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Chronic abscess of bone (Brodie)
CHRONIC
ABSCESS OF BONE (BRODIE)*
ABRAHAM 0.
WILENSKY, M.D., P.A.C.S. NEW YORK
T
HE subject of chronic abscess of bone has aIways been a surgicaI entity which has aroused interest especiahy since the isoIation of that group of cases which, originahy having been described by Brodie in 1830, has since been known by his name. A Iiterature of moderate extent has grown up around this disease and from time to time it has been reviewed by various writers (Thompson, Gross, Brickner, McWilIiams, Bancroft, Dowd, Martin, MiIIer, etc.), each of whom has brought the subject up to his time. Any confusion which may have arisen in adequateIy cIassifying this entity among other surgica1 diseases of bone has apparentIy arisen from the ease with which the Iesion has been confounded with chronic bone cysts and other simiIar conditions of neopIastic, bacteria1 or other origin and with the attempts which have been made to separate the Iesion compIeteIy, especiahy in its pathoIogica1 aspects, from the genera1 subject of osteomyeIitis. The purpose of this communication is to show the intimate reIationships of chronic bone abscess with the subject of acute and chronic osteomyeIitis in genera1 and to indicate the cIassification of this type of Iesion in that disease. In severa previous communications I have described the mechanism by which foci of acute osteomyeIitis became estabIished. This incIudes (I) a primary Iesion, (2) a consequent bacteriemia and (3) the formation of a thromboemboIic (metastatic, subsidiary) Iesion within the confines of the vascuIar structure of any bone. The actua1 pathoIogica1 process in the bone which deveIops at these fixation points is a thromboarteritis or thrombophIebitis. Great emphasis was pIaced in these various communications upon the dominating *From
the Mount
Sinai Hospital,
New
importance of the resuIts of the consequent bIockage of the vascuIar suppIy which necessariIy must foIIow the estabIishment of such thromboembolic Iesions. In cIassifying the manifoId Iesions which were formed by this mechanism, the various groups were found to foIIow anatomica lines and to become cIoseIy reIated to the Iocation of the thromboemboIic focus in the vascuIar tree of the bone. Lesions were described as (I) main stem Iesions with tota necrosis of the shaft between the conjuga1 cartiIages, (2) primary branch Iesions with necrosis of onehaIf of the shaft, (3) secondary or subsidiary branch Iesions with necrosis of irreguIar segments of the shaft of the bone and (4) end-vesse1 Iesions with IocaIized foci of infection in the region of the metaphysis near the conjuga1 cartiIage. These were main groupings; other atypical groups were found to be variations formed (I) by thrombophIebitic spreading of the original focus or (2) by changes which foIIowed or were caused by operative interventions, the Iatter serving to mask the essentia1 nature of the given Iesion because of the artificia1 spreading of the thrombophIebitic Iesion. In foIIowing our cases of 0steomyeIitis we have been abIe to determine that cases of abscesses in bone tissue are cIinicaIIy one of two varieties : (I) bone abscesses without history of any previous acute osteomyelitis, of sIow and insidious deveIopment, and of proIonged course, and (2) those with a history of a previous acute osteomyeIitis and with an intervening period of apparent weII-being or forming SimuItaneousIy with the deveIopment of the attack of acute 0steomyeIitis. The type of abscess in bone tissue described by Brodie does not correspond York. Submitted for Publication May rg, 1928. 455
456
American Journal of Surgery
Wilensky-Bone
clinically with the last major group of bone abscesses. The Iatter are of common occurrence, begin as an ordinary case of
FIG. I. A true Brodie abscess.
