Reprint from Medico-Legal Journal, June, 1886. 
DIAGNOSIS OF CONSUMPTION 
BY 
Means of the Microscope, 
WITH REFERENCE TO 
LIFE INSUR,ANGE, 
By EPHRAIM CUTTER, M. I)., of New York. 
W. A. Kellogg, New York. DIAGNOSIS OF CONSUMPTION BY MEANS OF 
THE MICROSCOPE. 
WITH REFERENCE TO LIFE INSURANCE.* 
By Ephraim Cutter, M.D., New York. 
Consumption has long been regarded as a deceptive 
disease in which the usual signs furnished by ausculta- 
tion and percussion may prove fallacious. So it has 
happened that some cases have proved to be consumptive 
that were regarded as not consumptive, and vice versa. 
Such confusion must add to the risks in life insurance. 
If it can be shown that there are any means of diagnosti- 
cating consumption in these doubtful cases when the 
usual physical signs do not clearly establish a diagnosis, 
it will certainly be advantageous to Life Insurance Com_ 
panies by lessening their risks from incorrect diagnoses. 
♦Read before the New York Medico-Legal Society, April 21st, 1886. 2 
DIAGNOSIS OF CONSUMPTION BY MEANS OF THE 
The object of this paper is to make known that there 
are means of diagnosticating consumptionany time with- 
in one year before the physical signs of lung necrosis and 
breaking down appear-that is in what may be called the 
pretubercular state. 
To show that this is no untried or unstudied idea, I beg 
to refer to a volume in my hands written in 1877, entitled 
"A New Physical Sign of the Pretubercular State of 
Consumption," illustrated with 63 microphotographs in- 
cluding some taken with objectives as high as the 1-75 
inch. 
As this essay is unpublished, I shall draw freely 
from it in the present case feeling that I have a right to 
present facts that have stood the test of ten or more years 
time in my own experience as not unworthy of consider- 
tion by life insurance examiners. To make my presen- 
tation stronger I would state that my work is antedated 
by a publication in 1868, entitled "Microscopic Examina- 
tions of Blood," &c., by Dr. J. H. Salisbury. At the 
same time he had ready for the press a work on the causes 
and treatment of consumption with XXX plates of illus- 
trations. This work I am happy to say is expected to be 
issued by W. A. Kellogg of this city as soon as the draw- 
ingscan be reproduced by the Homer Lee Bank Note Com- 
pany for printing. This contains a complete description 
of the subject matter of the present effort. The points 
made are in brief as follows : MICROSCOPE WITH REFERENCE TO LIFE INSURANCE. 
3 
1. Consumption of the lungs is characterized by a 
definite morphologyof the blood, which, taken in account 
with the other physical and rational signs is character- 
istic of the disease. 
2. This morphology differs from that of healthy blood, 
of syphilitic, of rheumatic blood, &c., &c., though it is 
possible for these morphologies to be present together 
two or more in combination. 
3. For any time within a year previous to the necrosis 
or breaking down of the lungs, this morphology of con- 
sumptive blood is found, so that- 
4. In a doubtful case where a medical examiner for 
life insurance-for example-finds it to be on the border- 
land of health and disease, the morphology of consump- 
tive blood comes in to settle at once the diagnosis and 
clearly define the line of action. 
5. This is regarded as of value in life insurance as no 
company wants to insure the lives of consumptives nor 
on the other hand to refuse a risk, other things being 
equal, for a non-consumptive. 
6. The importance of these statements as making out 
an advance in medical knowledge may well justify the 
presentation in a simple plain manner so that those who 
choose to avail themselves of them may do so in the most 
practical common sense way, and I crave your indulgence 
as I try to set forth the use of the new physical sign of 
microscopic inspection in the diagnosis of consumption. 4 
DIAGNOSIS OF CONSUMPTION BY MEANS OF THE 
MORPHOLOGY OF HEALTHY BLOOD. 
