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Chapter 1, Part 5

Medical Science Publication No. 4, Volume II

LABORATORY SERVICE IN SUPPORT OF SURGERY*

LIEUTENANT COLONEL ARTHUR STEER, MC

Introduction

In war, the god of economy assumes a new shape and demands that men, not money, be spent efficiently. As with other services, minimal laboratory support sufficient to meet essential requirements is provided in the combat zone and the mission of the organization determines those requirements. Research in a combat theater is at best a secondary mission and tables of organization and equipment do not provide for purely investigative functions. Despite this, some of the greatest medical advances are associated with war. I shall briefly describe the laboratory facilities available in the Far East, the support given to surgery in the combat zone, the special facilities provided for medical and surgical investigation and the present concept of the role the Medical General Laboratory plays in Army medical research as observed during the war in Korea from July 1950 to July 1953.

Laboratory Service in the Far East

In Korea, the laboratory of the Mobile Army Surgical Hospital was expected to provide only basic laboratory functions such as urinanalysis, hematocrit and blood counts and to maintain a blood bank. Two technicians were assigned but because of rotation policies, they frequently had inadequate training. However, all I met were conscientiously doing their best to provide the laboratory service required by a hospital of this type. Even under the immobile battle conditions present in Korea, there was no reason for augmenting the laboratory facilities of the surgical hospitals.

The evacuation hospitals had well organized laboratories supervised by an officer who generally had at least one year of laboratory training. They conducted all of the common laboratory examinations except histopathology and forwarded specimens for the more complicated technical procedures to the Army Field or the Medical General Laboratories. They performed autopsies and many of the chemical, hemotological, bacteriological and parasitological procedures, and maintained a blood bank. Generally they were fully occupied in giving laboratory support to the hospital and were able to spare only a portion of their efforts for investigation.


*Presented 26 Apri1 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.


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The Army Field Laboratory was the reference laboratory for the combat zone. Except for virology, some of the highly technical chemical and bacteriological procedures for which they did not have equipment, and for most procedures requiring animal inoculation, there was little that the Army Field Laboratory could not do. Histopathology for the combat zone was one of its important functions but in addition this laboratory had mobile units intended for investigation of outbreaks of disease and local laboratory support where needed. It had a secondary research mission and from time to time assigned skilled investigators to specific problems. However, the considerable work load carried by this organization limited the effort which could be applied to research.

In Japan the various hospitals either had well organized and staffed laboratories capable of carrying out all laboratory procedures required locally or were in close proximity to a larger laboratory which could peform such tests. Blood distribution centers were established in the laboratories at Osaka Army Hospital and the 118th (8162) Station Hospital in Fukuoka. Many of the hospital laboratories did histopathology, water analysis and even some toxicology.

The largest military medical laboratory in the Far East was the 406th Medical General Laboratory in Tokyo. Its mission was to "supplement the epidemiologic, sanitary, and diagnostic services available in other medical department laboratories, and to investigate outbreaks of disease and conditions which affect, or may affect the health of persons . . . of the command." The research mission was further emphasized by activation and assignment to the 406th Medical General Laboratory on 10 March 1952 of the Far East Medical Research Unit (FEMRU) with the basic mission "to conduct, coordinate, supervise and direct such medical research within the Far East Command as is directed or approved by appropriate authority. To support, assist, and advise those special teams entering the Far East Command for the investigation of special medical problems beyond the capacity of units and personnel available in the command."

There were few procedures which this Medical General Laboratory could not perform. For years before the outbreak of the war in Korea it had been conducting studies throughout the theater. It was staffed by highly trained and skilled American and Japanese investigators and had established close rapport with Japanese civilian and governmental institutions. Acting as a reference laboratory for judging the quality of Japanese laboratory equipment and supplies offered for Army purchase, it acquired a considerable knowledge of what was available. This was of extreme importance when the blood bank was established and later when special chemicals, animals and equipment were required.


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The Medical General Laboratory served medical installations throughout the theater including the Philippines and Okinawa as well as Japan and Korea. The Commanding Officer was the theater laboratory consultant as well as consultant to the Public Health and Welfare Section and to the Surgeon of the Japan Logistic Command. Almost all laboratory officers and most of the highly trained technicians entering the theater were assigned to the laboratory for a short period of orientation (prior to assignment to their duty station). The Commanding Officer of the Medical General Laboratory, therefore, had an intimate knowledge of the skills available and, as a result of visits to all medical installations in the theater, knowledge of the requirements and problems of all the laboratories. Through the technical channels available to him, he had direct communication with all of these as well as with higher echelon laboratories in the Zone of Interior. With the establishment of the blood bank and the policy of having all shipments of blood to Korea accompanied by a courier, means were available for the expeditious handling of valuable, important and perishable material to and from Korea. These included dry ice, radioactive isotopes, flame photometers, animals for inoculation, frozen specimens, cultures, and essential, often unreplaceable supplies and equipment.

The Medical General Laboratory conducted a variety of investigations frequently in collaboration with other organizations. In a certain measure these served to define the problems in Korea and to indicate the need for more intensive investigations. The incidence of fat embolism and lower nephron nephrosis, the vascular findings in amputated extremities, bacterial cultures of war wounds, stool cultures in dysentery, virus studies in Japanese "B" encephalitis and hemorrhagic fever, biochemical changes in the war wounded, and studies of blood distribution and use were some of the pilot studies undertaken.

