Some surgical considerations in pulmonary decortication

PULMONARY

DECOKTICATION

Some Surgical

Considerations D ecortication

in Pulmonary

PAUL C. SAMSON, M.D., Oakland, California

0

NE of the

important advances in thoracic surgery during WorId War II was the rediscovery, remodeIing and reapplication of In its narrowest medica “decortication.“4 sense, pmmonary decortication denotes only the stripping of a pathoIogic peeI, cortex, fibrobIastic membrane or rind from an essentiaIIy norma surface, the pleura. Since 1945 this concept has been extended to a variety of pathologic conditions and has incIuded the deveIopment of some new surgical technics. These will be reviewed in the present paper. The history of decortication up to WorId War II has been adequately covered elsewhere22~2g and repetition wouId be superfluous except for emphasis on basically important points. Sufice it to say that Fowler (1893)’ and DeIorme (1894)~ first reported the principle of the operation independently aIthough the was not ” apparentIy word “decortication empIoyed until 1896 and then by DeIorme.6 Both FowIer and DeIorme recognized the process of fibroplasia within the thorax and the essentia1 normaIcy of the pIeura, yet the mistaken idea of “thickened pleura” repeatedly found its way into the Iiterature. While the correct pathoIogic condition was recognized by a number of individuaIs throughout the years, the concept of thickened pleura has aIso remained even to the present, both in a where decortication is medical dictionary defined as “the remova of the pleura for the and in a recent French relief of empyema,” surgica1 voIume by IseIin.‘O With few exceptions, notabIy LiIienthaI,16 nearIy al1 the original decortications were attempted on patients with chronic pleura1 disease. SeveraI types of procedures were employed and resuIts were uniformIy poor by present day standards. These facts led to a American

Journal

of Surgery,

Volume

89.

Fehruarv,

19~s

364

virtua1 abandonment of the operation as a routine procedure. This has happened to other major surgica1 advances, discovered perhaps, too far ahead of compIementary specialties for a successfu1 outcome. In the earIy days of WorId War II the mass effect of Iarge numbers of soldiers with organizing and infected hemothoraces once more focused attention on the inevitabIe crippling and chronic invaIidism resuIting from these compIications, attention which had rather waned between the wars. This time, however, decortication was shortIy reborn. The time was ripe. BIood repIacement with blood became routine; anesthetic methods had improved; thoracic surgeons were intrepid and frequentIy were entering the thorax in the early stages of certain diseases; antibiotics were soon to appear, although I emphasize that only the sulfas were avaiIabIe in 1943 when the pioneering decortications were performed. ApparentIy the spark was first generated by extended discussions among thoracic surgeons of the Second Auxiliary SurgicaI Group earIy in the African campaign. The first planned decortication was for an uninfected organizing hemothorax, performed by Burford was shortly in May, 1943 .23 This operation folIowed by many others at the earIiest overseas Thoracic Center and in September, 1943, I first demonstrated the feasibiIity of appIying decortication to a totaIIy coIIapsed Iung compIicated by massive post-traumatic empyema.23 In this patient, an Italian Captain prisoner of war, there was prompt pulmonary re-expansion and primary healing in spite of the fact that the operation was performed through a compIeteIy infected fieId. It was inevitabIe that the news of successful operations such as these shouId trave1 wideIy, and, as so often

Surgical

Considerations

in Pulmonary

happens, independent observations also wcrc made. During the latter part of the War and in the early civilian years, the American and English literature alone contained independent as weI1 as supplementary contributions by many surgeons. i--3,11IZ,15.20.26,25,29,3? that surgeons B> 1946 it was obvious should think of applying the successful technics learned under the stress of combat to conditions and diseases more closely identified with civilian life. The extension of indications for decortication, however, has been built entirely upon its complete success in the treatment of the complications of hemothorax and is predicated on certain fundamental responses of the pleurae and pleural cavity to insult and injury. Probably these can be best understood by a brief review of the pathogenesis of hemoorganization. We still cannot explain the vagaries of the clotting mechanism as applied to free blood in the pleural cavity but the progression of organization has been followecl microscopically on numerous occasions. PATHOGENESIS