acute osteomyelitis, are of comparativeIy short history and of rapid development, occur anywhere in the shaft of the bone and most usuaIIy near its centre portion, are accompanied by fever, chiIIs and other evidences of an existing bacteria1 infection, frequentIy perforate the cortex and form purulent collections under the periosteum or in the fascia1 planes of the limb, must usuaIIy be subjected to operation in which drainage forms the main objective and are commonIy foIIowed by sequestration of some part of the adjacent bone tissue. PathoIogicaIIy acute bone abscesses are accumuIations of pus in the course of an acute thrombophIebitis of bone (osteomyelitis). The puruIent coIIections are situated within the canceIIous mesh or in the meduIIary cavity and within the endosteum. The margins of the abscess are aIways iI1 defined and there is no definite Within the meduIIary fibrous capsuIe. cavity the suppuration has a tendency to
Abscess extend through its entire Iength; this is not aIways true, however, and abscesses sharpIy limited in extent are also found. Bone destruction is predominant. Bone production occurs Iate and pari passu with the separation and sequestration of the of the bone. Such necrotic portions undrained coIIections of pus may ver) chronic bone abscesses. rareIy become Secondary abscesses also occur. These are residua and represent undrained pockets, or retention abscesses in the tracts of the various sinuses, or recurrences of infection. The primary chronic bone abscesses, the cIassica1 description of which was given by Brodie, never have an acute stage. Their onset is insidious. They are often Iatent and exist for twenty to thirty years before discovery. The chief symptoms are pain in a limb, generaIIy near a joint, increased at night and in changing weather, and in nearIy a11 cases without fever, chiIIs or other signs of bacteria1 infection. The tibia is most often affected. PathoIogicaIIy, the Brodie abscesses are aIways IocaIized affairs in the metaphysea1 region of a Iong bone near the conjuga1 cartilage. The signs of bone production are Iimited and usuaIIy correspond to a productive inflammation which resuhs in a hypertrophic thickening of the periosteum and of the cortica1 Iayers of the bone. Within the innermost Iayer of the latter, where it borders the abscess, one can usuaIIy differentiate a definite granulation membrane in which scar tissue (fibrosis) predominates. A carefu1 scrutiny of the roentgen-ray pictures shows that the abscess Iies within the canceIIous meshwork and not within the meduIIary cavity. That in Iate cases this may be simulated by the spreading of the process and by expansion of the abscess is confirmed by operating room observations. In a number of the cases there are scars of other previousIS existing foci of 0steomyeIitis present in other bones of the body and in other Iimbs. Much more commonIy the abscess is an isoIated phenomenon; in these the Iocation of the focus is usually in the upper end of
NEW
SERIES VOL. V, No.
5
Wilensky-Bone
the tibia, Iess commonIy in the Iower end of the femur, and Ieast often eIsewhere. The question of the origin and deveIopment of such a clinica and pathoIogica1 entity depends upon the interpretation of the avaiIabIe facts. In previous communications the anatomy of the vascuIar tree in the interior of a Iong bone was described and it was pointed out that one of the possibIe fixation points was Iocated in the end vesseIs of the nutrient artery circuIation. These end vesseIs are situated at the metaphysea1 ends of the diaphysis cIose to the avascuIar area and the conjuga1 cartiIage. BIocking of the circuIation at such a point by a thrombus-emboIus wouId quite necessariIy resuIt (I) in a Iesion of minimum size, (2) in a focus whose spreading was Iimited by osseous tissue and (3) in a Iesion in which bacteria1 growth and deveIopment wouId be hampered by mechanica conditions and by the accumuIations of bacteria1 excrementitious matters unavoidabIe because of the Iack of vascuIar and Iymphatic avenues by which these can be removed. The Iatter Ieads to a marked reduction of the viruIence of the bacteria contained within the abscess and many times to the fIna and compIete steriIization of the abscess. Such an abscess, then, becomes a dormant one and increases in size not at aI1, or very sIowIy, and flares up onIy when there is a recrudescence of infection. These facts expIain the insidious character of the process, the reIative absence of symptoms, the Iong periods for which it is Iatent and the reasons for the sudden exacerbation of symptoms which many times brings this Iesion to our attention. PracticaIIy a11 of the cases are due to infection by the StaphyIococcus aureus. The very few that are not are usuaIIy due to the typhoid baciIIus. This again is a point in common with the ordinary forms of acute 0steomyeIitis. The symptomatoIogy of true chronic abscess of bone (Brodie) has a very Iimited scope. The one symptom that caIIs attention to the Iesion is pain, CharacteristicaIIy
Abscess
American JournaI of Surgery
457
intensified at night, persistent and graduaIIy increasing in intensity. Examination then shows in onIy a part of the cases a
FIG. 2. An acute bone abscess in lower end of a radius. This form has an acute stage during which time, with rare exceptions, it must be treated surgically. A chronic abscess of the type shown in Figure I never folIows this form of acute osteomyeIitis. Compare with Figure I.
