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READ BEEORE THE ROYAL ACADEMY OF SCIENCES OF THE INSTITUTE OF FRANCE,
                APRIL 27, 1818.


       BY M. LE CHEVALIER RICHERAND,
PROFESSOR OF THE FACULTY OF MEDICINE, AND PRINCIPAL SURGEON OF THE

             HOSPITAL OF ST. LOUIS
TRAJVSLJ1TEI) BY THOMAS WlL&ON.  _^n ,
               PHILADELPHIA:

PRINTED FOR THE TRANSLATOR BY THOMAS TOWN, AND FOR SALE AT DUFIEF'*
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1818. 
 
ACCOUNT OF A RESECTION


               OF THE


   RIBS AND THE PLEURA;
BEAD -T.TORK TBS ROYAL ACADEMY OF SCIENCES OF THE IMTITUTE OF FBANGf.
    Gentlemen,

          I Have the honor to inform you
 of a Surgical operation with  which the re-
 cords of the  art furnish no example: a  new
 operation demanded  by necessity  and justi-
 fied by success.
   M. Michellau, Surgeon   at  NemourSj
 for  three years  had been   afflicted  with
a cancerous tumour  on the region of the
heart, the eradication of which a neighbour-
ing Surgeon performed in January last.  At
the removal of the first apparatus, a bloody
fungus appeared in the centre of the wound: 
4
cauterised at each dressing, it grew again with
activity.  A second operation was attempted :,
they penetrated  more deeply; after having
laid the ribs bare, they went to the pleura:
in the mean time new fungi displayed them-
selves and were reproduced, notwithstanding
repeated cauterisations,  by means of which
they endeavoured to repress them.  Griev-
ed at not reaping any benefit from so many,
and so painful operations, the patient came
to Paris towards the  end of March, fully de-
termined to suffer  every thing, in hopes of
being delivered from so dreadful a disorder,
and of escaping an inevitable death.
   At this  period  an enormous fungus was
springing up in the wound. From this brown
and flimsy  vegetation ooz,ed  an  abundant
sanies, reddish, and so foetid that it was im-
possible to remain  a quarter  of an hour near
the patient  without renewing the air of the
apaitment.   The pains, nevertheless,  were
moderate;  he  experienced  neither  sweats
nor colliquative diarrhea; and although tor-
mented  with an old and habitual cough, the 
5
 patient,  aged 40 years, of a robust complex-
 ion, presented the most encouraging moral
 dispositions.
    In this state of things, it was resolved to
 attempt a re-section of those ribs from which
 it was thought the cancer originated.   En-
 trusted with this  operation, I informed  the
 patient,  that very probably I should be
 obliged to cut away  a portion of the  pleu-
 ra :  he did not hesitate to submit himself
 to that  operation, all  the consequences of
 which we  did not conceal and of which he
 was able  to appreciate.
    AH things  being  ready, I proceeded
thereto on the 31st of March, encouraged in
this bold undertaking by the enlightened as
well as active assistance of my colleague
Professor Dupuytren, and by other persons
of the art  who were  so good as to lend  me
their  co-operation. The  patient  presented*
himself to the  instrument, refusing to be
held by the Surgical  aids, and  promising a
firmness  which did not  belie itself. 
6
   I  began by enlarging the wound,  giv-
ing it a crucial form :  I thus uncovered the
sixth  rib which appeared to me inflated and
uneven  in  about  four inches of its  length.
With  a buttoned bistouri the point of which
I conducted along the upper and lower rims,
I cut the intercostal muscles; afterwards with
a small  saw whose denticulated edge was on-
ly fifteen lines in length, I sawed  the bone
at the two  extremities  of the part affected.
This being done, I detached from the pleura
the fragment  thus isolated,  by employing
therefor a simple  spatula : I found in this an
unevpected facility—a facility  which pro-
ceeded  from the  condensation of the pleura
beneath the bone as the sequel of the opera-
tion has proved.
    The seventh rib  was laid bare for thje
same  extent, isolated  and detached in the
same  manner, but with much more difficul-
ty,  and not without a slight tearing.  The
pleura  discovered itself then evidently dis-
eased, thick,  fungous, and giving birth to
the vegetation in  the space of the  portion of 
7
 the ribs taken away.   The  cancerous state
 extended itself above the sixth rib so that the
 membrane  appeared affected in about eight
 inches square of its extent. To make no ex-
 cision of it was to leave incomplete an ope-
 ration  which  lasted  for twenty  minutes,
 and until  the present moment successful.
 Each of the assistants prepared  himself with
 something capable of stopping the excessive
 hemorrhage which was to be dreaded at the
 moment I should make the section of the in-
 tercostal arteries.  I cut the pleura with scis-
 sors whose blades were crooked on the side
