A male adult skeleton from the Han Dynasty in Shaanxi, China (202 BC-220 AD) with bone changes that possibly represent spinal tuberculosis

Bioarchaeological data for tuberculosis (TB) have been published very sporadically in China or the rest of East Asia. To explore the history of TB in this area, 85 skeletons excavated from the Liuwei Cemetery in Shaanxi, China (202 BC-220 AD) were macroscopically examined to record TB related bone changes. These skeletons represented inhabitants of Maolingyi, an urban area that had a high population density during the Han Dynasty (202 BC-220 CE). Seventeen of the 85 skeletons had spines that were well enough preserved to observe evidence of spinal disease. Among them, a male skeleton aged around 30 years (M34-E) manifested multiple lytic lesions in the eleventh thoracic to second lumbar vertebral bodies (T11 to L2). TB was considered a possible diagnosis for the spinal lesions observed, with differential diagnoses of brucellosis and typhoid. The dense population and overcrowding in urban Maolingyi were considered the potential social risk factors for TB found at this site. The findings of this study contribute to limited knowledge about the history of TB in East Asia and suggest a relationship between population density and the spread of TB in Maolingyi at that time. However, the lack of published bioarchaeological data of TB in East Asia hinders understanding the transmission of TB within Asia and its link to the rest of the world. Further intensive review of archaeological skeletons in Asia is urgently needed. 。, 。85, 17, 。, 30、、。, 。, 。、, , 。, 。, 。.

A 'cold case' of care: Looking at old data from a new perspective in mummy research

In 1973, analysis of the mummified remains of a young boy dated to 700AD and from the Late Nasca period (Peru) identified (i) chronic Pott's disease, leading to loss of lower body mobility, and (ii) acute miliary tuberculosis, affecting most organs and the immediate cause of death (Allison et al., 1973). This report was the first to establish, beyond dispute, the presence of tuberculosis in the Americas before the arrival of Europeans. Here, we revisit the 'Nasca Boy' from a bioarchaeology of care perspective. Contextualising the original study's results within what is known of contemporary lifeways, we apply the bioarchaeology of care methodology in considering the Nasca Boy's experience of living with tuberculosis; the type of care he required and how this may have evolved over a period of deteriorating health; and what such caregiving may suggest both about social organisation within his community and some of the more everyday aspects of Nasca existence. Up to now, the bioarchaeology of care approach has been employed almost exclusively with skeletal evidence; in this analysis of the Nasca Boy's remains, and in the accompanying wider-ranging discussion, we illustrate the potential of preserved soft tissue evidence to contribute to research into disability and care in the past. Although this report functions as a stand-alone case study, to obtain maximum benefit it should be read in conjunction with the Introduction to the special International Journal of Paleopathology issue on 'mummy studies and the bioarchaeology of care' (Nystrom and Tilley, 2018).

A paleopathological approach to early human adaptation for wet-rice agriculture: The first case of Neolithic spinal tuberculosis at the Yangtze River Delta of China

The earliest evidence of human tuberculosis can be traced to at least the early dynastic periods, when full-scaled wet-rice agriculture began or entered its early developmental stages, in circum-China countries (Japan, Korea, and Thailand). Early studies indicated that the initial spread of tuberculosis coincided with the development of wet-rice agriculture. It has been proposed that the adaptation to agriculture changed human social/living environments, coincidentally favoring survival and spread of pathogenic Mycobacterial strains that cause tuberculosis. Here we present a possible case of spinal tuberculosis evident in the remains of a young female (M191) found among 184 skeletal individuals who were Neolithic wet-rice agriculturalists from the Yangtze River Delta of China, associated with Songze culture (3900-3200 B.C.). This early evidence of tuberculosis in East Asia serves as an example of early human morbidity following the adoption of the wet-rice agriculture.