OF HEMO-ORGANIZATION

Hemo-organization begins with the laying down of a thin film of fibrin and blood cells over both pleural surfaces. A closed sac or envelope is shortly formed, the “inner” surface of which is bathed by the liquid and coagulated elements of the hemothorax and the “outer” surface loosely adherent to the pleurae. Within seven days there is microscopic evidence of angioblastic and fibroblastic proliferation in this thickening layer. The process is first visible extending into the walls of the envelope from both pleural surfaces. The peel increases in thickness through the progressive organization of the clott,ed blood which becomes attached to the inside of the envelope. The advancing inner border of active organization remains composed of young cellular tissue and wandering fibroblasts occasionally can be seen. Within four weeks adult fibrous tissue can be seen forming the outer portion of the pee1 with the fibers and nuclei arranging themselves roughly parallel to the outer surface. hiost of the capillaries appear to extend into the peel at right angles to the surface, having obviously penetrated from the pleurae. The parietal segment of the peel is always thicker than the visceral, a still unexplained finding. Within eight weeks smaI1 arterioles with recognizable smooth muscle and elastic fibrils can he demon365

Decortication

strated in the outer or older portion of the peel. hlicroscopic calcium particles may be deposited in the peel within three or four weeks and this has not always been a response to infection. In some cases layers of fat cells have developed in the peel along the older or pleural surface; this may be a regressive process, a forewarning of eventual degeneration or resorption of the peel. In rare cases the peel may develop complete fibrous tissue union with the pleura which then loses its identity as a delimiting membrane. I suspect that these are cases in which there is disease of the underlying lung. That the pleura itself does not become thickened requires continued reemphasis. For the most part, it remains a translucent elastic membrane. The occasional microscopic finding of pleural edema or a slight increase in subpleural connective tissue cannot be translated in radiologic terms. The term “thickened pleura” as used by many radiologists and others should be discarded. The complete incorrectness of this concept is obvious from the microscopic study of many decorticates of differing ages and from the knowledge of cleavage planes developed through extensive operative experience. For instance, thin, wavy elastic fibers are characteristically found immediately beneath the visceral pleura but are never seen in a resected peel unless the visceral pleura is knowingly taken with the peel and sectioned. This is well illustrated in Lindskog and Liebo\v” although I do not agree with their concept that a thickened subpleural areolar tissue will seal the alveoli. If the visceral pleura is removed, inevitably there is air leakage. In older peels, short curled elastic fibers may be found in the walls of the intrinsic arterioles. These frndings are at complete variance with the description of Il’illiams’s pathologist \vho purported to show numerous elastic fibers in the peel itself.3” This simpl? does not occur. The development of pyogenic infection in the central fluid of the hemothorax seems to speed the process of organization and, in some instances, to make the peel tougher but there is no qualitative change which can be recognized microscopically. Continuing experience with the formation of peels associated with either a p,yogenic or a specific infection confirms that the microscopic evidence of these infections is always found on the inner surface

SurgicaI

Considerations

in PuImonary

of the peel. In the case of pyogenic infection, the fibrin and bIood cIot which is in the process of organization shows infiltration with poIymorphonucIear Ieukocytes. In tubercuIosis, for example, the epitheIioid reaction, the giant ceIIs, and/or evidence of caseation necrosis is only found aIong the youngest and most ceIIular (inner) surface of the peel. I have never seen diffuse infihration of the pee1 by any tissue reaction which could be recognized as characteristicaIIy tubercuIous. During the war years it was common belief that there was some pecuIiar property of blood or bIood ciot which was responsible for the formation of the fibroblastic membrane. It is now known that this is a function of the pleurae, activated by a number of exciting agents in addition to blood. The pee1 may deve1op in response to pyogenic infections, specific infections (tubercuIosis and coccidioidomycosis), transudates from heart faiIure, non-infectious inff ammatory exudates (virus, chylothorax, chemica1 irritation), pneumothorax with or without cIinica1 Auid, “dry pleurisy,” and neopIastic effusion. Thick or thin, the fulIy deveIoped membrane in each case is composed of adult fibrous tissue reIatively poor both in nuclei and in blood supply. It’is an ineIastic membrane which keeps the lung compressed and immobilized. In a11 intrapIeura1 cortices, the outer portions and the pIeura1 “surface” of the enveIope are basicaIIy the same as in organizing hemothorax, i. e., there seems to be a fundamental substrate, a common reaction of the p1eura to irritation, to inflammation or to actua1 infection. It thus becomes obvious that decortication is or,Iy possible because a11 these changes are essentially within the confines of the interpIeura1 space. Since the pleura is not ordinarily affected, a cleavage pIane can be deveIoped. It is probable that the process of organization continues as long as fluid or air is present but ceases and remains reIative1y static when the enveIope becomes obliterated. While the appearance of fat cells is thought to be a retrogressive process, these have been seen onIy in young peeIs and there is Iittle evidence that aduIt scar tissue (the mature fibrous membrane) ever disappears from the pleura1 cavity. Much of the success of decortication depends upon the condition of the Iung rather than on the Iength of time the peel has been present. Continuing pulmonary disease means some 366