thickening of the shaft of the bone; the Iatter is tender to pressure or sudden jarring. Except for a very sIight grade of fever in some of these patients there are no genera1 manifestations of any kind. These are practicaIIy a11 of the avaiIabIe symptoms for diagnosis. BIood cuItures are aIways sterile. This is naturaIIy understood from the extremeIy chronic nature of the Iesion. Corroboration of the suspected diagnosis is invariabIy made from the roentgenographic studies which show the sharpIy demarcated area in the extremity of the shaft of a Iong bone of different
458
American Journal of Surgery
Wilensky-Bone
roentgen-ray intensity from the rest of the surrounding bone. The diagnosis under these conditions is always therefore a
NOVEMBER, 1928
Abscess
abscess of bone (Brodie), such as bone cyst, tumor, etc. Treatment is a very simpIe matter. In a certain number of the cases in which a steriIe abscess exists, one may foIIow the suggestion of Brickner and evacuate the abscess through a driI1 hoIe; heaIing subsequentIy occurs. In others, and even in some of those in which the technique of Brickner is foIIowed, this simpIe procedure is not sufficient. The abscess must then be Iaid wide open by an adequate osteotomy. The resuIting cavity shouId be aIIowed to hea from the bottom up with or without the aid of sterilization by Dakin’s soIution according to the technique of CarreI. In such granulating wounds the IocaI conditions may frequentIy be suffIcientIy favorabIe to permit secondary suture of the wound after steriIizing with Dakin’s soIution. Chronic abscess of bone (Brodie) is notoriousIy free from compIications either before or after operation. Before operation spontaneous perforation of the abscess very rareIy occurs. In one case reported by Bancroft spontaneous rupture was foIIowed by exacerbation of the infection. After operation heaIing invariably occurs foIIowing one of the methods outIined above. SUMMARY
The impression is given distinctIy and seems to be corroborated by cIinica1 and pathoIogica1 studies that Brodie’s abscess is a chronic abscess of bone which has its origin in a thrombophlebitis deveIoping around a thrombo-emboIus arrested in a termina1 vesse1 of the vascuIar network of the diaphysis of a Iong bone. This Iesion is the end resuIt of one of the manifestations of acute osteomyeIitis and shouId be so cIassified. FIG. 3. The end-resuIt of a focus of acute osteomyelitis in a femur. An abscess was present. Both cIinicaIIy and roentgenographicaIIy this is not a Brodie abscess.
positive one. In the present stage of our knowledge one can roentgenographic immediateIy excIude positiveIy the other conditions which might simuIate chronic
CASE
REPORTS
CASE I. Brodie’s abscess in the Iower end of the femur. Healing occurred promptly after osteotomy and drainage. Secondary suture was not done.
Abscess in the lower end of the foIIowed a trauma. UneventfuI heaIing foIIowed an oDen osteotomv. CASE II,
tibia
which
NEW SERIES VOL..V, No. 5
Abscess
WiIensky-Bone
CASE III. This was a case of abscess in the Iower end of the tibia which perforated spontaneously through the cortex and formed a subcutaneous abscess. Healing folIowed the properIy performed osteotomy. There were other foci in this patient, one of which was in the OS caIcis of the same Iimb. The spontaneous perforation of the abscess is an unusua1 phenomenon. a supCASE IV. SeveraI years previousIy purative focus Iying under the skin and overlying the upper end of the tibia was incised by another surgeon. The patient was assured that the focus did not invoIve the bone. HeaIing occurred after incision of the abscess. The Ieg, however, remained swoIIen and in the foIIowing year the sweIIing increased sIightIy in size. LatterIy, pain appeared which was intensified at night and the patient ran a Iow grade of fever. Roentgenograms (Fig. I) showed a typica Brodie abscess in the upper end of the tibia. HeaIing occurred after radica1 osteotomy; secondary suture of the wound was not attempted. It is not possibIe to say positiveIy whether the origina subcutaneous abscess was due to a perforation of a bone abscess, which at that time was in a more or Iess acute stage, or whether there was an associated subperiostea1
American Journal of Surgery
459
abscess. At the time of the second operation there was a definite Brodie abscess. The important point which this case brings out is the presence of the singIe pathoIogica1 mechanism which caused the ordinary manifestations of an acute osteomyeIitis and of the Brodie abscess. CASE v. EIeven years previousIy the patient was operated upon for an OsteomyeIitis of the Ieft tibia. The exact characteristics of the Iesion are not determinabIe. At the end of eight months the wound had entireIy heaIed but some sweIIing remained. Five weeks ago there was a recrudescence of symptoms. SeveraI_.days before admission the symptoms were aggravated markedIy after the patient had twisted her ankIe accidentaIIy whiIe waIking. The roentgenray pIate showed a typica chronic abscess of the upper end of the tibia with a11 the characteristics of the Iesion described by Brodie. A radica1 osteotomy was done and the wound was aIIowed to hea from the bottom outwards. The pus contained a hemoIytic streptococcus. This case has many simiIarities to the one previousIy reported.
