Reprinted from the New York Medical Journal for 
July 17, 1909. 
DIAGNOSIS OF INTESTINAL TUBERCULOSIS* 
By Joseph Walsh, M. D., 
Philadelphia. 
This paper was called forth by the number of 
cases of tuberculous ulceration of the intestines 
which came to the autopsy table without previous 
symptoms, and the number which showed the com- 
mon symptoms of intestinal tuberculosis without in- 
testinal tuberculosis being present. As is generally 
recognized tuberculous ulceration of the intestines 
presages a fatal termination and since the prognosis 
is so absolutely bad it is of great importance that 
the condition be diagnosticated, and, if it is impos- 
sible to diagnosticate it, it is of equal importance that 
this impossibility be acknowledged. 
This study is on the last hundred cases which 
came to autopsy in the Phipps Institute, and the 
cases, therefore, were in no way selected. 
Of these one hundred patients the youngest was 
nine, the oldest fifty-seven, and the average age was 
thirty-one; seventy-four were males and twenty-six 
females. Seventy-six showed ulceration of either 
the small or large intestine or both, and twenty-four 
no ulceration. 
The symptoms ordinarily recognized as being at 
least probably diagnostic of intestinal tuberculosis 
are diarrhoea and abdominal pain, tenderness, and 
rigidity, especially in the region of the ileocaecal 
valve. 
Of the seventy-six patients with ulceration thirty- 
one (40.8 per cent.) had diarrhoea; of the twenty- 
four patients without ulceration seven (29.2 per 
'Read before the fifth annual meeting of the National Associa- 
tion for the Study and Prevention of Tuberculosis, Washington, 
D. C., May 14, 1900. 
Copyright, 1909, by A. R. Elliott Publishing Company. Walsh: Diagnosis of Intestinal Tuberculosis. 
cent.) had diarrhoea; of the seventy-five patients 
with ulceration in which pain was recorded twenty- 
one (28 per cent.) had abdominal pain; of the twen- 
ty-three patients without ulceration in which pain 
was recorded seven (30.4 per cent.) had abdominal 
pain. Of the seventy-six patients with ulceration 
twenty-three (30.3 per cent.) had abdominal tender- 
ness ; of the twenty-four patients without ulcer- 
ation seven (29.2 ner cent.) had abdominal tender- 
ness. Of the seventy-six patients with ulceration 
nineteen (25 per cent.) had abdominal rigidity; of 
the twenty-four patients without ulceration six (25 
per cent.) had abdominal rigidity. In other words, 
these symptoms taken singly add little or nothing to 
the diagnosis of intestinal tuberculosis. 
Taking now the combination of the four symp- 
toms, namely, diarrhoea, abdominal pain, tenderness, 
and rigidity, in the seventy-six cases with ulceration 
they were all four present five times (6.58 per 
cent.) ; in the twenty-four cases without ulceration 
they were all four present once (4.2 per cent.). In 
the seventy-six cases with ulceration they were all 
four absent twenty-six times (34.2 per cent.) ; in 
the twenty-four cases without ulceration they were 
all four absent nine times (37.5 per cent.). 
Taking now the symptoms in all their various 
combinations we find that of the seventy-six patients 
with ulceration five had all these symptoms; four 
had diarrhoea, pain, and tenderness without rigidity; 
two had diarrhoea, pain, and rigidity without ten- 
derness ; two had diarrhoea, tenderness, and rigidity 
without pain; three had diarrhoea and tenderness 
without pain and rigidity; two had diarrhoea and 
rigidity without pain and tenderness; four had diar- 
rhoea and pain without tenderness or rigidity; two 
had pain and tenderness without diarrhoea and 
rigidity; three had tenderness and rigidity without 
diarrhoea and pain; nine had diarrhoea alone; four 
pain alone; four tenderness alone; and five rigidity 
2 Walsh: Diagnosis of Intestinal Tuberculosis. 
alone; in one case pain was not recorded; and in 
twenty-six cases all these symptoms were absent. 
Sometimes we fail to find ulceration, but do find 
from a few to many small macroscopic tubercles in 
the intestines. These tubercles represent probably 
the first infection of the intestine and later develop 
into ulcers. Moreover, these tubercles might be 
capable of causing diarrhoea. 
Tubercles without ulceration occurred in this se- 
ries three times. Of these three one had and two 
did not have diarrhoea; one had and two did not 
have abdominal pain; one had and two did not have 
tenderness; rigidity was absent in all three in- 
stances. 
Symptoms in connection with ulceration of the 
different parts of the intestine and with nonulcera- 
tion : 
Ulceration of 
Diarrhoea, pain, tenderness, 
and rigidity 
Diarrhoea, pain, and tender- 
ness 
u 
c 
o 
3 
e 
5 
a 
a? 
0 
o 
o e 
c ® 
~ o 
c * 
o g 
o 
c 
u c 
co 
" S 
J 3 
tig 
•S.g 
i-j.S 
0 
•S £ 
C "TZ u. 