Decortication

degree of parenchymal damage and greater ceIIuIar intimacy between pIeura and peel, consequently decortication may be more difIicuIt and puImonary expansion deIayed. It is probable that this is responsible for more decortication failures than any other single factor. Prompt, complete obliteration of the pleural space is our best insurance against both the renewa of pu1monary collapse and origina or recurring empyema. INDICATIONS

FOR DECORTICATION

It is diffrcu1t to give more than very general indications when considering the various types of disease in which decortication may be used. Organizing Hemothorax and tions. One must Hurst briefly

Its

Complica-

consider the newer chemical decorticants which have been more or less popular in the past few years, namely, SK-SD and tryptar.@ Fibrinolysing agents have been moderately successful where the pee1 was composed either of fibrin or of reIativeI,v young tissue. While these agents have enjoyed a certain vogue, they have been all but discarded by a number of physicians.30 Many patients have had severe febriIe reactions following injection and good results have not been universal. Enzymatic debridement has almost always failed when used in more chronic situations in which the pee1 is composed of adult scar tissue. In uninfected organizing hemothorax decortication may be considered in from three to five weeks under the folIowing circumstances. Granted lack of enthusiasm for the injection of enzymes, decortication should be performed in a patient who has continuing thoracic discomfort, radiologic evidence of a hazy chest, a compression of 25 per cent or more of the Iung with a collapsed apex, and retraction or narrowing of the interspaces. If infection supervenes in the organizing hemothorax, I recommend decortication as soon after infection is evident as the patient can be made a reasonable operative risk. Under these circumstances the operation becomes much more emergent than in an uninfected case. In infected organizing hemothorax, any degree of puImonary compression, particularly if the apex is collapsed, would caI1 for immediate surgical intervention. Post-traumatic

Of course, carefully,

or

Hemotboracic

if the patient decortication

Empyema.

had been followed should have been

Surgical

Considerations

decided upon long before gross pus b.xmc evident in the pleural cavity.. If, however, one is presented with such a patlent, decortication should be performed as soon as the patient becomes suitable for major surgery. The indications would include a pocket of more than and 300 cc., any degree of apical depression, any presumption that there is a foreign body in the chest. In these days of multiple antibiotics, sensitivity tests should be undertaken prior to surgery so that the patient has his best chance to bc protected against invasive infection. The presence of a clostridial empyema (frequent in war, rare in civilian life) would make no difference as to the treatment. The decision as to the necessity for preliminary rib resection drainage rests entirely upon the condition of the patient. If he can be made a sufficiently good risk by means of the usual supportive therapy, primary decortication should be undertaken* and preliminary drainage is then not only unnecessary but also unwise. iLfost often, patients with acute and subacute empyemas can be sufficiently improved without preliminary drainage. Occasionally in a patient with chronic empyema, wasting and debilitation, stop-gap external drainage may be necessary prior to decortication. Finally, there is the problem of the old neglected fibrothorax with or without calcification. A symptomatic thoracogenic scoliosis may be present. Even at this late date decortication may be indicated. It is possible to remove a cuirass of calcium which will give better function to the chest wall and which may well allow subsequent corrective surgical therapy for the scoliosisl” Miscellaneous Pyogenic Infections. Indications for decortication in these cases are not quite as clear-cut as in hemothorax. Primary decortication is not indicated in smaller empyemas with expanded pulmonary apex; our medical confreres have cured many of these by aspiration, lavage and the injection of the proper antibiotic. The time-honored method of adequate dependent rib resection drainage is likewise almost a certain cure for the usual posterior and lateral pocket. On the other hand, one mav be faced with a massive empyema and chronic subtotal collapse of the lung or with a smaller empyema unobliterated even by adequate drainage. In such patients supportive therapy plus early decortication will give a high percentage of cures.20,?6

