THE DIAGNOSIS of pulmonary tuberculosis in its early stages is often extremely difficult, and numerous factors have to be taken into consideration before a diagnosis can be made.

Out of 138 cases admitted to the Leeds Sanatorium only 35 per cent. had tubercle bacilli in the sputum, the Ziehl-Neelson acid-fast method of staining being used in every case, and the antiformin method when necessary. A total of 36 per cent. had slight but definite physical signs, leaving 29 per cent. of cases to be diagnosed by the tuberculin tests. In addition, I think it advisible to confirm the diagnosis by the tuberculin tests when no tubercle bacilli are found in the sputum.

Dr. John Robertson, at the meeting of the British Medical Association held at Birmingham this year, said: “We frequently hear it said that the good results of the sanatorium of tuberculin treatment are mainly due to errors of diagnosis. My experience leads me to say that these doubtful cases are just the cases that repay best the expenditure of public money. Over and over again I have seen cases develop from the doubtful to the well-marked condition because they were not properly treated.”

I entirely agree with this statement as I have seen cases which have reacted to the tuberculin test, there being no physical signs, develop into well-marked cases before admission to the santatorium.

At the British Medical Association meeting this year a paper was read by Mr. A. E. Lyster advocating the home treatment of pulmonary tuberculosis wherever possible. Dr. R. W. Philip recommended the establishment of the tuberculosis dispensary using tuberculin when necessary; to put it in his own words, “Those for whom tuberculin is desirable receive it as often and for so long a period as may be requisite.” Dr. Camac Wilkinson advocated tuberculin dispensaries, depending on the value of tuberculin as a cure for tuberculosis.

I have used tuberculin in the form of bacillary emulsion for nearly two years at The Leeds Sanatorium for Consumption and cannot regard it as a cure for every case. Tuberculin appears to me to have a place in the treatment of pulmonary tuberculosis, but that is not the first place. I consider that an unlimited amount of fresh air, a fair but not excessive amount of food, rest, and, best of all, graduated exercise when possible, are of much greater value than tuberculin given alone.

I have seen tuberculin have a very good effect on patients who were not doing well on the ordinary lines of sanatorium treatment, but this is not so with every case. There are many cases in which, were I given the choice of garden work for the patient or the administration of tuberculin, I should at once choose the former.

For 12 months I treated half the patients with tuberculin and the routine sanatorium treatment, the other half by routine sanatorium treatment alone. I had better results in the majority of patients when tuberculin was given. I think that much better results are obtained with tuberculin when a 1 per cent. solution of carbolic acid in sterilised water is used as diluent. For the last 10 months I have treated half my cases with carbolic acid injections (see British Medical Journal, July 15th, 1911) and the other half with tuberculin, and have come to the following conclusions.

1. Early cases do very well treated on the ordinary sanatorium lines and injections of carbolic acid.

2. In early cases treated on the ordinary sanatorium lines and tuberculin injections, using saline as diluents, the results are not so good as when carbolic acid is given.

3. In early cases treated on sanatorium lines and tuberculin injections, using a 1 per cent. solution of carbolic acid as diluents, the results are equal to those obtained by using carbolic acid injections.

4. In later cases carbolic acid by itself appears to be of no value, with a few exceptions; with these cases tuberculin undoubtedly gives better results.

5. Tuberculin is the only drug which I have known to reduce the temperature in pulmonary tuberculosis.

I therefore think that tuberculin plays an important part in the treatment of pulmonary tuberculosis in certain cases, and that its efficacy is greatly increased when it is diluted with a 1 per cent. solution of carbolic acid.

However, tuberculin cannot take the place of sanatoria. Too much value is placed on tuberculin by tuberculin enthusiasts. It has an important place in the treatment of pulmonary tuberculosis, but must on no account be allowed to usurp sanatorium treatment. Its use is restricted to certain cases.