. Manual of operative surgery. cleans the empyema cavity, and replaces the flap ofchest-wall, providing of course for drainage. This operation has not foundmuch favor. Roux in operating finds that a long incision through the indurated visceralpleura answers the same purpose as decortication. PULMONARY DECORTICATION AND DISCISSION 309 Ransohoff (Transactions Am. Surg. Assoc, 1914) makes use of discission,, a number of criss-cross incisions through the sclerosed visceral pleura andfinds this thoroughly satisfactory. Lilienthals Major Noncollapsing Thoracoplasty (Annals of Surg., July,1919).*
. Manual of operative surgery. cleans the empyema cavity, and replaces the flap ofchest-wall, providing of course for drainage. This operation has not foundmuch favor. Roux in operating finds that a long incision through the indurated visceralpleura answers the same purpose as decortication. PULMONARY DECORTICATION AND DISCISSION 309 Ransohoff (Transactions Am. Surg. Assoc, 1914) makes use of discission,, a number of criss-cross incisions through the sclerosed visceral pleura andfinds this thoroughly satisfactory. Lilienthals Major Noncollapsing Thoracoplasty (Annals of Surg., July,1919).* Place the patient on his sound side over a pillow to give a scolioticposture. Hips flexed. Pillow between the flexed knees. Step I.—^In the sixth or seventh interspace make an incision from the costalangle to the cartilage. Parts of the latissimus dorsi and serratus magnus aredivided. If possible avoid the old drainage wound. Divide the intercostalstructures in the middle of the wound for about two inches close to the upper. Fig. 428.—{Lilienthal). border of the lower rib. Enlarge the intercostal incision in both directionsuntil large enough to permit separation of the ribs by blunt traction and exposingenough of the interior to work safely and keep clear of the lung. Enlarge thewound to the full size of the skin incision. Separate the ribs slowly with a ribretractor. Usually a separation of three inches is possible. In old empyemacases the chest wall is so fixed by fibrous tissue that it is necessary to dividefrom one to three ribs upwards (occasionally downwards) at the posterior endof the wound. The blades of the retractor can now be separated 6 inches ormore (Fig. 428). (When ribs have been divided it is wise to cut away about 3^2or ^ inches of the anterior portion of each to prevent postoperative pain andtrauma by the grinding together of the cut ends.) *Anesthesia —intrapharyngeal (p. 288). 3IO OPERATIONS ON THE CHEST Step 2.—Every pari of the empyema cavity lies
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