History

Medical Science Publication No. 4, Volume II

LABORATORY SERVICE IN SUPPORT OF SURGERY*

LIEUTENANT COLONELARTHUR 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 laboratorysupport sufficient to meet essential requirements is provided in the combatzone and the mission of the organization determines those requirements.Research in a combat theater is at best a secondary mission and tablesof organization and equipment do not provide for purely investigative functions.Despite this, some of the greatest medical advances are associated withwar. I shall briefly describe the laboratory facilities available in theFar East, the support given to surgery in the combat zone, the specialfacilities provided for medical and surgical investigation and the presentconcept of the role the Medical General Laboratory plays in Army medicalresearch 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 expectedto provide only basic laboratory functions such as urinanalysis, hematocritand blood counts and to maintain a blood bank. Two technicians were assignedbut because of rotation policies, they frequently had inadequate training.However, all I met were conscientiously doing their best to provide thelaboratory service required by a hospital of this type. Even under theimmobile battle conditions present in Korea, there was no reason for augmentingthe laboratory facilities of the surgical hospitals.

The evacuation hospitals had well organized laboratories supervisedby an officer who generally had at least one year of laboratory training.They conducted all of the common laboratory examinations except histopathologyand forwarded specimens for the more complicated technical procedures tothe Army Field or the Medical General Laboratories. They performed autopsiesand many of the chemical, hemotological, bacteriological and parasitologicalprocedures, and maintained a blood bank. Generally they were fully occupiedin giving laboratory support to the hospital and were able to spare onlya 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.

The Army Field Laboratory was the reference laboratory for the combatzone. Except for virology, some of the highly technical chemical and bacteriologicalprocedures for which they did not have equipment, and for most proceduresrequiring animal inoculation, there was little that the Army Field Laboratorycould not do. Histopathology for the combat zone was one of its importantfunctions but in addition this laboratory had mobile units intended forinvestigation of outbreaks of disease and local laboratory support whereneeded. It had a secondary research mission and from time to time assignedskilled investigators to specific problems. However, the considerable workload carried by this organization limited the effort which could be appliedto research.

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

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

There were few procedures which this Medical General Laboratory couldnot perform. For years before the outbreak of the war in Korea it had beenconducting studies throughout the theater. It was staffed by highly trainedand skilled American and Japanese investigators and had established closerapport with Japanese civilian and governmental institutions. Acting asa reference laboratory for judging the quality of Japanese laboratory equipmentand supplies offered for Army purchase, it acquired a considerable knowledgeof what was available. This was of extreme importance when the blood bankwas established and later when special chemicals, animals and equipmentwere required.

The Medical General Laboratory served medical installations throughoutthe theater including the Philippines and Okinawa as well as Japan andKorea. The Commanding Officer was the theater laboratory consultant aswell as consultant to the Public Health and Welfare Section and to theSurgeon of the Japan Logistic Command. Almost all laboratory officers andmost of the highly trained technicians entering the theater were assignedto the laboratory for a short period of orientation (prior to assignmentto their duty station). The Commanding Officer of the Medical General Laboratory,therefore, had an intimate knowledge of the skills available and, as aresult of visits to all medical installations in the theater, knowledgeof the requirements and problems of all the laboratories. Through the technicalchannels available to him, he had direct communication with all of theseas well as with higher echelon laboratories in the Zone of Interior. Withthe establishment of the blood bank and the policy of having all shipmentsof blood to Korea accompanied by a courier, means were available for theexpeditious handling of valuable, important and perishable material toand from Korea. These included dry ice, radioactive isotopes, flame photometers,animals for inoculation, frozen specimens, cultures, and essential, oftenunreplaceable supplies and equipment.

The Medical General Laboratory conducted a variety of investigationsfrequently in collaboration with other organizations. In a certain measurethese served to define the problems in Korea and to indicate the need formore intensive investigations. The incidence of fat embolism and lowernephron nephrosis, the vascular findings in amputated extremities, bacterialcultures of war wounds, stool cultures in dysentery, virus studies in Japanese"B" encephalitis and hemorrhagic fever, biochemical changes inthe war wounded, and studies of blood distribution and use were some ofthe pilot studies undertaken.

