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Appendix B

Contents

APPENDIX B

The Field Laboratory

Establishment of a field laboratory was manifestly essential to accomplishment of the program mapped out by the Board, since collection of voluminous and complex biochemic data was fundamental to the plan of study. The laboratory supporting the study had to be mobile and readily available wherever observations were to be made on the recently and severely wounded; that is, near the front line.

The 15th Medical General Laboratory was to serve as base of operations for the field laboratory and thus was available for the examination of such specimens as the Board might send to it. All histologic work in fact was done at this laboratory. In theory many other procedures required by the Board could have been performed at the 15th Medical General Laboratory but this system would have been totally inadequate to the need for two principal reasons: It would not have provided immediate reports on laboratory procedures which could aid in guiding treatment and evaluation of each patient, nor would it have revealed findings of particular interest which might suggest and direct special follow-up analyses. Furthermore many types of analyses, such as the van den Bergh diazo test, and determination of blood pH, phosphorus, chlorides, and sugar, must be performed very soon after the specimen is collected.

It was recognized, in addition, that the laboratory must not be a burden on the unit to which it might be attached and therefore it had to be self-sufficient, not only in the performance of laboratory procedures but also with regard to its utilities, such as electric power, heat, shelter, water supply, and disposal of wastes. A means of supply must be established which would permit the laboratory to carry only minimum essential equipment and chemicals for day-to-day operation and to be able to count on regular and dependable replacement of supplies and equipment from a base. Some of the practical difficulties encountered in operating the laboratory have been mentioned in the Preface.


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The joint considerations of mobility and self-sufficiency were reflected in the transport and major equipment initially made available to the Board. A large mobile laboratory truck was obtained on loan from the 15th Medical General Laboratory. In addition to reconnaissance cars and jeeps there also was available a 2½-ton cargo truck. On the latter were carried adequate glassware to take care of one day's run of samples, a size No. 1 International Centrifuge, two Coleman Junior Spectrophotometers, complete, a Klett colorimeter, a hot plate, a prescription balance with weights, a drying oven, and alcohol burners. A 2½-kilowatt generator, five carboys of distilled water, a typewriter, and nine pyramidal tents for the laboratory and the personnel completed the equipment, which was loaded on a 4-by-4 cargo truck.

In view of the anticipated working conditions, it was considered inadvisable to carry an analytical balance for preparation of standard solutions; therefore, as mentioned below, arrangements were made for obtaining a supply of these solutions as needed. The needs of the study did not necessitate carrying a refrigerator. A vacuum pump and a field autoclave were available in the mobile laboratory truck. A serviceable spectroscope was needed and was obtained later from the University of Rome.

Assurance of a continuous supply of reagents and other laboratory supplies necessitated special arrangements. Certain common items could be obtained from any medical unit to which the laboratory might be attached, but adequate supplies of distilled water, standard solutions, and special reagents and apparatus could not be obtained in this manner. Fortunately such items were readily obtainable from the 15th Medical General Laboratory which was the base of operations for the Board. They were delivered as needed to the field laboratory by means of the carrier "blood-bank" plane which shuttled between the General Laboratory and the forward distributing unit of the 6713th Blood Transfusion Unit.

Shortcomings in basic physical arrangements were soon evident. The mobile laboratory truck proved too small to provide space for more than one technician to perform chemical analyses. The pyramidal tents were not adaptable for use as a laboratory, so a ward tent was requisitioned from the 94th Evacuation Hospital. A tent of this size permitted three technicians to work comfortably without interference and allowed a systematic distribution of reagents and equipment, thus eliminating the rehandling necessary in a confined space.

Tables, a working cabinet, and a glassware cabinet were added. A sink was


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made from a truck gasoline tank, and water was piped from a 50-gallon drum. The sewage system was simple. All blood, plasma, urine, and solutions from completed analyses were poured into a slop pail, which was emptied into a prepared soakage pit. Water used in washing glassware ran into channels and soaked into the ground. The tables and equipment were distributed so that all the analytic work, the washing and drying of glassware, the storage of surplus supplies, and the administrative and clerical work were performed in the same tent. Blood typing and agglutination studies were made in the laboratory truck.

For the collection and submission of specimens, boxes were prepared in triplicate to contain approximately:

    15 screw-cap, 22-ml. flat-bottom vials containing lithium oxalate to be used for collection of blood specimens.
    10 screw-cap, 8-ml. flat-bottom vials containing ammonium and potassium oxalate for holding blood specimens on which determinations of hematocrit value and plasma protein concentration would be made.
    5 corked test tubes for submission of clotted blood.
    4 screw-cap, 250-ml. urine bottles.
    12 sterile 10-ml. syringes.
    3 sterile 30-ml. syringes.
    2 sterile 2-ml. syringes.
    10 dry 10-ml. syringes.
    30 sterile 19-gage needles.
    Absorbent cotton, alcohol, and rubber tubing for tourniquets.
    Ampules of bromsulfalein, phenolsulfonphthalein, and a sterile solution containing 100 mg. per 100 cc. of the dye T-1824 for determination of blood volume.

The specimens were required to be labelled with the patient's name and the date and hour the sample was taken.

Analyses

The following analyses were undertaken on the Board's material:

Blood.-Volume, hemoglobin, hematocrit value, hydrogen ion, sugar, sulfonamides, methemoglobin, the bromsulfalein liver function test; plasma urea nitrogen, creatinine, lactic acid, bilirubin (van den Bergh reaction), uric acid, protein, free hemoglobin, carbon-dioxide combining power, magnesium, chlorides, phosphorus, and nonprotein nitrogen; serum sodium, calcium, and potassium.