Unusual spinal tuberculosis in an Avar Age skeleton (Csongrád-Felgyő, Ürmös-tanya, Hungary): A morphological and biomolecular study

The paleopathological analysis of a well-preserved young adult female skeleton from the AD 7-8th century (Avar Age) in Hungary revealed multiple lytic lesions in all of the thoracic and lumbar vertebral bodies. The lesions were characterized by smooth marginal zones and space-occupying mass appearance. The considerable loss of spongy bone in the thoracolumbar vertebrae resulted in angular deformity and fusion, characteristic of the healing stage of TB. Osteolytic lesions were also observed on the vertebral processes, ribs and sternum. On the endocranial surface, abnormal blood vessel impressions were revealed, indicating some kind of meningitis. The X-ray and CT analysis of the affected bones detected abnormal structures and cystic zones of destruction. The lesions were however not always bordered by areas of increased density, which is typical in cystic TB. Vertebral remains were also subjected to biomolecular analysis in two different laboratories, which attested the presence of Mycobacterium tuberculosis complex (MTBC) DNA and supported the paleopathological diagnosis of TB. Spoligotyping analysis confirmed the presence of MTBC DNA and more specifically an infection caused by bacteria belonging to the M. tuberculosis lineage. This case study provides new data for the paleoepidemiology of TB in this geographical area and historical period, and draws attention to the great variability of TB lesions in the human skeleton.

Skeletal lesions in human tuberculosis may sometimes heal: an aid to palaeopathological diagnoses

In three to five percent of active cases of tuberculosis, skeletal lesions develop. Typically, these occur on the vertebrae and are destructive in nature. In this paper, we examined cases of skeletal tuberculosis from a skeletal collection (Galler Collection) with focus on the manifestation of bony changes due to tuberculosis in various body regions in association with antibiotic introduction. This skeletal collection was created in 1925-1977 by a pathologist at the University Hospital in Zürich, Ernst Galler. It includes the remains of 2426 individuals with documented clinical histories as well as autopsies. It contained 29 cases of skeletal tuberculosis lesions. We observed natural healing of vertebral lesions through several processes including fusion of vertebrae, bone deposition and fusion of posterior elements. In these cases, we observed a higher frequency and proportion of bone deposition and fusion of posterior vertebral elements where pharmacological agents were used. There were also four cases of artificial healing through surgically induced posterior spinal fusion. With the introduction of pharmaceutical treatments, the number of individuals with multiple tuberculous foci decreased from 80% to 25% when compared to individuals who did not receive any drug therapy. Investigation of comorbidities showed that pneumonia, pleuritis and being underweight were consistently present, even with pharmaceutical treatment. Our results have applications in palaeopathological diagnoses where healing and consequent bone deposition may complicate differential diagnoses.

Percival Pott; Pott's fracture, Pott's disease of the spine, Pott's paraplegia

There is a commonly held belief that Percival Pott sustained that ankle fracture that bears his name. This probably is not true; the injury was more likely a fracture of the tibial shaft, as suggested by careful reading of the account of the accident left to us by his son-in-law.

Harvey Cushing, the spine surgeon: the surgical treatment of Pott disease

STUDY DESIGN

Review of historical archival records.

OBJECTIVE

Describe Harvey Cushing's patients with spinal pathology.

SUMMARY OF BACKGROUND DATA

Harvey Cushing was a pioneer of modern surgery but his work on spine remains largely unknown.

METHODS

Review of the Chesney Medical Archives of the Johns Hopkins Hospital from 1896 to 1912.

RESULTS

This is the first time that Cushing's spinal cases while he was at the Johns Hopkins Hospital, including those with Pott disease, have been described.Cushing treated three young men with psoas abscesses secondary to Pott disease during his residency: he drained the abscesses, debrided any accompanying necrotic vertebral bodies, irrigated the cavity with salt, and left the incision open to close by secondary intention. Although Cushing used Koch's "tuberculin therapy" (of intravenous administration of isolated tubercular bacilli) in one patient, he did not do so in the other two, likely because of the poor response of this first patient. Later in his tenure, Cushing performed a laminectomy on a patient with kyphosis and paraplegia secondary to Pott disease.

CONCLUSION

These cases provide a view of Cushing early in his career, pointing to the extraordinary degree of independence that he had during his residency under William Steward Halsted; these cases may have been important in the surgical upbringing both of Cushing and his coresident, William Stevenson Baer, who became the first professor of Orthopedics at Johns Hopkins Hospital. At the turn of the last century, Pott disease was primarily treated by immobilization with bed rest, braces, and plaster-of-paris jackets; some surgeons also employed gradual correction of the deformity by hyperextension. Patients who failed a trial of conservative therapy (of months to years) were treated with a laminectomy. However, the limitations of these strategies led to the development of techniques that form the basis of contemporary spine surgery-instrumentation and fusion.

