Chapter Th e Clinical Laboratories (Chemistry and Hematology) Donna MacMillan and Kent B. Lewandrowski he clinical laboratories (Clinical millions of tests per year with a menu of over TChemistry and Hematology) at the Mas- 1,500 diff erent tests (including those sent to out- sachusetts General Hospital (MGH) originated side reference laboratories), and with oversight with individual physicians interested in specifi c of all point-of-care testing as well. Th is chap- diseases for which biological and therapeutic ter traces the transition from the earliest docu- clues began to emerge from laboratory tests. mented times to the present day. Over time, custom tests developed for specifi c patients were repeated for patients with similar The Early Years symptoms; in this way laboratory tests progres- Clinical laboratories had a minimal role in sively moved from research to patient care. the early years of the hospital: “For the fi rst sev- Th e chemistry laboratory at MGH has a long enty-fi ve years of its life there was nothing really history. It began as a central facility but was worthy [of] the name of a laboratory. Impor- quickly accompanied by a group of independent tant work was carried out in a hole-and-corner specialty laboratories such as the Th yroid, Endo- way” (1). Even by 1872 the laboratory measured crine and Metabolism, Blood Gases, and Lipid only approximately 6 by 10 feet. Located on the Laboratories, which led to a decentralized and ground fl oor of the Bulfi nch Building, it was complex set of separate facilities. On the other described as a “small dark room used as a labo- hand, there is little mention of hematology as a ratory where specimens of urine were taken for laboratory science until the middle of the twenti- analysis” (2) (fi gure 20.1). Testing was performed eth century. For much of their history, therefore, by the house pupils (medical students) as part of the clinical laboratories were not recognized as their training. a unique specialty or operation: even as late as In 1851 Dr. John Bacon Jr. was appointed the the middle of the second half of the twentieth fi rst Chemist-Microscopist for the hospital. He century, the clinical laboratories were not iden- had graduated from Harvard Medical School tifi ed as a separate and distinct service. Th e last (HMS) in the class of 1840, and he was known two decades have witnessed progressive consoli- from his early years as a gentleman with a bent dations, resulting in centralization of laboratory for mechanics. While in Europe after graduation, services, although the recent emergence of point- he developed an interest in chemistry. Upon his of-care testing has moved some testing back to return, he quickly built a career around analytic the bedside. As a result, the present confi guration techniques. He was known for maintaining an is primarily that of a single large Core Labora- organized private laboratory with the highest tory in the department of Pathology, performing quality reagents, and his primary expertise was 280 pathology_chap20.indd 280 8/16/11 10:23 AM The Clinical Laboratories (Chemistry and Hematology) preparing specimens for crystal identifi cation. Dr. Consultants in Chemistry (chapter 1), Dr. James Bacon’s appointment to the MGH staff allowed C. White (1863–1872) and Dr. Edward S. Wood him to expand his activities and his reputation as (1872–1905), also had responsibilities at HMS. an authority on analytic chemistry (1). In making In 1893 the laboratories were described as “a this appointment, the Trustees were recognizing little den fi tted up under the front steps, and the early contributions of chemistry and micros- unfi t for human occupation; partly in the nurses’ copy to clinical practice and research: “Micros- rooms connected with the wards; partly at the copy and organic chemistry are now considered Medical School, a mile away; partly at the patho- legitimate specialties and a few among our most logical room in the department of out-patients” promising and intelligent medical men devote (1). In 1896 the new Clinico-Pathological Labo- themselves entirely to these interesting studies” ratory (chapter 3) was established in the Allen (1). Even after Dr. Bacon established a formal Street Building and included a chemistry labora- laboratory at the MGH, however, many physi- tory on the third fl oor. A separate house offi cer’s cians continued to do their own laboratory work laboratory for patient testing was located on the for their patients. second fl oor. Th e fi rst annual report from the In the mid-1860s the roles of Chemist and laboratory describes the facility as a model labo- Microscopist were divided, and Dr. Bacon’s title ratory for providing training opportunities. Dr. changed to Chemist. He served in this role