"Sc. 
o o ' 
<u 
<U 
c u Uj 
O 5 o 
3'4= 
4 
2 
c 
o 
rt 
o 
u 
3 
o 
I 
I 
d 
c 
o 
"co 
S : 
■ 
Q 
HH I 
0 
o 
V c fl'l 
.E.= S 
S.S E 
_T> 5 
zi.E o 
i 
o 
C 
o 
aj 
6 
0 
o 
Diarrhoea, pain and rigidity.. 
Diarrhoea, tenderness and 
0 
0 
I 
0 
0 
I 
0 
rigidity 
0 
0 
0 
0 
0 
2 
0 
Diarrhoea and pain 
0 
0 
0 
0 
I 
3 
I 
Diarrhoea and tenderness.... 
0 
0 
I 
0 
0 
2 
0 
Diarrhoea and rigidity 
0 
0 
0 
0 
0 
2 
0 
Pain and tenderness 
0 
I 
0 
0 
0 
I 
3 
Pain and rigidity 
0 
0 
0 
0 
0 
0 
I 
Tenderness and rigidity 
I 
o 
0 
I 
0 
I 
21 
Diarrhoea alone 
0 
I 
I 
0 
0 
7 
4 
Pain alone 
0 
0 
0 
0 
I 
3 
0 
Tenderness alone 
0 
0 
0 
I 
2 
I 
0 
Rigidity alone 
0 
0 
0 
2 
I 
2 
2 
Pain not recorded 
0 
0 
0 
0 
0 
I 
O 
No symptoms 
I 
3 
I 
2 
2 
17 
9 
Totals 
2 
5 
6 
6 
8 
49 
24 
'In one of these cases pain was not recorded. 
3 IValsh: Diagnosis of Intestinal Tuberculosis. 
Moreover, I would like to say that these patients 
had been in a hospital in which it is imperative that 
complete examinations be made and complete rec- 
ords preserved. In the study of these cases all the 
records were carefully gone over, even the nurses' 
records. It would not be possible, therefore, to miss 
the symptoms if they were present, for the reasons 
that, first, the number of bowel movements are re- 
corded on a temperature chart every day and this 
temperature chart was consulted; second, the night 
nurse makes a record every morning of the condi- 
tion of her patients during the night, therefore, 
when a patient vomits, has diarrhoea, or complains 
of pain she records it and her record is bound with 
the history of the case; third, all the patients who 
die in the institute are autopsied and the comparison 
of the clinical and pathological findings are brought 
before the staff every Monday evening, which 
makes the clinician careful with his records; and, 
fourth, examinations at stated times are compulsory. 
True, it sometimes happens that a patient dies with- 
in twenty-four or forty-eight hours after admission 
and before the clinician has made a complete exam- 
ination. I have included no such case in my sta- 
tistics. 
Gastric 
disturbance 
present. 
Gastric 
disturbance 
absent. 
Ulceration of small intestine..; 
2 
II 
Ulceration of large intestine... 
5 
9 
Ulceration of both intestines..., 
15 
34 
No ulceration 
5 
19 
GASTRIC DISTURBANCE IN RELATION TO INTESTINAL 
ULCERATION. 
Besides the symptoms ordinarily attributed to ul- 
ceration of the intestines I have endeavored to see if 
other symptoms and conditions would aid in the di- 
agnosis. A symptom that might be considered to 
have some bearing is gastric disturbance. A study 
4 Walsh: Diagnosis of Intestinal Tuberculosis. 
of the accompanying table, however, shows that it 
adds nothing to the diagnosis. 
ULCERATION OF INTESTINES IN RELATION TO ISCHIORECTAL 
ABSCESS. 
Ischiorectal Ischiorectal 
Ischiorectal 
abscess 
not recorded. 
Ulceration of 
abscess 
present. 
abscess 
absent. 
Small intestine 
. 0 
13 
0 
Large intestine 
. 0 
12 
2 
Both intestines 
. 8 
41 
0 
Rectum 
. 0 
i 
0 
No ulceration of intestines. 
.. i 
22* 
0 
- 
- - 
■ - 
Totals 
• 9 
89 
2 
This table shows that in ninety-eight cases in 
which the presence or absence of ischiorectal ab- 
scess or fistula in ano was definitely recorded at 
autopsy, ischiorectal abscess or fistula in ano was 
found nine times. Of these nine cases of ischiorec- 
tal abscess or fistula in ano eight showed ulceration 
of both intestines. In other words, it would seem 
that a predisposition to ischiorectal abscess is possi- 
bly accompanied by a predisposition to intestinal ul- 
ceration. 
Of course it is evident that the absence of ischio- 
rectal abscess means nothing, since in seventy-five 
cases of ulceration of the intestines ischiorectal ab- 
scess was absent sixty-seven times. 
ENLARGEMENT OF MESENTERIC GLANDS IN RELATION TO 
DIARRHOEA. 