I am indebted the aid
to Doctor CIarence WeiI of Mount Sinai HospitaI house staff for in Iooking up the Iiterature.
BIBLIOGRAPHY I. 2. 3. 4.
5. 6.
7. 8. 9. IO. I I.
12. 13.
BRODIE, B. London Med. Gaz., 36: 1339, 1845. THOMAS, A. Edinburgb Med. J., 19: 297, 1906. GROSS, H. Be&. z. k&n. Cbir., 30: 231, 1901. BRICKNER, W. M. Treatment of chronic bone abscesses by simpIe excavation through smah drill hoIe. J. Bone e?’ Joint Surg., 5: 492, 1923. BRICKNER, W. M. Chronic meduIIary abscess of Iong bones. Ann. Surg., 65: 483, 1917. BANCROFT, F. W. Two cases of IocaIized bone abscess (Brodie). Surg. C&n. N. Am., I: 1773, 1921. Down. C. N. StaphvIococcus bone infection. Ann. _ _ Surg., 44: III, 1906. MARTIN. W. Chronic suonurative osteomveIitis. Ann. hrg., 66: 254, 19;;. MILLER, A. M. Note on isolated abscesses of Iong bones. Ann. Surg., 67: 450, 1918. SYMONDS,C. Guy’s Hosp. Gaz., 1915. MCWILLIAMS, C. A. CentraI bone abscess; Brodie’s abscess; chronic suppurative osteomyehtis. Ann. Surg., 74: 568, 1921. DA COSTA, J. C. Modern Surgery. Ed. 8. PhiIa., Saunders, IgIg. SKILLERN, P. G. TubercuIosis cutis. Znternat. Clin., 24 S., I: 174, 1914.
14. Brodie, B. Brit. J. Surg., 9: 334, 1922. 15. AGILVIE, W. H. Clin. J., 51: 385, 1922. 16. CHOYCE, C. C. and BEATTIE, J. M. System of Surgery. Ed. 2. N. Y., Hoeber, 1923. 3: 743. 17. BAETJER, F. H. and WATERS, C. A. Injuries and Diseases of Bones and Joints. N. Y., Hoeber, 1921. P. 168. 18. BRYANT, J. D. and BUCK, A. H. American Practice of Surgery. N. Y., Wood, 19o6--IgI1. 3: 286. 19. ASHHURST, A. P. C., BROMER, R. S. and WHITE, C. Y. Cystic disease of bones. Arch. Surg., 6: 661, 1923. 20. MEYERDING, H. W. Am. J. Ortb. Surg., 16: 523,
1918.
21. BEVAN, A. D. Brodie abscess. Surg. Clin., 3: 743, 1919. 22. BRICKNER, W. M. Chronic bone abscess: treatment by simpIe evacuation through driI1 hoIe. Surg., Gynec. 0 Obst., 25: 84, rgzz. 23. TROTTER, W. Clin. J.. 29: 148, 1907. 24. MCWILLIAMS, C. A. Ann. Surg., I: 1774, 1921. 25. HENDERSON and SIMON. Arch. Surg., November, 1924. 26. MCWILLIAMS, C. A. Ann. Surg., November, 1926.
ABSCESS OF BONE (BRODIE)*
ABRAHAM 0.
