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Klinisk Biokemi i Norden Nr 1, vol. 30, 2018 - page 11
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Advance article alerts. He did not believe that chemical studies were relevant to clinical medicine. Trousseau was critical of the vanity of the chemists, who believed that they could explain the laws of life and of therapeutics because they knew the nature of some of the reactions that take place in the living body.
In The Microscope in Medicine , Lionel Smith Beale — wanted laboratories and microscope rooms to be established at the major hospitals, for research and teaching. Opposition to microscopic inquiries was voiced by some of the senior and most influential members of the medical profession. Medical research was held in low regard because it had little if any money-earning value The persons most suitable to engage in medical research, said Beale, were the young physicians and surgeons attached to the medical schools and hospitals. Could Beale not see ahead to the effect such spartan living for so extended a period would have on the quality of the medical research that he wanted to encourage?
The great hospitals in the country were established as charities for the relief of the sick poor, and it was considered inappropriate to spend these funds on laboratories or research workers. It took until the end of the century before the governors of the charity teaching hospitals realized that such laboratories were of the greatest service to the sick poor. In the United States, as of , the average medical student or average practitioner had barely a nodding acquaintance with chemistry and could not use a microscope. Clinical pathology was nothing more than simple examination of the urine Shortly thereafter, a chemical laboratory was provided and a chemist appointed The Philadelphia General Hospital created the position of microscopist in , and in —, a small two-story building was erected for a morgue and laboratory for clinical microscopy and bacteriology.
This was the first laboratory of its kind in the United States amply equipped for both routine work and research and provided with its own four-story brick building.
To cope with the growing number of chemical tests, the physician in private practice, rather than do the tests himself or hire an assistant, would usually enlist the help of chemists or physicians skilled in chemistry. This demand led to the establishment of private laboratory services. As early as , a Philadelphia physician, Judson Daland, advertised his willingness to make thorough chemical and microscopical urinary examinations … in the most careful manner, and to furnish promptly a written report of the results.
Biochemical analyses were making inroads in the curricula of medical education. Technical progress in the s and s was rapidly having an effect on practice in America. By the turn of the century, increasing numbers of physicians were relying on laboratory tests. Writing in , Camac said that the time had now come to bring the practical application of the knowledge and methods developed in the clinical research laboratories to the bedside in the hospital or to the ward clinical laboratory. Objections were raised by some authorities that such laboratories were scientific luxuries because they required space, were expensive, and imposed on the busy schedule of the interns.
George Dock described his experiences in clinical pathology in the s and s when, during the 17 years that he was head of medicine at University Hospital in Ann Arbor, his office was the clinical laboratory In , clinical pathology was defined as the examination of urine, blood, sputum, and the bile, but London hospitals did not always provide adequate facilities for this kind of work. The arrangements for clinical research were, as a rule, far inferior to those afforded for postmortem investigations.
In Continental hospitals, on the other hand, clinical laboratories were attached to the principal wards, a necessary arrangement if the work was to be properly done He clearly gives the term a wider meaning than we have today, for he includes the study of blood pressure in patients. Clinical Chemistry , by C. In America, Charles W. His book, Practical Uranalysis and Urinary Diagnosis. A Manual for the Use of Physicians, Surgeons, and Students , was adopted as a text in more than 60 medical colleges in the United States.
A fourth edition was published in Every practitioner received a free course in chemistry through the mails and was swamped with pamphlets detailing some recent chemical achievement. The whole practical medical world was studying chemistry. Publication in clinical chemistry was becoming the goal of the scientific practitioner The preoccupation with publication was seen as a hindrance to progress.
This minimal approach was still being advocated as late as , when a physician described 12 routine chemical blood tests in common use and the indications for the ordinary clinical patient. Why so dismissive an attitude toward chemical analysis at this late date? The reluctance to accept quantification stemmed from a dislike of submitting insights, cumulative wisdom, and experience to numerical testing. Physicians prided themselves on their intuitive skills in making a diagnosis by the use of their senses alone.
Such feeling usually appears within any discipline when it is first threatened, as this one was, by quantification Not all doctors adjust to change and continue to treat patients according to the authoritative judgments of past knowledge. In , Otto Folin proposed that American hospitals employ clinical chemists to advance their ability to differentiate between the physiologic and the pathologic.
He cautioned that although hospitals should become involved in biochemical research, clinicians could neither do nor direct chemical work. He made specific recommendations for correcting the deficiencies. The Report urged that universities take over control of medical training so that laboratories could be provided and properly equipped and staffed for the first 2 years of the curriculum.