That of ahealthy nursing infant with a healthy mother 
is the type. "To obtain the blood a clean puncture or cut 
is made in any part of the body desired, the surface being 
previously cleaned." The capillary blood is the one 
studied not arterial nor venous. " The blood at once is 
transferred to aslide, then quickly covered with thin glass 
and placed under the microscope with 1-5 inch objective 
and one inch eye-piece." At the present day a good 
enough microscope can be procured for this purpose for 
fifty dollars, ($50.00) but the definition should be clear 
and achromatic. "By a little experience the blood may 
be under observation in one second from the time it leaves 
the stream." 
FEATURES OF HEALTHY BLOOD. 
1. Colored corpuscles. 2. Colorless corpuscles. 
3. Serum. 4. Fibrine filaments. 
5. Foreign bodies accidentally present. 
1. COLORED CORPUSCLES, 
in healthy blood, appear biconcave with edges well 
rounded out, clear, distinct and well defined ; their color 
is a deep, lustrous, ruby red appreciable fully only by 
actual observation ; their size varies in the same indi- 
vidual, average 1-3400 of an inch; uniformly distributed 
through the field, sometimes in rouleaux; number in the 
field varies with method of manipulation. If the drop 
of blood is large for the cover, they will be crowded and MICROSCOPE WITH REFERENCE TO LIFE INSURANCE. 
5 
numerous ; if small they will be fewer; they are some- 
times nucleated. 
PASSIVE PHYSICAL MOVEMENTS OF RED BLOOD 
CORPUSCLES. 
These are caused by clotting-by the capillarity of the 
space between the slide and cover-by evaporation and 
drying. They will move in masses swayed to and fro 
like a collection of old bottle corks floating on a stream of 
water. In themselves they are very passive and differ 
in this respect very much from white blood corpuscles. 
They are not usually regarded as having amoeboid move- 
ments, but to the writer they have; as occasionally he 
has seen them move with the independence of the white 
blood corpuscles. The arrangement of the red blood 
corpuscles, in rouleaux or evenly distributed about the 
field, their ruby strong color, number, size and clear cut 
outlines'are the features which characterize health. 
2. COLORLESS CORPUSCLES IN HEALTHY BLOOD. 
Features: color, number, size, shape, amoeboid move- 
ments, and sticky qualities. 
1. Color-Their color is white, and they are rightly 
named. This is shown with beauty in the photographic 
illustrations. An objective that does not bring out their 
true color is not a good one for blood study. 
2. Number-This varies in health relative to the red, 
but one to 300 red is about the proportion. In consump- 
tion they are more numerous. 6 
DIAGNOSIS OF CONSUMPTION BY MEANS OF THE 
3. Size-Varies less in health than in disease. Rarely 
are they smaller than the red ; usually they are larger. 
Perhaps they may berated at 1-2200 inch on an average. 
In consumption they are large and vary more. 
4. Shape-Is usually globular but varies constantly; 
sometimes they are triangular, oblong, obovoid. They 
are surrounded with a deeply cut and irregular margin 
forming objects of weird, bizarre and awry characters dif- 
ficult to describe or imagine. Indeed the grotesque 
changes of outline go beyond the imagination. Some- 
times they will push out long lines of substance like an 
arm or handle to a pan. Sometimes they will project 
themselves like a leech, and change their place. Indeed 
these changes are so wonderful as to demand a separate 
paragraph. 
5. Amoeboid movements, (amoeba-change.)-The 
colorless corpuscles move among the red like policemen 
in a crowd of people. They break through the fibrine 
filaments ; they push the red corpuscles out of the way 
as with authority; they go over or under the red cor- 
puscles and pursue their straight forward movements 
like a determined officer. But they can do more than 
any such functionary, for they can divide themselves up 
into parts-separate to considerable distances-travel 
on and "apparently" reunite their separate segments 
and move on aqain whenever they will to be ready to go. 