in Pulmonary

Decortication

should shortly follow the decision (regardless of how long &is is delayed) that the lung will not expand under the regimen being used. Decortication

,1iliscellaneous Irritative or Inflammatory EfluThis group covers such varied diagnoses as postviral pleural fluid, effusions of unknown etiology, evanescent leakage without infection from a neighboring viscus such as stomach, esophagus or liver and chylothoras. In the past, effusions of this sort have been treated most often by repeated aspiration, with the acceptance of “pleural scar” an d immobile thorax, or by drainage if a pyogenic infection supervened after multiple thoracenteses. There is no doubt that decortication is frequently indicated in this type of pleural inflammatory reaction. Continumg experience with these irritative exudates has shown that a peel may develop relatively soon, often within a week or two. If it becomes evident that pulmonary re-expansion, obliteration of the pleural cavity and restoration of good respiratory function will be impossible under conservative management, decortication becomes urgently indicated as an early procedure. The development of a neoplastic effusion may rarely be an indication for exploratory operation with decortication and or parietal pleurectomy. When the diagnosis is known, thoracotomy may stiI1 be undertaken because of the increasing difficulties of frequent aspirations. In such cases, it has been found that the lung is tied down by a non-specific fibrinous sheet whereas the parieta1 pleural element of the peel is composed primarily of shaggy neoplasm. In several such instances we have performed decortication of the visceral pleura and a subtotal parietal pleurectomy not, of course, for cure but in an effort to do away with difficult and painful thoracenteses. In two cases of pIeural Iymphoma with effusion this goal has been achieved. sions.

DECORTICATION

IN

PULMONARY

TCBERCLLOSIS

Apparently Curd’s report caused a renewal of enthusiasm for decortication in tuberculosis;8 Mulvihill lx Weinbergzi and others”,19 added importan; technical contributions. The invaluable protection afforded by streptomycin and other antituberculosis drugs against invasive infection and spread in tuberculosis cannot be overestimated.?” Assuming stable surgical technics, these agents given on a

SurgicaI

Considerations

in PuImonary

long-term basis have matle decortication in tuberculosis safe. A combination of operations is frequent. Thus decorticaton may be the main procedure, it may share importance with thoracopIasty and/or resection, or it may even be a relatively minor maneuver accompanying Iobectomy. In tuberculosis the pre-existing conditions of the underlying lung and bronchi are of prime importance in a decision for or against decortication.25 Therefore, wherever possible, seria1 x-rays of the chest must be reviewed including those prior to pneumothorax or pneumoperitoneum. Preoperative bronchoscopy is mandatory. Knowledge of extensive though healed tubercuIosis or of bronchia stenosis (each suggesting a poor re-expansion potential) may not contraindicate an advisable decortication but it wouId counse1 the necessity for a concomitant thoracoplasty to reduce the size of the pIeuraI space. Both tubercuIous pIeura effusion and primary empyema have been foIlowed by static For a11 practica1 purposes, Iung compression. the Iung must be considered normal and, therefore, expandable. Hence decortication is indicated. An effective pneumothorax may be complicated by the deveIopment of a pee1 and a non-expandabIe lung. FIuid may persist or increase due to the development of high negative pressures when attempting to expand the Jung. Empyema may develop. Decortication is frequently very useful under these circumstances often combined with resection and/or a smaI1 tailoring thoracopIasty depending on the condition of the underIying lung. The aIternative procedure, with which we were a11 too familiar in the past, is an extensive deforming thoracoplasty. Ineffectual pneumothoraces with pleura1 complications are stil1 occasionally seen and here again decortication (aImost always combined with resection) appears the procedure of choice. There is a fairIy Iarge group of cases in which decortication is now being performed aImost casuaIIy as an accompaniment of resection. In these, due either to a former pneumothorax, dry pleurisy, or whatnot, there has deveIoped a thin, translucent but inelastic gIove over the remaining Iobes. This must be removed else the remaining Iobes wil1 expand poorly and the success of the resection wiI1 become thereby jeopardized. FinaIIy, there remain a few patients whose Iungs were captive because of a constricting