 of the edge; and either that the section, ope-
 rated by this  instrument which cuts less in
 sawing than in pressing, and bruises the tis-
 sue which  it divides,  had determined the
 retraction  of the  vessels,  or that their size
 had  diminished  in   consequence  of the
 antecedent cauterisations,  there did not run
 a drop of blood; but at this moment the ex-
 terior air made  an irruption into the chest,
■rushing in  with violence  and  compressing
the left lung which, with the heart enveloped 
8
in the pericardium was borne  towards the
orifice.  I  sought,  by placing  thereto the
left hand,  to moderate the entrance of the
air and to prevent suffocation, which appear-
ed imminent, whilst with  the  right hand I
applied on the wound a large bolster spread
with cerate.  The  entrance of the air was
suddenly stopped by this greasy cloth, large
enough to  cover  not only the wound, but
moreover all the side of the chest  correspon-
ding.  I fixed above a large and thick sindon
of lint;  I covered it again with some bol-
sters, and supported all the apparatus with a
rolled bandage, middling tight.
  The anxiety  and difficulty of  respiration
were extreme during the twelve hours which
succeeded the operation.  The patient passed
the night entirely in a sitting posture.  To-
wards morning,   sinapisms applied  to the
soles  of the feet and to the inner surface of
the thighs  rendered the  respiration more
easy. From that  moment the pulse grew
higher and the strength was reanimated. The
patient took  nothing else for his  drink and 
-9
diet, than an infusion of flowers of the Linden
tree and of violets sprinkled with some drops
of water  distilled from Orange flowers, and
sweetened with  the syrup  of Gum Arabic.
Three days passed thus : the fever was abated
and the oppression sufficiently great to deprive
the patient of sleep.  The first dressing was
removed ninety six hours after the operation.
iThe pericardium and the lungs had contract-
ed adherence with the contour of the quadri-
lateral aperture, a kind of window made in
front of the heart.  Happily the adhesion be-
tween the  pericardium and luhgs was not
complete; for, from the sixth to the twelfth
day, through want of this adhesion, an abun-
dant serum had run from the chest and gush-
ed out at each  dressing.   The quantity of se-
rum which ran by that, in the space of twenty
four hours,  might be  reckoned a half-pint.
On the fifteenth day,  this  serum,  produced
by an inflammation of the surfaces, ceased to
run, and on the eighteenth day the adhesion
between the pericardium and the lungs was
completed.  The air  thence forward  ceased
         B 
id
to introduce itself through the wound, the
patient could lay on his side, and his sleep
and appetite were entirely restored.
   The wound, although until then dressed
with a greasy linen rag immediately applied
to its surface, rapidly diminished and exhibit-
ed a better appearance.  On the twenty-first
day the greased linen rag was dispensed with-
and they dressed as a simple  wound, the
surface covered with fleshy pimples, which
sprung up from the lungs and the pericardi-
um.
   The patient who had for some days made
trial of his strength in a garden belonging to
the house which he inhabited, could not re-
sist the desire of riding in a carriage through
the streets of the capital.   Having experien-
ced a fatigue from a ride  of five hours  in
which he visited the school of Medicine and
caused to be shewn to  him the parts  of his
ribs and of his  pleura  deposited in the cabi-
nets  of that establishment, nothing  could
prevent him from departing  the twenty-se-
venth day after the operation, or from  re- 
li
 turning to his place of residence,  where he
 arrived  without accident, provided  with a
 piece of boiled leather large enough to cover
 the cicatrix completely, when perfected.
    I suffered not the  opportunity  to  escape
 which presented  itself to prove  anew the
 perfect insensibility of the heart and pericar-
 dium:  nothing warned the  patient   of the
 touch of the fingers softly applied  to the or-
 gans.  In the state of life, the pericardium
 in man is possessed of such a transparency
 that the heart is seen through this membrane
 as if it were under a glass bell perfectly dia-
 phonus,  it is so much  so that we might have
 been led to believe there were no envelop.  It
 is so far from being so that this complete trans
 parency is found on the pericardium of dead bo-
 dies, and it appears to me, that, in this point
 of view, this membrane may be compared to
the glass of the eye which becomes dim and
 obscure at the approach  of death.
    A large aperture, with loss of substance
 made in the contour of the chest, not being
necessarily followed by suffocation,  a bloodj 
                      is