Rheumatoid arthritis, Klippel-Feil syndrome and Pott's disease in Cardinal Carlo de' Medici (1595-1666)

OBJECTIVE

A paleopathological study was carried out on the she skeletal remains of Cardinal Carlo de' Medici (1595-1666), son of the Grand Duke Ferdinando I (1549-1609) and Cristina from Lorraine (1565-1636), to investigate the articular pathology described in the archival sources.

METHODS

The skeletal remains of Carlo, buried in the Basilica of San Lorenzo in Florence, have been exhumed and submitted to macroscopic and radiological examination.

RESULTS

The skeleton of Carlo revealed a concentration of different severe pathologies. Ankylosis of the cervical column, associated with other facial and spine anomalies suggests a diagnosis of congenital disease: the Klippel-Feil syndrome. In addition, the cervical segment presents the results of the tuberculosis (Pott's disease) from which the Cardinal suffered in his infancy. The post-cranial skeleton shows an ankylosing disease, mainly symmetrical and extremely severe, involving the large as well as small articulations, and characterized by massive joint fusion, that totally disabled the Cardinal in his last years of life.

CONCLUSIONS

The final diagnosis suggests an advanced, ankylosing stage of rheumatoid arthritis.

Tuberculosis of the spine: a historical review

Almost all ancient civilizations described tuberculous bacilli in their old scripts, and these bacteria have been found in prehistoric skeletal remains. The clinical availability of specific antitubercular drugs was the most important breakthrough in managing spinal tuberculosis. Any attempt at surgical excision of the disease prior to the antitubercular era met with serious complications, dissemination of disease and high mortality (nearly 50%). Antitubercular drugs markedly improved the results of management by operative treatment. Excellent healing of disease was also observed in those patients who were treated nonoperatively. However, it took many years (1950-1970) for clinicians to appreciate the efficacy of antitubercular drugs. Operations for spinal tuberculosis are now indicated less for control of disease (5-10% of all cases) than for complications, including nonresponding neural deficit (nearly 40% of neural complications), prevention or correction of severe kyphotic deformity, and for tissue diagnosis (approximately 5% of all cases). For a classic spondylodiscitis when surgery is required for débridement and decompression, an anterior approach through an extrapleural anterolateral route or through transpleural route is recommended. Healthy posterior elements should not be jeopardized by surgery. The real control of tuberculous disease requires a serious and sustained global effort to eliminate immunocompromised states, poverty, malnutrition, and overcrowding.

First report of Mycobacterium bovis DNA in human remains from the Iron Age

Tuberculosis has plagued humankind since prehistoric times, as is evident from characteristic lesions on human skeletons dating back to the Neolithic period. The disease in man is due predominantly to infection with either Mycobacterium tuberculosis or Mycobacterium bovis, both members of the M. tuberculosis (MTB) complex. A number of studies have shown that when conditions permit, surviving mycobacterial DNA may be amplified from bone by PCR. Such ancient DNA (aDNA) analyses are subject to stringent tests of authenticity and, when feasible, are invariably limited by DNA fragmentation. Using PCRs based on single-nucleotide polymorphic loci and regions of difference (RDs) in the MTB complex, a study was made of five Iron Age individuals with spinal lesions recovered from the cemetery of Aymyrlyg, South Siberia. A sensitive screening PCR for MTB complex mycobacteria was positive in four out of the five cases. Genotyping evidence indicated that all four cases were due to infection with M. bovis rather than M. tuberculosis and the data were consistent with the proposed phylogenetic model of the MTB complex. This is believed to be the first report of M. bovis causing Pott's disease in archaeological human remains. The study shows that genotyping of ancestral strains of MTB complex mycobacteria from contexts of known date provides information which allows the phylogeny of the model to be tested. Moreover, it shows that loss of DNA from RD4, which defines classic M. bovis, had already occurred from the genome over 2000 years before the present.

[G. F. d'Acquapendente and Don Carlo Medici's gibbosity]

Don Carlo dei Medici (1595-1666) is the son of Ferdinando I (1549-1609), Granduca of Tuscany, and becomes Cardinal of Catholic Roman Church in 1615. In 1604 Fabrizio d'Acquapendente is called in Florence to treat him, because of an aggravation of his health, and of his congenital neck's gibbosity. The recent paleopathological researches have diagnosed his congenital cervical gibbosity as effect of the Klippel-Feil's syndrome, and characteristic lesions of tubercolosis.