Decortication

peel and who obliterated a pneumothorax space more Jly mediastinal and cardiac shift than by pulmonary re-expansion. Some of these patients complain of dyspnea, tachycardia and thoracic discomfort or actua1 pain. Poor respiratory excursions are obvious. In one patient a heart murmur deveIoped, apparently the resuIt of cardiac torsion. Selected individuals in this Iimited group can be helped greatIy by thoracotomv and total removal of the scar which has- immobilized the Iung and the thoracic parieties. TECHNICS

._

OF PULMONARY

DECORTICATION

Many factors, including developmental contributions, have caused variations in the performance of this operation. The age of the peel, the presence or absence of infection, the condition of the underlying Iung and whether or not appreciabIe pulmonary or chest wall surgery was envisioned also have been important determinants. Perhaps the actual technic empIoyed is not as important as the remembrance of the basic aim to be accompIished: complete emancipation of the lung. The incision has become fairly standard: a posterior and Iateral thoracotomy of generous length. PersonaIIy, I prefer to remove a rib because I beIieve that a more secure chest wall cIosure can be performed. There seems to be no object in making a fetish of an intercosta1 incision. In generaI, fine non-absorbabIe suture materia1 is used throughout. If raw lung tissue needs to be repaired, I use fine catgut on an atraumatic needIe. Electrocautery is a great time saver and is always at hand. In what might be termed the simpIest or basic type of case, that of organizing hemothorax, the interior of the enveIope is entered directly by incision through the parietal pIeural segment. The centra1 contents together with a11 shaggy detritus are evacuated. Sharp incision is made through the visceral segment of the pee1 and by combined dissection, the cIeavage pIane between pee1 and pIeura is identified. Frequently this can be aided ,by sIight positive pressure through the anesthetic bag. As one carries this dissection from the viscera1 on to the parietal peeI, an obliterated space can be entered where the two pleurae are in apposition and where dissection is very easy. Such apposition extends for varying distances from the hihim. It was the recognition of this pIane and the ease with

Surgical Considerations in PuImonary Decortication which it is developed that prompted the technical contributions of WiIliams32 and of Pa&on.?’ They tend to enter this space first and re-expand the lung from the hilum outward, as it were, saving the remova of the visceral peel to the last. Once the lung is freed down to the hilum, any infoldings of the lobes are rectified as emphasized by Langston and Tuttle.15 The fissures are opened; patches of older membrane not removed by the primary decortication are either peeled off, or subjected to discission. In the meantime the anesthetist has given intermittent and progressive positive pressure so that by the end of the operation in favorable cases, the Lung practically fills the thoracic cavity. This seems to be a better way of obtaining re-expansion than attempting it all at once by unduly high endobronchial pressures. The diaphragm is freed and decorticated insofar as possible and the costophrenic sulcus is reconstituted. In these simple cases, I have usually not attempted parietal decortication as the results do not appear appreciably bettered. There is no absolute objection to the remova of the parietal peel, but it does not always seem to be necessary. It does increase the operating time and the bleeding. It is important that a11 pockets be opened. The parietal membrane must be smooth and should be thoroughly scraped. When established infection is present, hohvever, our technic differs and routinely the parietal peel is removed. This is most often done following visceral decortication: (I) to give the patient the benefit of better aeration as soon as possible; (2) to insure puImonary re-expansicn even if the operation has to be af>ruptly terminated. As stressed early by Weinberg31 and others, when peel and empyema are chronic such as typified in long-standing tuberculous infection, it is attempted to remove the enveIope completely without opening it or spilling the contents. It is surprising how often this can be accomplished even after twenty years. I am convinced, however, that on the chest wall side the parietal pleura is removed with the peel most of the time-a fact not generally appreciated.“’ Actually I do a parietal pleurectomy from preference because the cleavage plane is more easiIy developed extrapleurally than it is between pleura and pee1 and there is much less chance of breaking into the envelope. These