 discharge, or by a mortal inflammation of the
 organs  towards which the exterior  air finds
 there a free  access, it appears to me, there
 could be effected, in a disease to which  the
 patient would succumb, for example a dropsy
 of the pericardium, I  say, there could be ef-
 fected in front of the heart an aperture which
 would not only permit the water, in which
 that organ is immersed, to discharge itself j
 but also to effect a radical cure of the disor-
 der by determining the adhesive inflamma-
 tion of the surfaces, by processes similar to
 those used for the *ure of the hydrocele.*
 The same operation would be justified in order
 to expose the lungs partially affected and in
 taking away some parts of them by binding
 them with ligatures.   It will certainly be
 said that like  enterprises are rash ; but how


  *M. Richerand requests his professional brethren to whom a
patient not  too much debilitated by age or disease, afflicted
with the hydropericardium, should present himself, to address
the same to him;  if they do not prefer to attempt themselves
the operation he proposes. 
18
many operations, deemed impossible  within
the last fifty years, obtain  in our days the*
most brilliant and best attested success.
   I will not occupy much  longer the time
you have been pleased to grant me :  it is for
those among you who are particularly engaged
in the improvement of surgery, to  apprise
me whether in the views I propose, I am
not left to misconceive by  a vain desire of
improvement it is to those to whom it belongs
to judge whether the fact which  I submit to
their sagacity, can contribute in some  mea-
sure to the advancement  of the science, as
well as the comfort, of humanity.
 April 28,  1818. 
REPORT
 OF M. M. DESCHAMPS AND PERCY, ON A MEMOIR
   READ BY PROFESSOR  RICIIERAND,  BEFORE
   THE ACADEMY ON THE 27th OF APRIL,  EN-
   TITLED  " AN ACCOUNT OF THE RESECTION
   OF THE RIBS  AND THE PLEURA."
    The Surgery  of France for a long time
 was unrivalled.  Now that this so essential
 branch of Medicine is every where cultivated
 with an ardor  which most potentates have
 been particularly  attentive to excite and re-
 ward, the Surgeons of France are far from
 having lost their ascendancy.  Those of Eng-
 land are almost the only ones  who, on some
 points,  have equalled  them; and  without
 presumption we may justly believe that,  as
 our efforts always proceed in redoubling, and
 our improvements give not way  to our emu-
 lators in every  country,  these  very fortunate
 in equalling us, will never happen to  surpass
us.
    We  must concede, that,  united  for the
 honor of their  profession and  the welfare of
 humanity,  by an  esteem  and a reciprocal
 consideration,  there exists between the Sur-
 geons of France and of England a contest of 
15
talents, success,  and  activity  such as  fOi*
some years past particularly have made the
art march with  giant pace towards perfec-
tion.   The  English have effected astonish-
ing cures and lay until then unheard of ope-
rations.  The French have gone still farther
in sometimes following  and rectifying the
way traced out for them by their neighbours,
but oftener all at once opening themselves
new roads.  No sooner do they learn that a
bold and unusual operation has been perfor-
med by their  foreign brethren with  success
than they have to oppose to  it, with so much
good fortune,  a succession of others as little
known and at least as bold ;  and in the midst
of this conflict of the invention of genius and
success, in which the advantage has always
been to the French, the wondering  art has
extracted immense resources, and moreover
has seen from day to day, the increase of its
domain.
   The operation concerning  which M. Ri-
cherand has informed the Academy at a for-
mer sitting, is one  of those brilliant con- 
Iff
quests of which French surgery has a right
to be proud.   That M. Abernethy had da-
red, the first,  to put a ligature on the exter-
nal iliac artery, in an aneurism seated at the
uppermost extremity  of the thigh, is an act
of  surgery truly  efficacious  and transcen-
dant, but that our colleague had proceeded to
attack as far as the inner part of the chest,
even nigh the heart, the roots of a cancer
which the  ribs appeared irrevocably to hide
from the reach of the instrument, is also a
stroke of extraordinary surgery and in some
sort heroic,  in which we  know not which
most to admire, either the conception of the
plan, or the ability of the execution!
    We will make the remark before all, that
M. Richerand  has had to do with a patient
who was as  determined to undergo every
thing as his Surgeon was to undertake ; and
equally as convinced  that the only chance
left him to escape the most dreadful death
was an operation on the issue of which he (a
man of the profession) wag very far from de-
ceiving? himself. 
i7
    In a state of things so encouraging, sup-
 ported  by the learned co-operation and the
 steady  sang-froid of  Professor Dupuytren,
 and having around him surgical aids adroit
 and enlightened  (such as Dr. Breschet) M.
 Richerand could trust to all the strength of
 his talents, and  display all  the power of a
 hand a long time exercised in anatomical la-
 bours, and already tested by a great number
 of beautiful and difficult experiments.
    You recollect, Gentlemen, that the can-
 cerous tumor which laid in the region of the
 heart of  Mr. Michellau,  had been several
 times undertaken, cut away,  cauterised,  §c.
 and that it always was reproduced with an
 appearance more and more formidable : it is
 because the bottom, because the base  con-
 cealed under the ribs could not have been ac-
 cessible  either  to  steel, iron,  or to  fire,
 and that in this entrenchment the hydra had
braved these means moreover so  powerful.
    The ribs, in these several attempts, had
been laid bare; they must even have been al-
terated  by the action  of the cautery.   Per-
haps in the sequel they might have exfolia- 