Obviously, institutions in the Zone of Interior, both military and civilian, were conducting investigations on these and many other problems. Much of this was in the field of basic investigation which could not be undertaken in an overseas theater but a considerable number, such as the studies on burns and vascular surgery, to mention only two, were thoroughly studied. They required field testing of the preliminary recommendations to determine applicability, efficiency, practicability and evaluation. Teams of skilled investigators experienced in these problems were therefore recruited in the Zone of Interior and sent to the Far East where the teams were augmented by available personnel. The Medical General Laboratory was in the best position to furnish laboratory support to these teams and to collaborate with them in certain instances. Generally, the team and the special consultants sent to advise them were attached to FEMRU.


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Among the subjects investigated were: body armor, battle exhaustion, hemorrhagic fever, dysentery, hepatitis, vascular surgery, shock and resuscitation, use of blood and blood substitutes, acute renal failure, the pathophysiology of battle trauma, wound infection, anesthesia and burns.

It is evident that the research program during the war in Korea represented a coordinated, integrated, and seriously conceived plan. This was the logical outgrowth of experience in previous conflicts, especially experienced in World War II. Under the sponsorship of the Army Research and Development Board, the Army Medical Service Graduate School and other organizations stimulated and directed the program in the Zone of Interior. When basic research was sufficiently advanced, teams were sent to the Far East. Many of the investigations had their origin in this way. In other cases, reports from the field indicated that special investigation was needed and that experienced personnel to conduct these studies were not available. In still other instances it was more practicable to collect specimens in the combat zone and send them to the Zone of Interior for study. In this way the resources of the nation were made available in the study of these problems.

The Medical General Laboratory with its attached research unit was an important element in this investigative program contributing to, collaborating with, and supporting the research teams. It sent pathologists to assist the wound ballistics and body armor team. A pathologist assigned to the Surgical Research Team conducted studies on autopsy findings in patients dying of battle trauma. He was particularly concerned with determining the distribution of blood in patients dying of shock after receiving massive transfusions. Biochemical and bacteriological technicians were assigned for long periods of time both to the group at the Renal Failure Center and the team at the 46th MASH to assist in the studies on pathophysiology and bacteriology of battle trauma. Repeated visits to all sections of the Surgical Research Team were made by the Commanding Officer and the heads of the pathology, chemistry and bacteriology departments. They offered technical advice and recommendations and made arrangements for efficient maintenance of complicated apparatus, discussed collaborative projects and gave assistance in administrative matters.

The collaborative studies included: histologic examination of injured blood vessels to determine whether the entire damaged portion had been removed, histologic studies of muscle biopsies and amputated extremities to help evaluate the benefits of vascular surgery, histologic studies of healing wounds which was part of the study on the metabolic changes of trauma and acute renal failure, studies of fat embolization as part of the study of causes of death, studies of deterioration of bank


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blood with particular emphasis on liberation of hemoglobin and potassium and increased osmotic fragility as related to age of the blood, studies of steroid excretion rates, protein fractionation studies, vitamin assays, studies of the absorption rates of morphine and penicillin, studies of wound infections with particular emphasis on clostridial infection and bacteremia, evaluation of plastic containers for blood and plasma expanders, and study of autopsy tissue after use of dextran. Medical photographers were sent to the research teams in Korea and in Japan. They also photoduplicated records and charts for use by research teams.

The Medical General Laboratory furnished admistrative support, maintained records, provided secretarial assistance and transportation, and sponsored the members of the team and their consultants on visits to the Theater and Eighth Army Surgeons. Usually a member of the laboratory staff accompanied the consultant to Korea and on their return the various problems and recommendations were discussed. Recommendations concerning new studies and others, such as one on blood use which would have seriously affected the entire blood program, were considered in great detail.

With this long list of functions of the Medical General Laboratory, one might conclude that research in the combat zone would hardly have been possible without assignment of the research units to that laboratory. As all of you who were in Korea know, this is not true. I believe that this assignment was of considerable value and that the Medical General Laboratory is the organization best suited to carry out this mission. We believe that the faith of The Surgeon General and his planning staff was not misplaced when they assigned the research unit to the laboratory. However, unless the value and importance of the research program is sold to both the theater and combat zone surgeons, unless their full support and confidence are won, the research program will not be effective. While overseas the research teams must keep the surgeons in Korea and Japan informed of progress attained and they must not make unreasonable demands. The reports presented at this meeting are a testament of the support given by the Theater Surgeon and the Eighth Army Surgeon. Their consulting staffs were keenly interested in the work of the teams, visited them frequently and gave advice and support. Available medical officers were assigned to the teams by the Eighth Army Surgeon. Without the very active support and interest of General Shambora the Medical General Laboratory would not have remained at the overstrength level which made possible the assistance given the research teams.

It must be realized that the Medical General Laboratory in supporting the research program extended the services of the Army Medical


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Service Graduate School. Many of the research programs originated at the School, many of the investigators and consultants were members of the School staff and almost all of the special supplies and equipment were furnished by the School. To illustrate how extensive and close was the relation between the School and the General Laboratory, during the year July 1952 to July 1953, 172 cables were transmitted concerning supplies and 16,610 pounds of supplies and equipment were shipped by air to the General Laboratory.

In summary, the laboratory facilities presently available to medical units in overseas and combat areas are sufficient for their assigned mission. During war, Army medical research as currently conceived originates in both the overseas theater and the Zone of Interior. The research program as a whole is planned, integrated and coordinated under the sponsorship of the Research and Development Board of the Army. The surgical research and most of the infectious disease programs were supervised by the Army Medical Service Graduate School. In the overseas theater the Medical General Laboratory was responsible for giving support and advice to the research teams and medical research programs originating in the theater.