WILENSKY, M.D., P.A.C.S. NEW YORK
T
HE subject of chronic abscess of bone has aIways been a surgicaI entity which has aroused interest especiahy since the isoIation of that group of cases which, originahy having been described by Brodie in 1830, has since been known by his name. A Iiterature of moderate extent has grown up around this disease and from time to time it has been reviewed by various writers (Thompson, Gross, Brickner, McWilIiams, Bancroft, Dowd, Martin, MiIIer, etc.), each of whom has brought the subject up to his time. Any confusion which may have arisen in adequateIy cIassifying this entity among other surgica1 diseases of bone has apparentIy arisen from the ease with which the Iesion has been confounded with chronic bone cysts and other simiIar conditions of neopIastic, bacteria1 or other origin and with the attempts which have been made to separate the Iesion compIeteIy, especiahy in its pathoIogica1 aspects, from the genera1 subject of osteomyeIitis. The purpose of this communication is to show the intimate reIationships of chronic bone abscess with the subject of acute and chronic osteomyeIitis in genera1 and to indicate the cIassification of this type of Iesion in that disease. In severa previous communications I have described the mechanism by which foci of acute osteomyeIitis became estabIished. This incIudes (I) a primary Iesion, (2) a consequent bacteriemia and (3) the formation of a thromboemboIic (metastatic, subsidiary) Iesion within the confines of the vascuIar structure of any bone. The actua1 pathoIogica1 process in the bone which deveIops at these fixation points is a thromboarteritis or thrombophIebitis. Great emphasis was pIaced in these various communications upon the dominating *From
the Mount
Sinai Hospital,
New
importance of the resuIts of the consequent bIockage of the vascuIar suppIy which necessariIy must foIIow the estabIishment of such thromboembolic Iesions. In cIassifying the manifoId Iesions which were formed by this mechanism, the various groups were found to foIIow anatomica lines and to become cIoseIy reIated to the Iocation of the thromboemboIic focus in the vascuIar tree of the bone. Lesions were described as (I) main stem Iesions with tota necrosis of the shaft between the conjuga1 cartiIages, (2) primary branch Iesions with necrosis of onehaIf of the shaft, (3) secondary or subsidiary branch Iesions with necrosis of irreguIar segments of the shaft of the bone and (4) end-vesse1 Iesions with IocaIized foci of infection in the region of the metaphysis near the conjuga1 cartiIage. These were main groupings; other atypical groups were found to be variations formed (I) by thrombophIebitic spreading of the original focus or (2) by changes which foIIowed or were caused by operative interventions, the Iatter serving to mask the essentia1 nature of the given Iesion because of the artificia1 spreading of the thrombophIebitic Iesion. In foIIowing our cases of 0steomyeIitis we have been abIe to determine that cases of abscesses in bone tissue are cIinicaIIy one of two varieties : (I) bone abscesses without history of any previous acute osteomyelitis, of sIow and insidious deveIopment, and of proIonged course, and (2) those with a history of a previous acute osteomyeIitis and with an intervening period of apparent weII-being or forming SimuItaneousIy with the deveIopment of the attack of acute 0steomyeIitis. The type of abscess in bone tissue described by Brodie does not correspond York. Submitted for Publication May rg, 1928. 455
456
American Journal of Surgery
Wilensky-Bone
clinically with the last major group of bone abscesses. The Iatter are of common occurrence, begin as an ordinary case of
FIG. I. A true Brodie abscess.
acute osteomyelitis, are of comparativeIy short history and of rapid development, occur anywhere in the shaft of the bone and most usuaIIy near its centre portion, are accompanied by fever, chiIIs and other evidences of an existing bacteria1 infection, frequentIy perforate the cortex and form purulent collections under the periosteum or in the fascia1 planes of the limb, must usuaIIy be subjected to operation in which drainage forms the main objective and are commonIy foIIowed by sequestration of some part of the adjacent bone tissue. PathoIogicaIIy acute bone abscesses are accumuIations of pus in the course of an acute thrombophIebitis of bone (osteomyelitis). The puruIent coIIections are situated within the canceIIous mesh or in the meduIIary cavity and within the endosteum. The margins of the abscess are aIways iI1 defined and there is no definite Within the meduIIary fibrous capsuIe. cavity the suppuration has a tendency to
Abscess extend through its entire Iength; this is not aIways true, however, and abscesses sharpIy limited in extent are also found. Bone destruction is predominant. Bone production occurs Iate and pari passu with the separation and sequestration of the of the bone. Such necrotic portions undrained coIIections of pus may ver) chronic bone abscesses. rareIy become Secondary abscesses also occur. These are residua and represent undrained pockets, or retention abscesses in the tracts of the various sinuses, or recurrences of infection. The primary chronic bone abscesses, the cIassica1 description of which was given by Brodie, never have an acute stage. Their onset is insidious. They are often Iatent and exist for twenty to thirty years before discovery. The chief symptoms are pain in a limb, generaIIy near a joint, increased at night and in changing weather, and in nearIy a11 cases without fever, chiIIs or other signs of bacteria1 infection. The tibia is most often affected. PathoIogicaIIy, the Brodie abscesses are aIways IocaIized affairs in the metaphysea1 region of a Iong bone near the conjuga1 cartilage. The signs of bone production are Iimited and usuaIIy correspond to a productive inflammation which resuhs in a hypertrophic thickening of the periosteum and of the cortica1 Iayers of the bone. Within the innermost Iayer of the latter, where it borders the abscess, one can usuaIIy differentiate a definite granulation membrane in which scar tissue (fibrosis) predominates. A carefu1 scrutiny of the roentgen-ray pictures shows that the abscess Iies within the canceIIous meshwork and not within the meduIIary cavity. That in Iate cases this may be simulated by the spreading of the process and by expansion of the abscess is confirmed by operating room observations. In a number of the cases there are scars of other previousIS existing foci of 0steomyeIitis present in other bones of the body and in other Iimbs. Much more commonIy the abscess is an isoIated phenomenon; in these the Iocation of the focus is usually in the upper end of
NEW
SERIES VOL. V, No.