IS
 ted so as *o form a double seques'rntion which
 would at length have manifested the cancer-
 ous root.
    But would it not have been the height of
 imprudence and  timidity to expect a  long
 time from  nature  a like  effect, whilst art,
 without being rash, could in a few moments
 produce it, and in  a manner still more com-
 plete.
   Thns the portions of the two ribs which
 covered the interior fungus, and through the
interstices  of  which its vegetations,  inces-
 santly  springing  up,  again made irruption,
were  sawed and taken  away,  after  having
been isolated from  the  muscular parts and
others  to  which they adhered.  There was
scarcely any effusion of blood, to the astonish-
ment of the operator and assistants,  so thai
one could see  immediately and without any
obstacle, the real seat and extent of the dis-
ease which M. R'eherand eradicated as far as
he could, by cutting away from the Pleura a
surface of eight inches square which had be-
come thick and evidently carcinomatous.
   Scarcely was this shred separated and ex-
tracted  than  the  air rushed  through the
'* 
19
 wound, into the thoracic cavity of that side.
 and gave place to anguish and evident symp-
 toms of suffocation which caused anxiety far
 a moment;  but they soon closed  the aper-
 ture with a linvin cloth plastered with cerate,
 and  this,  aided by  a  soft compression,
 had  soon re-established the calmness and
 natural respiration.
    In the sequel, this twofold accident was
 so trifling when the wound was  uncover-
 ed, either for dressing or facilitating the eva-
 cuation more or less abundant of the serositx
 furnished by the irritated pleura, that time
 could be taken to examine the heart,  which
 continually presented itself at the orifice, to
 be assured of its little sensibility, by touch-
 ing it, and to observe the transparency,  al-
 most glazed  of its envelop :  a contemplation
of the most curious character, of which, the
occasion so extremely rare,  should  singular-
ly interest two of the most learned physiolo-
gists of our day.
   The  wound grew narrower  by degrees,
in consequence  of the adhesion of the  lungs
with the pericardium,  as well as from some
fleshy   granulations  which  raised  up  one 
go
above  another;  and on the twenty-seventh
day after the operation the patient was ena-
bled to ride in a carriage and gratify a desire
with which  he was teazed, to go and see  at
the faculty  of Medicine,  the two  pieces  of
his ribs which M. Richerand had deposited
there, and which the patient would have wil-
lingly carried away.
   iVt the end of the month, he departed for
Nemours  where he had  fixed his  residence
and where he proposed to  recommence his
profession as Surgeon, if his cure goes on as
it has done, andhe has the good fortune of esca-
ping the relapse of a disease, the ever terrible
effects of which even in cases the most perplex-
ed, the art had caused to  disappear;  but the
hidden cause of which it is not always in its
power to destroy.
   It is to  be wished that M. Michelleau.
should no more  experience the cruel attacks
of cancer: for his resignation  and courage
he meets this recompence; but should he be
so unfortunate as to experience a relapse, will
on that account, the proud operation of M.
Kicherand lose its rights to our admiration
and the acknowledgements  of  the  art? Cer-
tainly not! For this operation, rivalling the 
21
most famous and important of those whose
recital has reached us from England for some
years, was not a hazardous undertaking, nor
a  desperate  trial;  indispensable  necessity
had demanded it: knowledge, reason and pru-
dence had delineated and ripened its plan;
sagacity and talent presided at its execution:
and it may be presumed that they who have
otherwise spoken of it,  were not of good
faith; had been ill informed,  or were not in
the enjoyment of sound sense.
    Completely satisfied,  M.  Richerand  is
himself well  preserved from seeing in his
operation only one of those expedients unfor-
seen for an only case, and in an occurrence
which  would  no more  exhibit  itself: on
the contrary he has endeavoured to  extend
its benefits and application to other diseases.
and wished to link it with a system of opera-
tions  determined beforehand, and  which the
art should keep in reserve for unforseen.  or
at best,  presumed affections.
    Thus the fact, so honorable to them, esta-
blishing not only the possibility, but more-
over the almost inocuitv of the excision of a
certain extent of ribs, a,id of penetrating into
the chest by a larger or smaller aperture,
this learned practitioner has extended his re-
flexions on a disease which is usually fatal. 
88
 which can only be recognized by symptoms
 a long time doubtful, and to which only slow
 and consequently i.seless ren edits can lie ap-
 plied, to the dropsy of the pericardium, mu: h
 more common than is generally believed, and
 which  perhaps would yield to an operatory
 means which succeeded so well in the hydro-
 cle of the vaginal tunic.
    The business would be, after having early
 collected tokens the most specially  descrip-
 tive of  this disease,  to  uncover the aqueous
 tumor,  by taking awa^ a part of the rib or
 rib* which are found above it;  to open the
 pericardium t« give passage to the overflow-
 ing liquid, and  to make in its cavity, injec-
 tions, capable of exerting therein a slight  iu-
 fliimmation called adhesive, which most  com;
 monly makes it dry up these kinds of collec-
 tions.
    We must avow,  that the theory of this
 opt ration is bold:  there is nothing but expe-
 rience  which can justify it; and it is to  its
 minor that it belongs to make the trial of it,
 if the chance which produced him the oppor-
 tunity to handle and cure, in M. Miehelleau,
 a disease not less formidable  than the  hy-
 dro-pericardium  brings  him  withj this last
affection,  patients as intrepid and as deter-
 mined as was the Surgeon of Nemours, 
                     23

