Osseous tuberculosis with concurrent pulmonary lesions.

With the discovery of streptomycin by Waksman in 1943, a new era in treatment of tuberculosis made its entrance. Glowing reports of its effectiveness in pulmonary and other types of the disease led us first to conclude that it would wipe out tuberculosis. But the effectiveness in bone and joint tuberculosis was minimal. True, it appeared to slow down the rate of destruction, but it did not reverse the destructive process, nor bring cure to the many involvements of spinal, sacroiliac and peripheral joint tuberculosis. Disappointment was the lot of the orthopedic surgeon, and reliance upon the old rules of treatment was the usual course of procedure. To briefly paint the background of this previously accepted and undisputed therapeutic regimen, we should recall that arrest of the disease was based upon the evidence that skeletal tuberculosis was almost always a joint region involvement and practically never a destruction of the shafts of long bones. Principles were based on the fact that if motion could be stopped, the disease would become quiescent, and if fusion with complete obliteration of the joint secured, by whatever means, then cure of the disease was possible. Only with the absolutely fused joint was this to be attained. Only the ingenuity of the physician limited the various methods of using splinting, frames, casts, traction, and braces. Improvement required years of patient care. The subsequent surgical procedures of bone grafting, osteotomy etc., to secure solid bony arthrodesis and good functional positions, then became the final problem. The existence of cold abscesses was looked upon with alarm, and aspiration, to relieve the internal tension, and prevent its breaking through the skin, was resorted to, because the formation of a draining sinus with subsequent secondary pyogenic infection was felt to be the cause of the almost invariably fatal “amyloid disease.” The statement that “draining the tuberculous abscess frequently signs the patient’s death warrant” was quoted in many texts of bone and joint tuberculosis. This generally was the status of the treatment of osseous forms of tuberculosis in 1946, 10 years ago, when this reported study was begun. The decision to depart radically from these accepted tenets of treatment was based upon tha following theoretical thinking: 1. An analysis of reported success and failures of streptomycin of various forms of tuberculosis revealed the success to be largely related to location of lesions as to adequacy of physiologic drainage. For example, laryngotracheo bronchial lesions-with surface drainage easily attained, responded rapidly in comparison with interstitial fibrotic lesions in the pulmonary tis-