5
Wilensky-Bone
the tibia, Iess commonIy in the Iower end of the femur, and Ieast often eIsewhere. The question of the origin and deveIopment of such a clinica and pathoIogica1 entity depends upon the interpretation of the avaiIabIe facts. In previous communications the anatomy of the vascuIar tree in the interior of a Iong bone was described and it was pointed out that one of the possibIe fixation points was Iocated in the end vesseIs of the nutrient artery circuIation. These end vesseIs are situated at the metaphysea1 ends of the diaphysis cIose to the avascuIar area and the conjuga1 cartiIage. BIocking of the circuIation at such a point by a thrombus-emboIus wouId quite necessariIy resuIt (I) in a Iesion of minimum size, (2) in a focus whose spreading was Iimited by osseous tissue and (3) in a Iesion in which bacteria1 growth and deveIopment wouId be hampered by mechanica conditions and by the accumuIations of bacteria1 excrementitious matters unavoidabIe because of the Iack of vascuIar and Iymphatic avenues by which these can be removed. The Iatter Ieads to a marked reduction of the viruIence of the bacteria contained within the abscess and many times to the fIna and compIete steriIization of the abscess. Such an abscess, then, becomes a dormant one and increases in size not at aI1, or very sIowIy, and flares up onIy when there is a recrudescence of infection. These facts expIain the insidious character of the process, the reIative absence of symptoms, the Iong periods for which it is Iatent and the reasons for the sudden exacerbation of symptoms which many times brings this Iesion to our attention. PracticaIIy a11 of the cases are due to infection by the StaphyIococcus aureus. The very few that are not are usuaIIy due to the typhoid baciIIus. This again is a point in common with the ordinary forms of acute 0steomyeIitis. The symptomatoIogy of true chronic abscess of bone (Brodie) has a very Iimited scope. The one symptom that caIIs attention to the Iesion is pain, CharacteristicaIIy
Abscess
American JournaI of Surgery
457
intensified at night, persistent and graduaIIy increasing in intensity. Examination then shows in onIy a part of the cases a
FIG. 2. An acute bone abscess in lower end of a radius. This form has an acute stage during which time, with rare exceptions, it must be treated surgically. A chronic abscess of the type shown in Figure I never folIows this form of acute osteomyeIitis. Compare with Figure I.