No law seems to govern their movements except inde- 
pendent volition if such a term can be applied to such 
minute bodies. While these movements are being made,. MICROSCOPE WITH REFERENCE TO LIFE INSURANCE. 
7 
with an exceptionally good objective, the granular con- 
tents of the corpuscles may be seen whirling and pushing 
along in currents and vortices of visual violence and 
force. 
6. On the other hand, white blood corpuscles present 
a phase directly opposed to that just described, when 
not undergoing movements they stick fast to the slide as 
if they meant to move only when ready to do so. While 
the colored are rushed helplessly along in swift torrents 
the colorless corpuscles will be seen underneath still and 
quietly resting and resisting the charges and onsets of 
the scudding movements over them. They split the 
stream like a rock in the rapids of a river ; they will also 
stick in the vacuoles of drying blood. Certainly this 
sticking power compared with the amoeboid movement 
are two remarkable features to occur in the same body. 
3. Serum. When coagulation has become thoroughly 
established in the specimen of blood the red corpuscles 
contract together leaving inter-spaces which in health 
should be clear and clean, except the serum, white cor- 
puscles, and the filaments of fibrine, which in health are 
faint and seen with difficulty. 
Although to inspection, the serum is clear and dia- 
phanous, it is really one of the most complex fluids of 
the body. The chemical elements embrace all those 
found in solution in the system and are invisible, save 
fibrine, which may be regarded as an insoluble form of 
albumen. It is on the clearness and cleanness of the 
serum that the diagnosis of healthy blood mainly turns. 8 
DIAGNOSIS OF CONSUMPTION BY MEANS OF THE 
It is very likely possible to discover some diseased ele- 
ments in an otherwise apparently healthy person's 
blood. In such a case the significance would be void ; no 
one physical sign of disease taken alone stands out 
against, controls or "orients" so to speak, all the other 
signs when healthy. The writer has seen a case of crepi- 
tant rales in the lungs of an otheiwise healthy person, 
but that single sign did not decide that consumption was 
present. The comparison with the rational excludes the 
diagnosis. People exist in a slightly impaired state of 
health, and have evidences of disease in the blood while 
systemically, it is latent as in rheumatism and syphilis. 
The subject is so new as to have many points yet to'set- 
tle; however, no subject is so old as to have no unsettled 
points. Still with these limitations, it may be said that in 
the great majority of cases the serum of the healthy 
blood is clear of dirt like debris, dots, spots and masses, 
or if present the quantity is limited. 
4. Fibrine Filaments. As has been observed, these 
naturally exist in the blood, but they are very faint and 
delicate, and elude observations unless specially con- 
ducted with great care and under favorable auspices. 
The reverse of this is true in some diseases. They form 
a striking and impressive feature in the field and need 
but little pains to be seen. 
5. Foreign Substances accidentally present in the 
blood of health. These come from the skin, the slide, 
cover and instrument of puncture as dirt or " matter out 
of place." This dirt may be to a great extent eliminated MICROSCOPE WITH REFERENCE TO LIFE INSURANCE. 
9 
by careful washing. Dirt furnishes material enough for 
a volume. It includes all dust and debris arising from the 
friction of various bodies and surfaces that come in con- 
tact in the wear and tear of life. Air teems with them. 
Dirt, includes smoke, clouds of dust, sweepings, orga- 
nized substances, as fibers of cotton and wool, linen and 
silk from clothing, feathers from animals and beds 
straw, wood and fibres, leather, salts of excretions and 
secretions, starch grains of all kinds, pollen grains, 
hairs of plants, spores, cryptogamic plants, algae, fungi, 
mosses, lichens, ferns, vegetations of fermentation, putre- 
faction and decay, fragments of inorganic bodies in im- 
palpable powder, earths, insects, dead epithelia, &c., 
&c. It is a long work to understand the various sub- 
stances that enter into dirt. It is a micrographic field 
that is exhaustless, always present, most penetrating and 
when overlooked, most fruitful of error. As the import- 
ance of having a clean slide and cover is an injunction 
that will bear repetition, so also the eye pieces and ob- 
jectives must be clean. It is a good plan to study before 
hand the field of the microscope without any objects in 
order to know how clean they really are. 