operations

are very

time-consuming

and

it is advisable to have a great deal of blood on hand. The critical point of such an operation employing pleurectomy is recognition of the exact line where the two pleurae themselves come into apposition. When the line is reached, further extrapIeura1 dissection is unnecessary. The cleavage plane shouId be changed from extrapleural to interpIeura1 and the hilar structures identified and freed. One can then come back on the visceral pleura1 surface and, compIete a true decortication. by degrees, When the technic is successful, a bag filled with pus may be totally removed from the thoracic cavity without leakage of contents. The advantages, particuIarIy in tuberculous infections, are obvious. A natural extension of this means of treating chronic empyema is the technic of Sarot”’ in which the extrapteural separation is carried to the hilum and pneumonectomy performed. Thus a badly damaged lung and an extensive empyema can be exenterated en masse without spillage. The technic of the “casual” decortication which may be associated with Iobectomy is not di&uIt. The important point is to recognize that a thin, non-opaque peel is present and that such a peel is relatively inelastic. It is amazing how tough-fibered such peels are and it is highly gratifying to note the improvement of re-expansion folIowing their removal. The proper cleavage plane is identified after meticulous incision of the peel with the lung supported by moderate positive pressure. Small blunt gauze or cotton dissectors will uncover glistening visceral pleura covered with meniscule punctate hemorrhages from the divided vessels entering the peel. If an air leak develops, the visceral pleural is being dissected with the peel. Air leaks are inevitable in most decortications and for the most part can be ignored. If they are troubIesome or if on expansion the amount of leakage seems unduly great, the area of parenchymal denudation may be either patched by spare peel or the edges approximated by continuous fine catgut. Postoperative adequate drainage is mandatory and two fort!-caliber right angle tubes have been found useful. Rarely a third tube may be necessary. A simple water seal system is employed and it is only in the presence of undue air leakage that increased negative suction is applied. The postoperative treatment differs in no way from other major thoracotomies. Rigorous

SurgicaI Considerations arm and shoulder exercises are earIy as are Harken’s remedial exercises9 CONCOMITANT

instituted

breathing

OPERATIONS

AS indicated throughout this report, decortication may necessarily be combined with other operations. If there are chest wall wounds, these should be excised and cIosed with separate instruments prior to making the main thoracotomy incision. The handling of sinus tracks previousIy estabhshed for the drainage of an empyema has varied. In the case of endocutaneous flaps of the Eloesser type (frequentIy used in mixed infection tuberculous empyemas) an elliptic incision has been made with remova of skin and the subcutaneous portion of the track down to the ribs. With further dissection between the ribs, a flap has been folded in and sutured to be removed with the empyema sac at later thoracotomy. MuscIe and skin are then cIosed over the area; gowns, gIoves and instruments discarded and the thoracotomy incision made with a new set-up. Dependent tube drainage sinuses may well be left aIone and the same track used for the insertion of the postdecortication drainage tube. Necessary work on the inner portion of the chest waI1 for rib spicules, etc., or the remova of foreign bodies from the lungs must await the completion of decortication; tissue relationships can then be more accurately assessed and foreign bodies paIpated. The exact order of the concomitant operations most often empIoyed in tuberculosis depends upon what is considered to be the main pathoIogic disorder. In cases of empyema or unexpanded lung, decortication would be the primary operation. On the other hand, resection of some type may be proceeded with first and decortication of varying degree then acts as a suppIementa1 operation. UsuaIIy the decision for or against a taiIoring thoracopIasty is delayed unti1 it is seen whether pulmonary re-expansion is adequate following decortication and/or resection.