[Cripples at the medieval hospital of Bátmonostor, Hungary--archeological findings]

Cripples from the medieval hospital of Bátmonostor, Hungary. People with disabilities were generally burdened with a painful fate in ancient times, however in the hospitals was no effective therapy. The hospital of Batmonostor was founded at late 13th century, The authors examine by morphological, radiological and histological methods 426 complete skeletons excavated from medieval (14th-15th century) cemetery of Bátmonostor (Hungary). Among them 30 cases (7.1%) of bony ankylosis, (24 cases on lower limb and 6 cases on upper limb) was found. Sacroiliac ankylosis 3 cases, Bechterew's spondylitis ankylopoetica 1 case was seen. Spondylitis tuberculosa and malum Potti 4 cases, and hunchback with other aetiology 2 cases was detected. Beside the cases with ankylosis severe posttraumatic osteomyelitis (7 cases), primary malignant bone tumors (2 cases) and an osteoplastic metastatic tumors (probably prostata carcinoma) was diagnosed. Paleopathologic study of the physically disabled may yield information and insight on the prevalence of crippling disorders. The authors hypothetize, that crippled persons lived in the hospital until their deaths.

[Pott's disease before antibercular agents: from Pott to Ménard]

Percival Pott (1714-1788), an eminent surgeon, has given his name to a spinal pathology with curvature due to tuberculous abscesses; he was the first to show that it may cause paralysis of the lower limbs and that tragic consequences could be avoided or reversed through surgery. Victor Auguste Ménard (1854-1934) played a major role in the orthopaedic treatment of this disease in the Maritime Hospital of Berck-sur-Mer where he was the founder of a surgeon school. In 1900, he published a work entitled : A Practical Study of Pott's Disease. Since there were no antibiotics to treat tuberculosis and because most patients were children, they had to be submitted to intensive care. Ménard's treatment consisted of a complete and long immobilization associated to strict rules of hygiene, involving sun and sea-air therapy. The use of surgery in some cases recalls Pott's general principles.

Paleopathological examination of medieval spines with exceptional thoracic kyphosis most likely secondary to spinal tuberculosis. Historical vignette

Spinal tuberculosis (TB) infrequently involves more than one to three vertebrae, and kyphotic angulation of greater than 30 degrees is rare in paleopathological specimens and clinical studies. The authors describe findings obtained in two spines (dating from the Early and Late Middle Ages). Spinal TB was present in both as well as sharply angulated kyphosis (approximately 180 degrees) resulting from complete destruction of five and seven vertebral bodies, respectively. In these two specimens obtained in individuals older than 12 years of age at the time of death we observed no involvement of the disease in posterior vertebral elements, and the laminae showed osseous fusion without signs of infection. The osseous diameter of the spinal canal was not narrowed in either case. These findings are discussed in the context of modern medical knowledge and paleopathological and genetic examinations.

A surgical revisitation of Pott distemper of the spine

BACKGROUND CONTEXT

Pott disease and tuberculosis have been with humans for countless millennia. Before the mid-twentieth century, the treatment of tuberculous spondylitis was primarily supportive and typically resulted in dismal neurological, functional and cosmetic outcomes. The contemporary development of effective antituberculous medications, imaging modalities, anesthesia, operative techniques and spinal instrumentation resulted in quantum improvements in the diagnosis, management and outcome of spinal tuberculosis. With the successful treatment of tuberculosis worldwide, interest in Pott disease has faded from the surgical forefront over the last 20 years. With the recent unchecked global pandemic of human immunodeficiency virus, the number of tuberculosis and secondary spondylitis cases is again increasing at an alarming rate. A surgical revisitation of Pott disease is thus essential to prepare spinal surgeons for this impending resurgence of tuberculosis.

PURPOSE

To revisit the numerous treatment modalities for Pott disease and their outcomes. From this information, a critical reappraisal of surgical nuances with regard to decision making, timing, operative approach, graft types and the use of instrumentation were conducted.

STUDY DESIGN

A concise review of the diagnosis, management and surgical treatment of Pott disease.

METHODS

A broad review of the literature was conducted with a particular focus on the different surgical treatment modalities for Pott disease and their outcomes regarding neurological deficit, kyphosis and spinal stability.