Sometimes the eye piece will be dotted with spots that 
cannot be wiped away ; simply rotating the eye piece 
will reveal these blemishes by showing them in motion, 
which could not be when the slide is still. Fat is an- 
other thing which may be found in healthy blood and 
mistaken for diseased conditions. Epithelia from the 
■skin and the lining of blood vessels, bubbles of air in 10 
DIAGNOSIS OF CONSUMPTION BY MEANS OF THE 
globar and other shapes, are found in healthy blood- 
To recapitulate : in healthy blood there should be good 
color, clean and plump outlines, very faint fibrin fila- 
ments, clear interspaces, and accidentally, fat, epithelia, 
dirt, and epidermal vegetations. 
MORPHOLOGIES OF DISEASED BLOOD. 
In the work above quoted as published in 1868, allu- 
sion was made to the diseased appearances in consump- 
tion, ansemia, rheumatism, carbuncle, variola, vaccinia, 
remittent fever, typhoid fever, and in other places syph- 
ilis, malaria, and erysipelas. These quotations show 
the broad scope of the researches, and that they are not 
mere hap-hazard observations. We have not time to- 
allude to more than the 
MORPHOLOGY OF CONSUMPTIVE BLOOD. 
1. Red corpuscles, generally massed and sticky. 
2. Colorless corpuscles, enlarged. 
3. Serum presents 
4. Fibrine filaments, large, dense, strong and 
5. Foreign substances; a abnormal, vinegar yeast;• 
b accidental. 
These elements in consumptive blood taken in connec- 
tion with the rational signs constitute the diagnostic 
evidence of tuberculous disease and what is here termed 
a new sign of the 
PRETUBERCULAR STATE. 
1. Red corpuscles are diminished in number, not uni- 
formly distributed in the field of the microscope, are- MICROSCOPE WITH REFERENCE TO LIFE INSURANCE. 
11 
strongly clotted and massed together, edges not well 
defined, not well ronnded out, flattened-not clean cut, 
sticky, pasty, flabby ; they form themselves into regu- 
larly rounded masses rather than rouleaux. The rou- 
leaux may be seen partially formed ; color is a pale, 
yellowish red or sickly look, as the countenance of an 
ordinary consumptive looks to the naked eye as com- 
pared with a robust healthy person. Number of red 
corpuscles less than in health, and sometimes nucleated. 
It should be remembered that the red blood cor- 
puscles are very sensitive to exercises that fatigue the 
body or mind. A single night of overwork has been 
known to diminish their number and brilliancy in health. 
2. White corpuscles, color a dirty white; sometimes 
the red are so bleached and the white so dark that they 
cannot be distinguished by their color. Size varies more 
than in health; sometimes aggregate themselves in 
masses and appear like foreign bodies, number decidedly 
more than in health. Shape varies as in health. 
Amoeboid movements are the same as in health; they are 
so distended by the changes (growths,) going on 
that they often burst and discharge their contents to 
form spore masses. The white corpuscles deserve a 
separate and careful study in all complaints as affording 
a pasture ground for the feeding of chronic diseases, as 
in syphilis for example. Rational signs remove the 
chances of error. 
3. Serum constantly shows morbid elements-con- 
sumptive. Its spaces look as if filled with dirty debris 12 
DIAGNOSIS OF CONSUMPTION BY MEANS OF THE 
in marked contrast with the clearness and cleanness of 
the same space in healthy blood. These objects in the 
serum are regarded as vinegar yeast developed in the 
blood. 
