Clinical Value of the Bacillus of 
Tuberculosis. 
BY 
A. K. S TONE, A. M., M. D. 
REPRINTED FROM 
THE BOSTON MEDICAL AND SURGICAL JOURNAL, 
November 27, 1890. CLINICAL VALUE OF THE BACILLUS OF TUBERCULOSIS. 
A. K. Stone, A.M., M.D. 
I wish by the narration of a few cases which have fallen 
under my observation to show what a valuable aid in diagnosis 
the presence of the tubercle bacilli can be. The cases have 
occurred both in private and hospital practice, and I have to 
thank the physicians for permission to use the material. 
Case I. The first case which I shall present came to the 
Boston City Hospital in February, 1887. The patient was a 
well-built man of twenty-two years. There was no phthisis in 
his family. He, himself, had never been sick before. He was 
a bar-tender, and drank some liquor every day, otherwise his 
personal history was good. For some two weeks previous to 
his entrance, he had not felt quite like himself, but he had had 
absolutely no cough, though during the winter he had had sev- 
eral "colds.” 
One week before, he had several times vomited ( ?) bright 
blood in considerable amounts. At the time of the examination 
he was weak, but felt first-rate. He had " no cough,” but raised 
from time to time a small amount of sputa streaked with blood. 
There were signs of consolidation at the right apex, consisting 
of dulness, extending a broad finger’s breadth below the clav- 
icle, whispered and spoken broncophony, with broncho and 
broncho-vesicular breathing over this area, and a few moist 
lAles in the back. 
Such was the result of my examination, for the case had been 
given me as a "clinical case,” and I gave my diagnosis as 
phthisis. 
To my great discomfort, the physician in charge of the case 
had a different opinion, and overthrew all the weak arguments 
advanced in the support of the theory of phthisis. Indeed, as 
I found later, the patient had been presented to the third-year students on the previous day, as a well-marked case of pneu- 
monia with the unusual symptom of severe haemoptysis. 
Though unable to hold my ground in argument, I was uncon- 
vinced, and after the hour procured a specimen of the sputum, 
which, on examination, showed the tubercle bacilli in small 
numbers, yet easily found in each preparation. A week later 
the official diagnosis had been changed, on account of the pneu- 
monia showing no tendency to resolve. 
Case II. was a private patient of Dr. Greenleaf’s. A young 
man, with both parents alive and well advanced in years. He, 
himself, was tall and thin; a lawyer by profession. He had 
been steadily at work through the summer, and though of late 
he had not been feeling quite as well as usual, attributed it to 
a slight pharyngitis, and to his need of a vacation. 
About the last of August, he suddenly, and without any 
previous sickness, spit up several teaspoonfuls of clear blood. 
So little was he disturbed by this occurrence that he came to 
town and tried to work, but after a few hours he gave it up and 
called upon the doctor. He was promptly sent home and sent 
to bed, and the next day a physical examination was made, 
which failed to disclose any abnormal physical signs in the 
chest. During the next few days the patient from time to time, 
and without any cough, spit up a little blood. At the end of 
about three days there appeared a slight cough and a small 
amount of sputa. 
Meanwhile, the patient was much displeased with being kept 
in bed, as he felt perfectly well. I was asked to make an exam- 
ination so that all possibility of phthisis could be eliminated. 
But the examination showed the presence of tubercle bacilli in 
small numbers. I will add that at the present writing, over a 
month from the first attack, the only sign of trouble is a per- 
sistent slight cough, while repeated physical examinations have 
failed to detect any modification of either resonance or respira- 
tory sounds. 
Case III. A few weeks ago a boy of sixteen years came to 
the Massachusetts General Hospital, out-patient department, 
service of Dr. Ernst. Up to one week before, he had been 
quite well, when he had an attack of vomiting accompanied by 3 
headache. During the week he had had two slight hemorrh- 
ages. He had, the day he presented himself, a hot, moist skin ; 
some cough, with bloody expectoration ; severe pain in the right 
chest; a temperature of 100°, and a pulse of 90. 
Physical examination showed diminished resonance over the 
whole right chest, vocal fremitus and resonance both slightly 
increased, an<l moist r&les, both coarse and fine, were present. 
The general condition of the patient suggested pneumonia, 
and directions were accordingly given for treatment. But 
partly from the element of doubt which presented itself, and 
partly as an exercise in differential diagnosis with the micro- 
scope, Mr. Rowen, Dr. Ernst’s assistant, was asked to stain 
some of the sputum to see whether the pneumo-coccus or the 
tubercle bacillus could be found, and numerous bacilli of tuber- 
culosis were found, thus giving a positive diagnosis. 
The next two cases illustrate the assistance which an exami- 
nation of the urine for the tubercle bacilli may give in certain 
genito-urinary troubles. 
The first patient appeared at the Massachusetts General Hos- 
pital, in the service of Dr. Beach. He was a carpenter of forty- 
six years of age, with good family history, and good general 
health till within the last six months. There was no venereal 
history whatever. Four years ago he had had a fall on some 
rocks, which had caused pain and swelling of the penis and 
perineum, accompanied by a slight urethral discharge. All of 
these symptoms, however, disappeared at the end of two 
months. Five months before the entrance to the hospital there 
was gradual increasing frequency of micturition, accompanied 
by some pain and smarting. He had been treated by the pass- 
age of sounds, but the symptoms of acute cystitis steadily 
increased until there was necessity for micturition every hour. 
On entrance, the heart and lungs were found normal, and the 
urine, according to Dr. Wood’s examination, had much sedi- 
ment; a specific gravity of 1,024; was acid; had a trace of 
albumen, and also of sugar; while the sediment consisted of an 
excess of small, round cells, bladder epithelium, a few blood 
globules. 