RESULTS

Whereas a variety of management schemes have been used for the debridement and reconstruction of tuberculous spondylitis, there has also been a spectrum of outcomes regarding neurological function and deformity. Medical treatment alone remains the cornerstone of therapy for the majority of Pott disease cases. Surgical intervention should be limited primarily to cases of severe or progressive deformity and/or neurological deficit. Based on the available evidence, radical ventral debridement and grafting appears to provide reproducibly good long-term neurological outcomes. Furthermore, recurrence of infection is lowest with such techniques. Posterior operative techniques are most effective in the reduction and prevention of spinal deformity.

CONCLUSIONS

Unlike historical times, effective medical and surgical management of tuberculous spondyitis is now possible. Proper selection of drug therapy and operative modalities, however, is needed to optimize functional outcomes for each individual case of Pott disease.

History of surgery for the correction of spinal deformity

During the last century the technological advances in the field of spinal surgery had a dramatic impact on the treatment of spinal deformity in children and adults. Before the advent of medications and vaccines to treat and/or prevent tuberculosis and poliomyelitis, patients suffering from these disorders often became incapacitated by the resulting kyphoscoliosis. In the early 1900s Lange began to address this problem mechanically by using foreign materials to stabilize the spine internally. In the 1950s and 1960s, owing to the efforts of Harrington and others, the process evolved to create the first generation of modern spinal instrumentation. The Harrington rod was able to correct a spinal deformity primarily through distraction. In the next wave of advances, some of the shortcomings of Harrington rods were addressed. Segmental fixation involving sublaminar wires was introduced in the 1970s by Luque. Anterior approaches and instrumentation-related techniques developed by Zielke and colleagues as well as Dywer and coworkers in the late 1960s and mid-1970s allowed for better correction of deformity with immobilization of fewer motion segments compared with posterior surgery. Transpedicular fixation of the spine was popularized by Cotrel and Dubousset in the 1980s; they used the technique to perform segmental stabilization, which better reduces the rotational aspect of a deformity. Finally, in the mid-1990s, thoracoscopic techniques were developed and are currently in use for anterior release and placement of instrumentation. The authors review the major technical developments for the surgical treatment of spinal deformity.

Mycolic acids and ancient DNA confirm an osteological diagnosis of tuberculosis

SETTING

The underlying trends in the past epidemiology of tuberculosis (TB) are obscure, requiring recourse to the archaeological record. It would therefore be of value to develop methods for reliable TB diagnosis in ancient populations.

OBJECTIVE

To test the capability of two biomarkers, Mycobacterium tuberculosis complex mycolic acids and a DNA target (IS6110), for confirming an osteological diagnosis of TB in medieval individuals, based on the presence of Pott's disease and/or rib lesions.

DESIGN

Osteological examination of three archaeological individuals (Medieval: approximately 1000 years old) revealed a Pott's disease case, one with no changes consistent with TB and one with rib lesions. Rib samples from these individuals were examined for the presence of Mycobacterium tuberculosis complex mycolic acids and mycobacterial DNA.

RESULTS

Mycobacterium tuberculosis complex mycolic acids and the DNA target were detected in the Pott's disease case, whilst mycolic acids (insufficient for confirmation) alone were detected in the rib lesion case.

CONCLUSIONS

Biomarkers provide a sensitive tool to detect ancient TB. Mycobacterium tuberculosis DNA is not distributed homogeneously, making multiple sampling essential. Mycolic acids seem more reliable for ancient TB diagnosis than IS6110. The demonstrated stability of mycolic acids show that they may be of value in tracing the palaeoepidemiology of tuberculosis back into antiquity.

Paleopathology in osseous remains from the 16th century. A survey of rheumatic diseases

OBJECTIVE

To describe the rheumatic conditions found in skeletal remains of Amerindian ancestry disinterred from a 16th century Mexican cemetery.

METHODS

A physical anthropologist and 2 rheumatologists surveyed the recovered skeletal remains.

RESULTS

We examined the skeletal remains of 443 subjects. We found 19 cases of Pott's disease, 17 of osteoarthrosis in various anatomical locations, 2 spondyloarthropathies, probably ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis, one probable septic arthritis in the stemoclavicular joint, and 2 compression fractures of the spine. We found no cases of gout or rheumatoid arthritis.

CONCLUSION

This is the first report on the presence of rheumatic conditions in colonial Mexico. Studying the remains of these populations can provide useful information about the origin and evolution of different rheumatic conditions.