4. Fibrine Filaments.-Are always present in con- 
sumptive blood-are numerous, large, coarse, distinct, 
long and fill the field with a beautiful net work which 
presents different angles in different directions. Their 
strength in clotting is one of the causes of the masses and 
huddles of the red corpuscles alluded to. This is also 
found in rheumatic blood, but the rational signs would 
exclude rheumatism, though it is not impossible to have 
both together. 
5. Foreign Abnormal Substances.-a spores single of 
vinegar yeast; & spores of vinegar massed in collects. In 
bad cases they are very abundant and large enough to fill 
the field ; the forms vary as might be expected under the 
physical conditions found in living blood: viz., swift 
motions-friction with themselves and the blood elements 
in the narrow and crooked walls of the blood vessels. 
Accordingly they are found flattened, rolled, twisted, 
torn into irregular divisions, broken up into small 
masses, divided, linear, and filamentous. It is somewhat 
important not to confound them with white corpuscles 
whose airy, fantastic and impressive changes can imitate 
almost anything. 
The abnormal appearances described are not found 
always together in the same specimen, and to the neo- 
phyte they may not appear at first sight. Time, pa- MICROSCOPE WITH REFERENCE TO LIFE INSURANCE. 
13 
tience and study will make the matter clearer. Those 
who follow out this line of research are respectfully re- 
quested to follow: 
1. The method of collection, which is to take the blood 
direct from the blood stream. 
2. The best kind of microscope and illumination. 
3. Be sure to take a decidedly tuberculous case, and 
then, with some experience, these cases can be distin- 
guished. , 
ILLUSTRATIVE CASES. 
Case 1. A managed about 24 years of age took a se- 
vere cold; his cough was troublesome ; expectoration not 
copious; lost flesh, strength and voice; was pale,anmmic, 
thin and not robust. His father died of consumption ; 
had a sister in the last stages of consumption, who died 
subsequently ; there were no physical signs of lesion in 
the lungs. Inspection with the laryngoscope revealed a 
reddened and thickened condition of the vocal cords and 
larynx. Inspection of the blood by the microscope re- 
vealed fibrine filaments very abundant and strongly 
marked ; spores and collections of spores very numerous 
and large ; white corpuscles too numerous for health and 
much enlarged ; red corpuscles thin, flabby, outlines not 
clearly cut, pale, sticky and aggregated in irregular 
masses. 
Case 2. A mother of a family of four children began to 
run down rapidly. She was 33 years of age. She 
coughed badly and was partially aphonic ; no copious 
POSITIVE. 14 
DIAGNOSIS OF CONSUMPTION BY MEANS OF THE 
expectoration ; she lost flesh and strength ; was hardly 
able to keep about in the performance of her ordinary 
household duties. She had night-sweats, throat was 
sore, deglutition painful. There were, at the examina- 
tion, no physical signs of lesion in the lungs. The blood 
inspection revealed fibrin filaments abundant and 
marked. Sporesand spore collects in great abundance. 
Red corpuscles, sticky, adhesive, massed and huddled 
together. White corpuscles too numerous • and too 
much enlarged. Also to the naked eye the color of the 
blood was a light red. Taking all the circumstances, 
the general and rational signs pointed to some rapidly 
increasing systemic trouble of a very serious nature. At 
a later date the same physical signs were found and 
added to them was a diminished resonance over the left 
upper third front chest, with ruder respiration. 
NEGATIVE. 
Case 3. April 15, 1876.-Mr. C. A. W., meat dealer, 
age about 50 years, complained of a constant, severe and 
harassing cough; there were considerable expectoration, 
some emaciation and loss of strength with a slight alter, 
ation in his phonation. The laryngoscope revealed a 
redness and injection of the mucous membrane of the 
larynx. There was no paralysis of the vocal cords, but 
well marked patches of ulceration were found in the 
pyriform fossae. The chest was not developed as much 
as it ought to have been, but it exhibited no physical 
signs of tubercle inthelungs, though his family regarded MICROSCOPE WITH REFERENCE TO LIFE INSURANCE. 