until Franz Pfaff (chapter 3) was appointed Chemist in 1863, when he resigned because of illness and his 1897 and put in charge of the Chemistry Labora- growing workload at HMS as Professor of Chem- tory in 1898, but much of the laboratory work istry. He died in Boston in 1881, at the age of 64. was still performed by house offi cers. From 1863 to 1897 the role of Chemist changed In the early 1890s Drs. William Gannett and to that of Consultant in Chemistry. Th e next two Richard C. Cabot (house offi cer from 1893 to Figure 20.1 Bulfi nch Building fl oor plan, 1872, with the laboratory (C) highlighted 281 pathology_chap20.indd 281 8/16/11 10:23 AM Keen Minds to Explore the Dark Continents of Disease 1894) started their work in the fi eld of hematol- patient and of using laboratory data to monitor a ogy (considered a medical specialty that included patient’s progress. In 1907 he wrote: examination of blood for malarial parasites) by When I see statements of blood counts which counting white cells in their patients’ blood spec- tell us, for example, that the patient had 5,633 imens. William Gannett (chapter 1) was born in leucocytes to the cubic millimeter, I cannot Boston in 1853, a descendent of John Winslow, help making two comments. First, that the one of the leaders of Plymouth Colony. He degree of accuracy to which the statement entered HMS in 1874 and was the fi rst student pretends is wholly useless; and second, that it to extend his studies to a fourth year for post- is only the pretense of accuracy after all. It is graduate work. During this year Gannett worked pseudo-science and not science. Now, if there as an assistant to physicians at the MGH. He is one thing which we who try to do scientifi c joined the MGH as a house pupil and received work should avoid more than another, it is, I his medical degree in 1879, offi cially joining the think this pseudo-scientifi c pretension—the MGH Medical Service after his graduation. He appearance of accuracy expressed in fi gures and fi rst spent a year in Vienna studying pathology, diagrams, when there is no such accuracy in and then returned to MGH in 1882 to start his fact. All blood counts should end with at least career as an Assistant in Pathology and Visiting two zeros, usually three. Physician. At HMS, Dr. Gannett was responsi- Th ere should be no diagnoses made merely ble for the laboratory work in pathological his- in the laboratory, and none merely at the bed- tology. Between 1882 and 1891 he also served as side, unless what are called “laboratory meth- Pathologist at Boston City Hospital and Carney ods” are carried out, as they may be carried out, Hospital. Dr. Gannett was an accomplished and at the bedside. (3) highly regarded diagnostician, and he continued seeing and consulting on patients in addition to In the early twentieth century, therefore, the his laboratory work. role of the laboratory in the clinical diagnosis was Richard C. Cabot (chapter 24) worked on still in question. Most physicians, like Dr. Cabot, blood pathology in collaboration with Dr. James emphasized the power of observation and overall Homer Wright. Dr. Wright’s research included medical knowledge; information from the labora- hematology (chapter 4), and the Wright stain is tory only provided confi rmation of the diagnosis. still used today. In 1894, Dr. Cabot was the fi rst recipient of the Dalton Scholarship and con- Typical Laboratory Workflow: tinued his work on the “minute examination of Early Twentieth Century blood.” During this time, he discovered red cell Laboratory specimens were usually collected by inclusions associated with certain anemias and interns in the fi rst six months of their training. disorders of erythropoiesis that are now termed Urinalysis and blood counts were performed in Cabot rings. His fi rst book, A Guide to the Clini- the ward laboratory under the supervision of the cal Examination of the Blood for Diagnostic Pur- laboratory leadership (“point-of-care testing,” in poses, was published in 1886. today’s lexicon). Orders for blood counts were Dr. Cabot’s career highlights the uncertainty of sent to the central laboratory. An intern was the role of laboratory testing in clinical diagnosis. assigned to collect the samples and perform the He rejected an off er to serve as the fi rst bacteri- counts. In the central laboratory, urgent (stat) ologist of the hospital in favor of a position in the tests were performed by interns on a rotating Outpatient Clinic. Nonetheless, he was an early basis. By today’s standards, the process for report- proponent of providing a specifi c diagnosis to the ing and archiving test results was cumbersome 282 pathology_chap20.indd 282 8/16/11 10:23 AM The Clinical Laboratories (Chemistry and Hematology) and labor-intensive.