SUMMARY

The history of puImonary decortication, particuIarIy during and since World War II, has been briefly reviewed. It has been noted that within the past ten years, decortication has been employed in a variety of pathoIogic

in Pulmonary

Decortication

conditions. This has necessitated certain variations of surgica1 technic. The pathogenesis of hemo-organization has been described. The formation of a mature pee1 in organizing hemothorax and in other pathologic states of the pleurae has been discussed. It has been emphasized that the development of a pee1 or IibrobIastic membrane is a function of the pIeurae and is in response to a number of exciting causes. Indications for, and differing technics of decortication have been Iisted in the foIlowing morbid conditions: organizing hemothorax with or without infection; pyogenic empyemas of varying etioIogies; specific pleural infections such as tubercuIosis and coccidioidomycosis; persisting pneumothorax; either transudates or exudates arising from a variety of irritative, inff ammatory or chemical sources, neopIastic effusions. REFERENCES

I. BLADES, B. and DUGAN, D. J. War wounds of the chest. J. Tboracic Surg., 13: 294, 1944. 2. BIYRFORD,T. H., PARKER, E. F. and SAMSON,P. C. EarIy pulmonary decortication in the treatment of posttraumatic empyema. Ann. Surg., I 22: 163, 1945. 3. CHAMBERLAIN, J. M.

In discussion,

Samson

and

4. CHURCHILL, E. D. The surgical management

of the wounded in the Mediterranean theatre at the time of the fail of Rome. Ann. Surg., 120: 268,

1944. 5. DELORME, E. Nouveau

traitement des empyemes chroniques, Gaz. d. bbp., Par., 67: 94, 1894. 6. DELORME, E. Du traitement des empyemes chroniques par la dbortication du poumon, IO ieme CongrGs Francais de Chirurgie, 1896, P. 379. 7. FOWLER, G. R. A case of thoracoplasty for the remova of a Iarge cicatricial fibrous growth from the interior of the chest, the result of an old empyema. M. Rec., 44: 838, 1893. 8. GURD, F. B. Decortication in chronic empyema of tubercufous origin. J. Tboracic Surg., 16: 587, 1947. 9. HARKEN, D. E. A review of the activities of the thoracic center for the III and IV hospital groups, European theatre of operations. J. Thwack Surg., 15: 31, 1946. LO. ISELIN, M. Quoted in Gurd.8 I I. JOHNSON. J. Certain aspects of battle wounds of the thoracic cavity. &r&y, 20: 26, 1946. 12. KAY, E. B. and MEADE, R. H. War injuries of the chest. Surg., Gynec. &+Obst., 82: 13, 1946. ‘3. KERGIN, F. G. and DEWAR, F. P. Pleural decortication in the prevention and treatment of thoracogenie scohosis. Arch. Surg., 61: 705. 1950. 14. LAM, C. R. Decortication in the treatment of tubercuIous empyema. Arch. Surg., 56: I, 1948.

Surgical Considerations in PulmonaryDecortication I j. I.ANGSTON, 13. T. and

TUTTLE, U’. M. The pathology of chrome traumatic hemothorak. J. Thorn& .%lT&‘.,16: 99, 194; 16. LILIEF~THAL, H. Empyema. Ann. Surp., 62: 309,

‘915. 17. LINDSKOG, G. E. and LIEBOW, A. A. Thoracic Surgery and Related Pathology, p. 7. New York, 1953, AppIeton-Century-Crofts, Inc. 18. MULVIHILL, D. A. and KLOPSTOCK, R. Decorticntion of the nonexpandable postpneumothoras tuberculous lung. J. Thoracic Surg., ~7: 723, 1948. See also discussion of Curd.* 19. O’ROURKE, P. V., O’BRIEN, E. J. and TUTTLE, \I:. hl. Decortication of the lung in patients with pulmonary tuberculosis. Am. Rec. Tuberc., 50: 3% ‘949. 20. PARKER, E. F. and BUKFORD, T. Ii. Pulmonarv decortication in the treatment of early pyogenic empyema. Surger,v, 24: 371, 1948. 21. Pnu~sou, D. I.. In discussion of Samson and Burford.22 22. SAMSOU, P. C. and BURI;OKD, T. tl. Total pulmonary decortication. J. Thoracic Surp., 16: 127, ‘947. 23. SAMSO>, P. C., BURFORD, T. iI., BREWER, L. A. and BURBANK, B. The management of war wounds of the chest in a base center. J. Tboracic Surg., I$: I, 1940.

371

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