    We say as much of the excision of the
 ligature of a part of the pulmonary substance
 in certain injuries of the lungs, if to practice
 the one or the other  it should only be requi-
 site, by taking away the ribs, to  open an ac-
 cess for the instrument.
    But  in praising  the desire of our  col-
 league to be able to give an useful extension
 to an ingenious resource, which we should re-
 gret as well as he to  see restricted to an only
 ease  which must needs be very  scarce,  we
 cannot forget the sage  advice which  Celsus
 has given, to  stop at  the limits of possibility
 and probability, in order not to be reputed in
 disorders even the most desperate, to have
 caused him to perish whom it was your in-
 tention to  save:  " ne qliem salvare volueris,
 occidisse videaris."
    It is then  true that there has been  and
 can be made a window in front of the heart;
 it is  this  which  the Grecian Philosopher
 wished,  curious to espy in that  organ, the
 play of the passions, but who did not reflect,
 that could the heart be observed in like man-
 ner as the countenance, it would become per-
 haps equally as deceitful and hypocritical.
    Harvey once caused Charles II. to see a
 man who, by the ravages of a cariosity in  the
sternum and ribs, had the window in  ques- 
34
tion, on which he wore in form of a window-
shutter, a large  plate of silver:  " There is
then,"  cried the English Monarch,  " the
{i heart of a living man!  Is  mine  the same
"as that?'* he demanded of Harvey, "yes,"
answered the illustrious Anatomist.  " And
'* did that of the ferocious Oliver  resemble
" that there?" "Assuredly," said Harvey. "And
" that of the pusillanimous Dryden, who has so
;* much flattered, him and who now offers me
'• incense?"  "All  the same,''  continued the
learned man. " So much the worse,''  added
Charles,  sadly,  and  taking  out  his  purse,
•• take it" said he to the unfortunate man; " it
*• is for the lesson vou have procured for your
•  king."
   We love to remind the Academy  how
many titles to its  esteem  and good will  the
professor has already acquired, in whom se-
veral works, already become classical  and a
profound learning, have preceded his years;
and we assure him that the new success he
has just obtained,  a success in which French
Surgery prides and glories, justifies more and
more the high reputation which he has ac-
quired in his own as well as foreign countries.
                         DESCHAMPS.
                         PERCY.
Paris, May 25. 1818. 
 
 
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