15 
his case as consumptive. Inspection with the microscope 
showed in the blood no so-called filaments; no spores; 
no collections of spores and no enlarged white cor- 
puscles. However, the red corpuscles were less numer- 
ous and less highly colored than normal, but not massed. 
The case was pronounced non-tuberculous. History has 
proved the judgment correct. 
Case 4. Mrs. M., in May 1875, was found in bed and 
suffering from severe pain in the left chest, middle and 
lower thirds; from severe cough ; from night sweats ; 
from emaciation and an excessively irritated nervous 
■system. 
She was a chronic invalid, turned over to the writer by 
her physician as a case that would soon die of tuber- 
culous consumption ; her father died thus. 
Suspiciously there were no marked signs of physical 
abnormal changes going on in the lungs, still the case 
had a very bad look. On exploring the blood micro- 
scopically, the red corpuscles were pale, thin and flat- 
tened. The white corpuscles were not enlarged, neither 
were they too numerous. There were no spores; no 
fibrine filaments ; no debris. The hematic interspaces 
were clear and clean. From this examination immedi- 
ately no tubercle was diagnosticated, whatever else 
might be the matter. A month's treatment restored the 
blood to full color. The general symptoms improved 
markedly. The case proved one of general debility, re- 
sulting mainly from old uterine retroversion combined 
with two excessively severe labors, in which there was 16 
DIAGNOSIS OF CONSUMPTION BY MEANS OF TItB 
complete rupture of the perineum. As this patient was 
naturally frail and weak, it is fair to conclude that she 
might eventually have realized the end feared by Dr. 
. The writer believes such cases are extremely 
liable to tubercule ; just as parasitic diseases 
affect plants that are not vigorous and sickly. 
Case 5. Miss R., aged 17 years, was a pale, wan, thin 
girl. Her mother is a feeble person, laboring under a 
large uterine fibroid. • After the conception and before 
the birth of Miss R., her mother underwent a very 
trying experience with the sickness and death of two 
children from scarlet fever. The feeble constitution of 
Miss R. is attributed to this fact. She had a cough 
which was dry. Her appetite was good, but her physique 
was bad ; and she moved about like a person of declin- 
ing years, entirely unlike girls of her age. She suffered 
from anteversion of the womb, which probably prevented 
healthy locomotion. Aside from narrowness, her chest 
showed no sign of disease. The colored corpuscles 
showed a decided paleness and diminution of number, 
but the interspaces between them were devoid of abnor- 
malities and were beautifully transparent. The history 
of more than two years has justified the decision of non- 
tuberculosis. 
Case 6. Mrs. Dr. , aged about 55 years, mother of 
one child, in July, 1876, was seized with a cough of 
severity, sore throat and pain in chest; followed by loss of 
flesh and strength; stooping posture, with general malaise 
with coarse crepitant rales, more or less scattered 
throughout both lungs. There was no dullness on per- MICROSCOPE IX REFERENCE TO LIFE INSURANCE. 
17 
cussion anywhere about the chest. Her husband, a prac- 
titioner of the largest experience and the highest success, 
feared that with the bronchitis there might be tubercu- 
losis, as some members of her family had died of it, and 
particularly as he had buried his former wife and a 
daughter from the same disease. 
The microscopical examination of the blood showed no 
evidence of tuberculous disease. The hematic inter- 
spaces were entirely clean and clear of spots, masses, or 
debris. The anxious physician was confidently assured 
of the fact that no tuberculosis difficulty was present; 
decided by the absence of the physical sign hereinbefore 
described. The woman is now restored to health and 
confirms the negative diagnosis of tubercle. 
Note. The reading of this paper was followed by a de- 
monstration with a Marcy's sciopticon of 2o or more plates 
taken from microphotographs of the morphologies of 
healthy and consumptive blood; the microphotographs 
had been taken by the reader and Dr. G. B. Harriman of 
Boston.