Mesenteric 
glands 
enlarged. 
Mesenteric 
glands 
not enlarged. 
Diarrhoea present 
34 
4 
Diarrhoea absent 
54 
8 
'This table shows only twenty-three cases of no ulceration of the 
intestines instead of twenty-four as stated in previous tables. The 
reason is that one case of ulceration of the rectum without ulcera- 
tion elsewhere was previously reckoned with the cases of no ul- 
ceration of the intestines. This case gave only the clinical symp- 
toms of abdominal tenderness and rigidity. 
5 Walsh: Diagnosis of Intestinal Tuberculosis. 
In addition I looked for conditions that might 
give rise to a diarrhoea apart from the ulceration of 
the intestines. For instance, I looked first at en- 
largement of the mesenteric glands in connection 
with diarrhoea. Out of eighty-eight cases in which 
the mesenteric glands were enlarged diarrhoea was 
present thirty-four times and absent fifty-four 
times. 
Again I tabulated diarrhoea and albumin with and 
without ulceration, but it added nothing. 
Relation of albumin, casts, indican, and diazo reac- 
tion in the urine to ulceration of the intestines. 
Ulceration of 
O £ 
£ c 
o 
C V 
<u a 
c 1 
c 
° E 
c_° 
o « 
c >> " 
rt 3 
rt C 
G tn u. 
<u C z 
W g s 
8 
.2.2,s 
.2 3 
■S « 
C '> o 
c 
o 
6 
3 
c 
JD 
75 
£ «« 
.2.2 E 
_ -o 5 
o 
75 
E 
£ 
•S.E 
£ be 
o S-.c 
3 bCw 
CO 
<v 
o 
□ 
5 
« 
3 
be 3 
c 
3 
L 
E ° 2 
o 
W.2 o 
u 
►3.2 
Wo'S 
z 
Albumin alone 
0 
I 
2 
I 
I 
14 
4 
Casts alone 
0 
0 
0 
I 
I 
3 
5 
Albumin and casts 
2 
I 
0 
I 
3 
i5 
11 
No albumin or casts 
0 
I 
3 
3 
2 
IO 
3 
Albumin or casts not recorded 
0 
2 
I 
0 
I 
7 
I 
Indican: 
Present 
0 
0 
2 
3 
2 
19 
11 
Absent 
I 
I 
2 
I 
0 
9 
7 
Not recorded 
I 
4 
2 
2 
6 
21 
6 
Diazo reaction: 
Present 
0 
0 
2 
0 
3 
I I 
4 
Absent 
0 
3 
3 
6 
4 
27 
19 
Not recorded 
2 
3 
0 
0 
I 
11 
I 
The table shows the association of intestinal ul- 
ceration with albumin and casts in the urine, but 
there seems to be no relationship between the two, as 
can be seen from the following two items: Out of 
forty-nine cases of ulceration of both large and 
small intestines albumin or casts or both were pres- 
ent in thirty-two and out of twenty-four cases with- 
6 Walsh: Diagnosis of Intestinal Tuberculosis. 
out ulceration albumin or casts or both were present 
in twenty. 
There is apparently also no relation between indi- 
can or the diazo reaction in the urine and intestinal 
ulceration. Indican was present in the urine in six- 
ty-five per cent, of the recorded cases with ulcera- 
tion and in sixty-one per cent, of the recorded cases 
without ulceration. The diazo reaction was present 
in the urine in twenty-seven per cent, of the record- 
ed cases with ulceration and in twenty per cent, of 
the recorded cases without ulceration. 
Finally, I would like to say that almost all the in- 
testines, both with and without ulceration, were ex- 
amined microscopically. The very great majority 
of intestines showed enteritis, and this enteritis was 
present both with and without symptoms. 
As a consequence of these findings I never make 
a positive diagnosis of intestinal tuberculosis, and 
when called in consultation on a patient in whom 
the diagnosis has been made, if the case is not abso- 
lutely hopeless apart from the abdominal condition 
I suggest that we work on the possibility of ulcera- 
tion not existing in order to improve the prognosis 
and make what is done, done heartily and not indif- 
ferently, as is liable to be done when the prognosis 
is absolutely unfavorable. 
1. The symptoms diarrhoea, abdominal pain, ten- 
derness, and rigidity mean very little or nothing in 
the diagnosis of intestinal tuberculosis. 
2. The presence of an ischiorectal abscess in an 
advanced case adds to the .probability of intestinal 
ulceration. 
3. The diagnosis of intestinal tuberculosis cannot 
be made with the slightest degree of certainty from 
our present known symptoms, and since the condi- 
CONCLUSIONS. 
7 Walsh: Diagnosis of Intestinal Tuberculosis. 
tion carries with it such an unfavorable prognosis, 
in order to reassure the patient, the nurse, and the 
physician himself the diagnosis should not be made 
so that the patient will have a better chance for 
hopeful treatment. 
732 Pine Street.