Jacques Calvé

Jacques Calvé was born August 18, 1875, In Paris, France, and died on March 10, 1954. His main interest in medicine was the treatment of tuberculosis of the spine. Therefore, he established a very differentiated plan for the treatment of the Pott's disease. Calvé was also one of the pioneers in the radiologic evaluation of the skeletal system. He was among the first to describe the osteonecrosis of the hip and its radiological features-with his name still a part of the disease name today: the Morbus Legg-Calvé-Perthes. Furthermore, he was the first to describe the radiologic image of histiocytosis X of the vertebral body, but he interpreted it as a special form of tuberculosis of the spine. It was years later that the correct diagnosis of this particular radiologic change was found. This paper provides a short account of Jacques Calvé's life as a medical scientist.

Victor Horsley's surgery for cervical caries and fracture. The Centennial Anniversary

On August 25, 1895, Victor Horsley, the doyen of British neurosurgery, presented the results of his surgery for trauma and caries (tuberculosis) of the cervical spine at the Surgery Section of the British Medical Association Annual Meeting. All of the patients recovered from their operations and four were in attendance at the meeting to attest to the results of their operations. For the surgeon of 1895, laminectomy of the cervical spine was a daunting undertaking. Although effective anesthesia and antiseptic techniques had become available, roentgenologic evaluation of spinal fracture and disease was still a future diagnostic modality. The special relationship of Victor Horsley with William Gowers, neurologist of Queen's Square Hospital, London, is presented. The status of therapy for cervical fracture and tuberculosis at the close of the 19th century is described to gauge the magnitude of this event as a major contribution to the progress of spinal surgery.

Percivall Pott: tuberculous spondylitis

Tuberculous spondylitis, also known as Pott's disease, is an entity that produces a characteristic kyphotic deformity, and was described by Sir Percivall Pott in 1779 and 1782. The majority of his patients were infants and young children. Although the incidence of tuberculosis in the industrialized world has since declined dramatically, the number of cases of extrapulmonary disease, though small, has remained relatively unchanged. In developing countries, spondylitis is still generally a disease of children, but in Europe and North America, it more commonly involves older adults. Pott's spondylitis represents a reactivation of latent disease, frequently years after the initial infection. Clinical findings include complaints of back pain and symptoms of fever, chills, weight loss, malaise, and fatigue. Characteristically a late finding, paraplegia is occasionally the initial indicator of spinal involvement. There is an average delay of a year between the onset of symptoms and patient presentation. Plain spinal radiographs usually are the initial diagnostic modality utilized. Computed tomography scanning and magnetic resonance imaging can be used to further define the process. The differential diagnosis includes neoplasm, pyogenic or disseminated fungal infection, and sarcoid arthritis.

Lewis Albert Sayre

Lewis Albert Sayre (1820-1900) was an American pioneer in the field of orthopedic surgery, and medicine in general. In addition to much work on spinal and other deformities, Sayre was a founder of what later became the New York University Medical School, where he headed the first department of orthopedics in the United States. Sayre also was a charter member of the American Medical Association and served as its vice president and later as president. He was instrumental in developing the Journal of the American Medical Association, and his extensive work as Resident Physician of New York City led to improvements in sanitation, vaccination, and quarantine for smallpox and cholera.

[Incapacitating spinal curvature in a skeleton discovery from the Middle Ages (7th/8th to the beginning of the 9th century). A case of probable spondylitis tuberculosa]

A case is presented of disability due to spondylitis of probable tuberculous etiology found in a skeleton from the early Middle Ages in Switzerland. It is suggested that the young woman had not been rejected from her family community or kinship because of her invalidity, as is thought to have often been the rule at that time.

The classic. Streptomycin in tuberculous bone and joint lesions with mixed infection and sinuses

At the present time, streptomycin represents a tremendous advance in the treatment of patients with these lesions. Streptomycin undoubtedly will be improved upon and superseded by some other agent in the future, giving us better control of this disease and possibly enabling us to eradicate it. In closed lesions streptomycin, in dosages of 90 grams in a period of 90 days, has failed to arrest the tuberculous process permanently. Failure of treatment with streptomycin suggests strongly the presence of a sequestrum, a thick-walled abscess, or inadequate surgery. Healing seems to be related to the duration of administration of streptomycin and not to the total dosage. In patients having sinuses, streptomycin should be continued after healing for a period at least half as long as the healing period itself. Surgical ankylosis, or resection of non-weight-bearing joints, is apparently as necessary now as it ever has been, but is much safer and more effective. Indeed, at times surgical attack is made possible only by the use of streptomycin.