe Auguste built its enclosing wall.
That wall still existed long after the young days of Richelieu. Its broad ditches, its battlements and frequent towers, its seven or eight formidable gateways, two of which defended a bridge and a ferry over the Seine, while the Tour de Nesle, at the western corner, frowned across at the Louvre—all enclosed with mediæval strength that Latin quarter, a half-moon in shape, which sloped up, a mass of lanes, colleges, convents, churches, to the old royal abbey and Church of Ste. Geneviève, where her shrine, the chief religious treasure of Paris, was kept; destroyed in the eighteenth century and replaced by the Pantheon with Voltaire’s bones and Soufflot’s ugly dome.
The University existed before the colleges. They were founded, one by one, by charitable men and women, mostly for the benefit of the poor scholars of different special towns or countries. Often their names told their story; but sometimes they were called by the name of the founder, such as the “Collège du Cardinal Lemoine.”
The College of Navarre was one of the best known and highest in reputation. It was founded in 1304 by Jeanne, wife of Philippe le Bel and Queen of Navarre in her own right, in memory of the victory of Mons-en-Puelle in Flanders. It was thus nearly three hundred years old when Armand de Richelieu entered it, and had already that royal and military reputation which lasted through three or four centuries more. An old writer on Paris says that the sons of the greatest nobles in the kingdom boarded in this college, and in order that they might not be distracted by intercourse with outside students—a real
danger, one would think, and of worse things than distraction—no other scholars were received. “Navarre” did not always remain so exclusive. But this was probably its character in Richelieu’s time, though we do not positively know whether the young gentleman, with his private tutor and his footmen—all of whom remained many years in his service—lodged in the college or at his grandfather’s house in the Rue Hautefeuille.
The College of Navarre had had famous men among its tutors and professors. Nicolas Oresme, one of its early head masters, was tutor to King Charles V., who owed to him his surname of “The Wise.” He was a translator of Aristotle, and is supposed to have made the first French version of the Bible. Somewhat later, the celebrated mystic, Jean Gerson, believed by many to be the real author of the Imitatio Christi, was a teacher in the college and became Chancellor of the University. A famous Principal, also Chancellor, was Cardinal d’Ailly, Archbishop of Cambray, a theologian of tremendous strength, known at the Council of Constance as the “Eagle of France,” and “the Hammer of the Heretics.”
The traditions of “Navarre” were inspiring and severe. At the end of the sixteenth century, when young Richelieu was going through its courses of “grammar” and “philosophy,” the college was ruled by Jean Yon, a lover of Cicero, of discipline, and of Church ceremonies. Long after the days of dry study and compulsory Latin were over, the Cardinal kept a friendly recollection of his old master, and declared that he could never see him without “a feeling of respect and fear.” Probably, therefore, Jean Yon was wisely careful to hide his admiration of the boy, who, according to one of his biographers, “avala comme d’un trait toute la grammaire,” knew by instinct how to baffle his examiners by puzzling counter-questions, and dazzled both teachers and comrades by the bold and sparkling flashes of his genius.
But Master Yon was not always the stern pedagogue. The Cardinal ever remembered with peculiar pleasure taking part, as a singing boy, in the great procession which marched from Ste. Geneviève on her hill, right across Paris, to visit the tomb of St. Denis. The whole University joined in the procession, and on this
occasion it was led by Jean Yon and a chanting choir from the College of Navarre.
Once upon a time, they say, that procession was so long that when the head was entering the Church of St. Denis, far away in the northern outskirts of the city, the tail, of great dignity, had not yet come forth from the Church of the Mathurins, where the general rendezvous had been fixed. This was in the time of Charles VI., when all Paris was praying and making processions that his lost senses might be restored to him. In those days, we are told, the University of Paris was the centre of learning for all the nations of Europe and the mother of all their universities, including “Oxfort en Angleterre.” Her European fame and the number of her students had dwindled a good deal before the day when Armand de Richelieu, the slim, keen, black-haired boy of twelve, marched in her procession as an enfant de chœur.