thickening of the shaft of the bone; the Iatter is tender to pressure or sudden jarring. Except for a very sIight grade of fever in some of these patients there are no genera1 manifestations of any kind. These are practicaIIy a11 of the avaiIabIe symptoms for diagnosis. BIood cuItures are aIways sterile. This is naturaIIy understood from the extremeIy chronic nature of the Iesion. Corroboration of the suspected diagnosis is invariabIy made from the roentgenographic studies which show the sharpIy demarcated area in the extremity of the shaft of a Iong bone of different
458
American Journal of Surgery
Wilensky-Bone
roentgen-ray intensity from the rest of the surrounding bone. The diagnosis under these conditions is always therefore a
NOVEMBER, 1928
Abscess
abscess of bone (Brodie), such as bone cyst, tumor, etc. Treatment is a very simpIe matter. In a certain number of the cases in which a steriIe abscess exists, one may foIIow the suggestion of Brickner and evacuate the abscess through a driI1 hoIe; heaIing subsequentIy occurs. In others, and even in some of those in which the technique of Brickner is foIIowed, this simpIe procedure is not sufficient. The abscess must then be Iaid wide open by an adequate osteotomy. The resuIting cavity shouId be aIIowed to hea from the bottom up with or without the aid of sterilization by Dakin’s soIution according to the technique of CarreI. In such granulating wounds the IocaI conditions may frequentIy be suffIcientIy favorabIe to permit secondary suture of the wound after steriIizing with Dakin’s soIution. Chronic abscess of bone (Brodie) is notoriousIy free from compIications either before or after operation. Before operation spontaneous perforation of the abscess very rareIy occurs. In one case reported by Bancroft spontaneous rupture was foIIowed by exacerbation of the infection. After operation heaIing invariably occurs foIIowing one of the methods outIined above. SUMMARY
The impression is given distinctIy and seems to be corroborated by cIinica1 and pathoIogica1 studies that Brodie’s abscess is a chronic abscess of bone which has its origin in a thrombophlebitis deveIoping around a thrombo-emboIus arrested in a termina1 vesse1 of the vascuIar network of the diaphysis of a Iong bone. This Iesion is the end resuIt of one of the manifestations of acute osteomyeIitis and shouId be so cIassified. FIG. 3. The end-resuIt of a focus of acute osteomyelitis in a femur. An abscess was present. Both cIinicaIIy and roentgenographicaIIy this is not a Brodie abscess.
positive one. In the present stage of our knowledge one can roentgenographic immediateIy excIude positiveIy the other conditions which might simuIate chronic
CASE
REPORTS
CASE I. Brodie’s abscess in the Iower end of the femur. Healing occurred promptly after osteotomy and drainage. Secondary suture was not done.
Abscess in the lower end of the foIIowed a trauma. UneventfuI heaIing foIIowed an oDen osteotomv. CASE II,
tibia
which
NEW SERIES VOL..V, No. 5
Abscess
WiIensky-Bone
CASE III. This was a case of abscess in the Iower end of the tibia which perforated spontaneously through the cortex and formed a subcutaneous abscess. Healing folIowed the properIy performed osteotomy. There were other foci in this patient, one of which was in the OS caIcis of the same Iimb. The spontaneous perforation of the abscess is an unusua1 phenomenon. a supCASE IV. SeveraI years previousIy purative focus Iying under the skin and overlying the upper end of the tibia was incised by another surgeon. The patient was assured that the focus did not invoIve the bone. HeaIing occurred after incision of the abscess. The Ieg, however, remained swoIIen and in the foIIowing year the sweIIing increased sIightIy in size. LatterIy, pain appeared which was intensified at night and the patient ran a Iow grade of fever. Roentgenograms (Fig. I) showed a typica Brodie abscess in the upper end of the tibia. HeaIing occurred after radica1 osteotomy; secondary suture of the wound was not attempted. It is not possibIe to say positiveIy whether the origina subcutaneous abscess was due to a perforation of a bone abscess, which at that time was in a more or Iess acute stage, or whether there was an associated subperiostea1
American Journal of Surgery
459
abscess. At the time of the second operation there was a definite Brodie abscess. The important point which this case brings out is the presence of the singIe pathoIogica1 mechanism which caused the ordinary manifestations of an acute osteomyeIitis and of the Brodie abscess. CASE v. EIeven years previousIy the patient was operated upon for an OsteomyeIitis of the Ieft tibia. The exact characteristics of the Iesion are not determinabIe. At the end of eight months the wound had entireIy heaIed but some sweIIing remained. Five weeks ago there was a recrudescence of symptoms. SeveraI_.days before admission the symptoms were aggravated markedIy after the patient had twisted her ankIe accidentaIIy whiIe waIking. The roentgenray pIate showed a typica chronic abscess of the upper end of the tibia with a11 the characteristics of the Iesion described by Brodie. A radica1 osteotomy was done and the wound was aIIowed to hea from the bottom outwards. The pus contained a hemoIytic streptococcus. This case has many simiIarities to the one previousIy reported.
I am indebted the aid
to Doctor CIarence WeiI of Mount Sinai HospitaI house staff for in Iooking up the Iiterature.
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