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THE TWO LABORATORY TENTS and the laboratory truck used by the Board for the Study of the Severely Wounded, shown at Monghidoro, Italy, autumn of 1944. Later the laboratory tents were winterized as shown.


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ITALY PROVIDED VARIETY OF CLIMATE. Winter snows and spring rains mired the laboratory truck and dampened equipment. Wherever possible the laboratory was housed in a building, but more often the work was done in tents.


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Urine.-Routine urinalysis, hydrogen ion, free hemoglobin, myoglobin, creatinine, creatine, ammonia, titratable acidity, chlorides, urea nitrogen, organic acids, magnesium, bile, urobilinogen.

Tissue.-Myoglobin.

Renal Function Tests.-Phenolsulfonphthalein excretion, mannitol clearance, para-amino hippuric acid clearance, and pituitrin concentration test.

Effort was made to synchronize the submission of specimens so that several of the same tests could be performed simultaneously; immediate analyses of single specimens were, however, made when requested.

Each technician kept a notebook in which he recorded the details of the particular determinations assigned to him. The calculations were checked, entered into the main laboratory book, and read back. After an adequate number of cases had been completed, the laboratory data were transcribed onto five copies of laboratory sheets and each set was stored in a different place (one copy being filed with the case record) in case storm, fire, or warfare would spare one or more sets. Even so, the laboratory sheets of some cases were lost in transit.

Many of the specimens submitted were irreplaceable. During the entire course of the study, no sample was sacrificed due to breakage upon centrifugation. The No. 1 International Centrifuge yielded results which far outweighed the inconveniences attached to moving and servicing it. The more easily moved table centrifuge had caused many tube breakages and was therefore not used.

The majority of the ultimate measurements made required colorimetric readings. The Coleman Junior Spectrophotometer, powered by its own 6-volt battery, contributed in several respects to improving the caliber of the work. It broadened the scope of procedures that could be carried out, it reproduced the readings accurately, and in all cases it allowed us to standardize the observations which, particularly in visual colorimetric reading of yellow, varied among technicians. Most of the color tests, except sugar and phosphorus which entailed comparison of easily-read blue colors, were set up for spectrophotometer readings. The spectrophotometer sturdily resisted the stresses and strains of repeated packing, unpacking, and moving, and no replacement of parts was necessary during the entire study.

The initial move up to the combat line was made with emphasis on care and protection of our supplies and equipment. Each subsequent move required speed. For this, boxes were prepared with individual cubicles for all the reagent


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bottles. The glassware was rolled up in blankets and these blanket rolls were snugly wedged between the shelves of the glassware cabinet. The test tubes and blood-drawing equipment were kept during the working period in the same boxes in which they were moved, and the pipets were bound in groups of 10 and wedged into the working cabinet drawer. The laboratory could therefore be dismantled, packed, and loaded within four or five hours.

The first move into the field indicated that certain standards of protection in inclement weather were imperative. During the winter period the laboratory tent was winterized by completely boarding up the front and back as illustrated. A close-fitting door was installed, the floor was gravelled, and an oil stove was kept burning day and night. The final set-up during the spring was the most convenient. No stove was required and the work tables were grouped about the center of the tent. To eliminate the discomforts of heat and the roar of the ovens, the dishwashing, drying, and autoclaving were done in a pyramidal tent adjacent to the chemistry tent.

The need of conservation of electricity made it quite obvious that drying could not be effected by electric oven nor could hot plates be used. Alcohol burners and gasoline stoves served satisfactorily for this purpose. During one particularly dusty period it was necessary to operate the centrifuge and spectrophotometer in the mobile laboratory vehicle, and it was often necessary to plug with cotton all the flasks and cylinders and to box the tubes and pipets to keep them dust-free.

In the 8 months of the study, the laboratory moved seven times, and over 12,000 biochemic analyses representing 56 different types of tests were made: 8,269 on blood (31 types), 3,961 on urine (22 types), and 58 (3 types) on tissue. The scope of these chemical analyses is shown in Appendix C where the methods used are described.

A detailed listing of the number of chemical analyses is given on page 322. All work was done in connection with the Board material except for a 3-day hepatitis survey.

The field laboratory proved its value in this study. It was shown that a mobile laboratory unit could be established and could function well close to the line of combat, and that it could do accurate and comprehensive biochemic analyses in this situation.


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CHEMICAL ANALYSES

Blood Chemistry

Hemoglobin

636

Hematocrit

636

Plasma protein

639

Plasma hemoglobin

892

Nonprotein nitrogen

605

Creatinine

580

Chlorides

591

Uric acid

195

Carbon-dioxide combining power

381

Van den Bergh

700

Phosphorus

440

pH

28

Sodium

174

Potassium

26

Calcium

42

Magnesium

158

Sulfonamides

108

Glucose

377

Blood volume

207

Bromsulfalein

451

Sulfate

2

Methemoglobin

15

Urea nitrogen

80

Vitamin C

8

Cephalin flocculation test

119

Mannitol clearance

75

Renal blood flow

40

Total mass-hippurate

29

Total mass-glucose

6

Lactic acid

27

Bilirubin (acetone)

2

Total

8,269

Urine Chemistry

Routine urinalysis

670

pH

774

Benzidine

662

Myoglobin

144

Chlorides

289

Phenolsulfonphthalein

385

Concentration test

43

Sulfadiazine

33

Hippuric acid

1

Bile

32

Creatinine

197

Creatine

83

Ammonia

130

Titratable acidity

130

Organic acids

91

Urobilinogen

7

Bromsulfalein

6

Urea nitrogen

96

Magnesium

65

Methylene blue test

119

Spectroscopic examination

2

Titratable alkalinity

2

Total

3,961

Tissue Chemistry

Myoglobin

41

Sulfadiazine

6

Magnesium

11

Total

58

Total Analyses

12,288


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