Obviously, institutions in the Zone of Interior, both military and civilian,were conducting investigations on these and many other problems. Much ofthis was in the field of basic investigation which could not be undertakenin an overseas theater but a considerable number, such as the studies onburns and vascular surgery, to mention only two, were thoroughly studied.They required field testing of the preliminary recommendations to determineapplicability, efficiency, practicability and evaluation. Teams of skilledinvestigators experienced in these problems were therefore recruited inthe Zone of Interior and sent to the Far East where the teams were augmentedby available personnel. The Medical General Laboratory was in the bestposition to furnish laboratory support to these teams and to collaboratewith them in certain instances. Generally, the team and the special consultantssent to advise them were attached to FEMRU.

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 pathophysiologyof battle trauma, wound infection, anesthesia and burns.

It is evident that the research program during the war in Korea representeda coordinated, integrated, and seriously conceived plan. This was the logicaloutgrowth of experience in previous conflicts, especially experienced inWorld War II. Under the sponsorship of the Army Research and DevelopmentBoard, the Army Medical Service Graduate School and other organizationsstimulated and directed the program in the Zone of Interior. When basicresearch was sufficiently advanced, teams were sent to the Far East. Manyof the investigations had their origin in this way. In other cases, reportsfrom the field indicated that special investigation was needed and thatexperienced personnel to conduct these studies were not available. In stillother instances it was more practicable to collect specimens in the combatzone and send them to the Zone of Interior for study. In this way the resourcesof the nation were made available in the study of these problems.

The Medical General Laboratory with its attached research unit was animportant element in this investigative program contributing to, collaboratingwith, and supporting the research teams. It sent pathologists to assistthe wound ballistics and body armor team. A pathologist assigned to theSurgical Research Team conducted studies on autopsy findings in patientsdying of battle trauma. He was particularly concerned with determiningthe distribution of blood in patients dying of shock after receiving massivetransfusions. Biochemical and bacteriological technicians were assignedfor long periods of time both to the group at the Renal Failure Centerand the team at the 46th MASH to assist in the studies on pathophysiologyand bacteriology of battle trauma. Repeated visits to all sections of theSurgical Research Team were made by the Commanding Officer and the headsof the pathology, chemistry and bacteriology departments. They offeredtechnical advice and recommendations and made arrangements for efficientmaintenance of complicated apparatus, discussed collaborative projectsand gave assistance in administrative matters.

The collaborative studies included: histologic examination of injuredblood vessels to determine whether the entire damaged portion had beenremoved, histologic studies of muscle biopsies and amputated extremitiesto help evaluate the benefits of vascular surgery, histologic studies ofhealing wounds which was part of the study on the metabolic changes oftrauma and acute renal failure, studies of fat embolization as part ofthe study of causes of death, studies of deterioration of bank

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

The Medical General Laboratory furnished admistrative support, maintainedrecords, provided secretarial assistance and transportation, and sponsoredthe members of the team and their consultants on visits to the Theaterand Eighth Army Surgeons. Usually a member of the laboratory staff accompaniedthe consultant to Korea and on their return the various problems and recommendationswere discussed. Recommendations concerning new studies and others, suchas one on blood use which would have seriously affected the entire bloodprogram, 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 beenpossible without assignment of the research units to that laboratory. Asall of you who were in Korea know, this is not true. I believe that thisassignment was of considerable value and that the Medical General Laboratoryis the organization best suited to carry out this mission. We believe thatthe faith of The Surgeon General and his planning staff was not misplacedwhen they assigned the research unit to the laboratory. However, unlessthe value and importance of the research program is sold to both the theaterand combat zone surgeons, unless their full support and confidence arewon, the research program will not be effective. While overseas the researchteams must keep the surgeons in Korea and Japan informed of progress attainedand they must not make unreasonable demands. The reports presented at thismeeting are a testament of the support given by the Theater Surgeon andthe Eighth Army Surgeon. Their consulting staffs were keenly interestedin the work of the teams, visited them frequently and gave advice and support.Available medical officers were assigned to the teams by the Eighth ArmySurgeon. Without the very active support and interest of General Shamborathe Medical General Laboratory would not have remained at the overstrengthlevel which made possible the assistance given the research teams.

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

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

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