During the next three weeks the condition improved a little, 
the temperature was normal, and the cystitis was less severe. 4 
A few hyaline casts appeared in the urine, which otherwise 
remained as before, excepting that the sugar had disappeared. 
Repeated physical examinations by the medical staff gave no 
clue to the general condition of the patient, and examination 
with the dry lens failed to show any tubercle bacilli. At the 
end of a month and a half there was no marked change, except- 
ing that the patient’s strength had gradually but surely failed, 
while the temperature had gradually increased till it was 101°- 
102° each evening. Dr. Beach made up his mind that it was 
not a surgical case, all medical authority to the contrary, and 
sent the urine for a bacterial examination, with the result that 
tubercle bacilli were found present in moderately large num- 
bers, thus establishing a diagnosis. 
The second case occurred in the private practice of Dr. F. 
C. Shattuck. It was an ordinary case of pulmonary phthisis, 
which had been running about a year and a half when a cystitis 
suddenly appeared, persistent and severe from the first. An 
examination of the urine at once showed the presence of the 
tubercle bacilli, and made the diagnosis of tubercular cystitis. 
The two following cases show that the absence of the tubercle 
bacilli may prove an important factor in settling a difficult 
diagnosis. 
The first occurred in the service of Dr. F. C. Shattuck, at 
the Massachusetts General Hospital. The patient was an Irish- 
man, about forty-eight years of age. with a negative family 
history, who had had no previous sickness, excepting pleurisy, 
twenty-five years before. He entered the hospital December, 
1886. The patient stated that four weeks previously he had 
taken a severe cold, and had coughed a good deal and felt very- 
weak. At the end of a week he had a chill, which was followed 
by fever. A constant pain came in the left side, which was 
increased and lancinating on cough or deep inspiration. On 
entrance, there was pain on the left side, a slight cough with a 
small amount of white and frothy expectoration, headache and 
shortness of breath. The physical examination was as follows : 
the left chest expanded less than the right; below the angle of 
the scapular to the junction of the fourth rib with the sternum 
there was flatness, absence of respiration and of vocal fremitus, 
otherwise normal. Heart was moved a little to the right. The 5 
expectoration gradually became sero-purulent, and the area of 
flatness extended while the patient began to have night-sweats. 
Jan. 7, 1887, I examined the sputa, and found no evidence 
of the tubercle bacilli, though other bacteria were found 
in large numbers. This report so surprised the physicians that 
the sputa was again examined, Jan. 17, but with similar 
result. Meanwhile, the fiat area became somewhat less, and on 
Jan. 22, the patient was reported as gaining in strength, 
with respiration to the very base of the left lung, with moist 
and dry r&les. By Feb. 4 there was no cough, and no 
night-sweats, with only a slight dulness at the base, and with 
fair respiration everywhere present, and only a few dry r&les. 
On this date the patient was sent to the Convalescent Home, 
where he continued to improve steadily, and was finally dis- 
charged, weighing one hundred and seventy-nine pounds, or 
thirty-one pounds more than he weighed when he first was able 
to sit up, and nineteen pounds more than when he left the 
hospital. 
The sputum from the following case was sent to Dr. Ernst 
by Dr. D. W. Cheever, with the simple request that it should 
be examined for the tubercle bacilli. Careful examination, 
however, failed to show any, but Dr. Ernst was struck by the 
large number of cocci which appeared to have a capsule ; prob- 
ably Friedlander’s pneumo-cocci. The result of the examina- 
tion, and the conjecture that the sputum came from a pneumonic 
process was returned, together with the request that there 
should be another specimen of the sputum sent, together with 
some account of the case. Dr. Cheever replied that it was a 
case in which a diagnosis of phthisis had been made, and indeed 
the tubercle bacilli were reported to have been found (but this 
was probably due to a dry lens). Dr. Cheever was inclined to 
think the case one of chronic pneumonia, and sent the sputum 
for examination, with the complete confirmation of his opinion. 
The patient from this time on began to gain so rapidly that 
no more sputum could be obtained for further examination, and 
to-day, Sept. 21, the man has completely recovered, and is 
enjoying perfect health.1 
1 This case is mentioned in the Proceedings of the Association of American 
Physicians, 1890. A large number of cases — ordinary, every-day cases— might 
be given, where an early and sure diagnosis has been made by 
the sputum examination ; but enough have been cited to show 
to any one who has taken the trouble to read the above, that 
the presence or absence of the tubercle bacilli is often of the 
greatest importance in settling difficult diagnoses, and, what is 
of more importance, making the prognosis and line of treat- 
ment clear. 
One word as to the methods. To learn to stain the bacilli 
is not a difficult task, and when they have been well stained it 
is not hard to recognize them, provided one has sufficient light 
and a suitable lens. But it is absolutely useless, and will lead 
the observer into all kinds of error, to attempt to search for the 
tubercle bacilli if he does not have a sub-stage illuminator and 
an oil emersion lens. Where the bacilli are present in large 
numbers (and I have seen them in such large masses in sputum 
as to be recognized with a Zeiss A. A. objective), they can be 
seen with a dry lens. But when there are only four or five in 
a cover-glass preparation, though these may be perfectly typical 
in form and color, it is very easy to entirely overlook them, or 
else to call them bits of colored detritus ; while in cases where 
none are present, small crystals and dirt can too easily take on 
the appearance of bacilli, and lead to a false diagnosis, and, 
what is of more importance, cause an unfavorable prognosis.