Down the hill they wound, threading the dark labyrinth of high college walls, then perhaps following the Rue St. Jacques, the old Roman road, down to the Petit Châtelet, guarding with its tunnelled gateway the entrance to the Petit Pont; or, more likely, keeping to their own Latin-speaking quarter as far west as the Pont St. Michel— the Pont Neuf was not yet finished—and there crossing to the Island and passing in front of the Palais de Justice, through crowds of men of law, red-robed councillors, officials and hangers-on of the Parliament, quite as busy and as noisy as the ecclesiastical throng they had left behind them. The Pont-au-Change, haunt of moneychangers and bird-catchers, carried them on to the farther shore; one of those steep and ancient bridges, chiefly built of wood and blocked with houses, shops and stalls, which were difficult to cross at all times and were constantly in danger from flood or fire. Then the procession’s way was almost blocked by the great round towers and frowning prison walls of the Grand Châtelet. Then through dark and narrow ways it passed out into the wider spaces, the gayer air, of the Paris of the north bank, of kings and their palaces, and leaving the Louvre to the left, the Hôtel de Ville, Bastille, and Temple far to the right, went on by the Rue St. Denis towards the gate of that name,
and so out into the frequented road leading to the old towers that sheltered the shrine of the Saint.
All the way there was a constant carillon of bells from a hundred steeples; the red and gold of vestments and banners glowed in the sunshine; trumpets brayed; and with loud chanting the procession paced along. To a boy fresh from his lessons, who was to live on into more colourless times, such a holiday glimpse of the Middle Ages may very well have been a pleasant recollection.
At this time young Richelieu was looking forward to nothing but the life of a soldier, and of course a mercenary one, for his family was likely to endow him with little means of living. The world was his oyster, which he with sword must open. It was nothing new: he would walk in the footsteps of his father and his great-uncles, with the advantage of serving a King whom he heartily admired; of this his Memoirs give proof enough.
When the usual University course was over, M. de la Porte proceeded to make a man and a soldier of his nephew. He placed him at the famous Academy of M. de Pluvinel, a former companionin-arms of the Grand Provost, who had made a career for himself as a trainer of young gentlemen. He taught them fencing, riding, dancing, music, mathematics, various manly games. He was an authority on fashion and style, wit and manners, the ways of foreign nations; in short, he turned boys fresh from college into men of the world, courtiers, soldiers, diplomatists. There was scarcely a leading man in France in the early seventeenth century who had not passed through the “manège royal” of M. de Pluvinel.
A title was necessary, in order to swagger successfully among the gay cadets of the Academy. Armand became Marquis du Chillou, taking the name from a small estate in Poitou brought into the family by his great-grandmother.
His years of study at the Academy seem to have been among the happiest of his life. Made mentally of steel and flame as he was, ancestral hardness and strength of will joined with a passionate ambition all his own, the fighting career of a successful soldier was likely to attract him irresistibly. When he was young, it seemed
indeed the one chance of shining in the world, of commanding men. And he never lost his love for the profession he had to renounce, though it became clear that for a daring spirit such as his, the red robe was as practical a garment as the buff coat. “Sous le prêtre, on retrouve toujours en lui le soldat,” says M. Hanotaux.
There was one drawback to the military prospects of Armand de Richelieu. The delicate, aguish boy had not grown into a strong youth. His keen spirit was now, as ever, a sword too sharp for its frail sheath. Hard study and lack of fresh air during his college days had had their likely effect on his weak constitution and slight frame. For his sake, his mother did not mourn over the family circumstances that forbade him, after all, to be a soldier. “Mon malade,” as she called him, was not of those who could sleep on open field or fell, in mud or mire, as soundly as within stone walls with curtains round his bed.
For the family, it was a question of losing the revenues of the see of Luçon. Alphonse de Richelieu, its intended Bishop, at the age of nineteen or twenty, turned away in disgust from the worldly-wise arrangement, and decided to become a Carthusian monk. It may not be unfair to describe him as “dévot et bizarre”; but one seems to see in this singular resolution an outcome of the reaction against the dead and conscienceless state into which the sixteenth century had brought the French Church; the reaction which was already living and moving in such men as François de Sales, Vincent de Paul, Pierre de Bérulle, though leading them, as to their religious life, into reforming action rather than lonely contemplation.
Armand’s choice was soon made. No doubt the change was to him inevitable. There could not be two young men more different than himself and Alphonse; yet he too had a conscience of his own, of the truly Latin kind which demands any and every sacrifice for the sake of the family. He is said to have written to his uncle, who, one may well believe, was sincerely sorry for him: “The will of God be done: I accept all, for the good of the Church and the glory of our name.” The latter aspiration, at least, was fulfilled.