On the eve of World War I, judging from P. The tests were based on qualitative visual observation of color changes or precipitate formation. The author admitted that little information of any clinical value could be obtained from such methods because no purely chemical examination of the blood had, at that time, any wide application in clinical medicine Medicine is the only winner in wartime. The contributions of military experience to civilian medical practice, surgery, and nursing are milestones of history.
But the impetus that World War I gave to the spread of laboratory medicine is less generally recognized.
Early in , the American Army laboratories overseas, as well as competent personnel to staff them, were few, and equipment was makeshift. Worse yet, the usefulness of the pathologists was limited by the indifference of many medical officers who were unaccustomed to the consultant services of laboratory doctors in civilian practice. In most base hospitals, simple urine and sputum examinations were something to fill the time when things were slow Following the war, there was rapid development in the number of clinical laboratories, leading to an additional shortage of medically trained men.
Despite the training of many technicians by the Army during the war and the laboratory courses offered by several medical schools, the demand for reliable, well-trained technicians greatly exceeded their availability Gradwohl — proposed the establishment of schools for the proper training of laboratory technicians and for the organization of a laboratory examining board to pass on their qualifications for employment.
Gradwohl also suggested the formation of some kind of national association by the technicians themselves to bring about recognition by the medical profession 50 De facto recognition of the role of trained technicians was not long in coming, as a word of caution was sounded in No sooner were clinical laboratories on the hospital landscape than the naysayers felt obliged to voice their criticism.
Klinisk Biokemi i Norden Nr 1, vol. 30,
This tendency, which is becoming more pronounced each year, appeals strongly to those faddists among whom any test which suggests an easy approach to the solution of any problem, or which promises a division or evasion of responsibility, is assured of a kindly reception. Whether its credentials are written in the language of science or in that of pseudoscience appears to make little difference. The laboratory was not always accorded the respect its importance deserves. It is thus that we find this department frequently located in basements, in out of the way nooks and corners, in outhouses or roof structures built as an afterthought.
A hospital has been defined as a hotel with an operating room and laboratory attached. After , and aided by generous government funds that fueled the boom in hospital construction in the United States, building plans provided for adequate space and equipment needs of service and research laboratories. With the start of the 20th century, clinical chemistry emerged into its own space on the mosaic of medical practice. The pattern of its future growth and development took shape during the first two decades of the new century, the United States leading the way with the decisive breakthrough.
Until then, the United States had played no role in the growth or development of clinical chemistry. Afterward, the nation quickly achieved leadership, which it never relinquished. Two names dominated this period: Otto Knut Folin — Fig. Their systematic explorations on blood and urine set the style and shaped the parameters for clinical chemistry for the remainder of the century as they developed practical and clinically applicable methods of analysis.
On the basis of a new approach to methodology—analysis of small volumes of biological fluids—they determined reference intervals, correlated variations with pathologic conditions, and elucidated metabolic pathways in health and disease. Neither Folin nor Van Slyke held medical degrees, yet their research and teaching of biochemistry and clinical chemistry demonstrated that chemists could make great contributions to advances in medical diagnosis and the treatment of disease. These developments made the chemist immediately useful and necessary for the clinician.
Occurring about the time of the discovery of insulin, these advances brought the chemist from an annex of the mortuary into close relationship with the wards. For this reason the modern name, clinical chemistry, is a more valid description than the older term, chemical pathology The development of modern clinical chemistry depended on the introduction of colorimetric methods of analysis that were at the same time simple and accurate.
It gave great impetus to the development of additional colorimetric methods for quantitative analysis of other nonprotein nitrogen compounds in urine and later in blood. Laboratories in England were still dominated by the classical analysts who would recognize only volumetric and gravimetric procedures.
Prior to , colorimetric methods were regarded with the greatest suspicion by analytical chemists, and anyone who advocated them was regarded as being irresponsible, if not slightly immoral There were problems with colorimetric analysis. Donald Van Slyke did not believe that the chromogenic substance could all be attributable to creatinine.
The controversy over the actual existence of creatinine in normal blood was decided in by the isolation of bacterial enzymes capable of decomposing creatinine. The Duboscq-type visual colorimeter was the mainstay of the clinical chemistry laboratory for nearly half a century. By the early s, all colorimetric methods had been adapted to the photometer and were in the process of being adapted to the new arrival in the chemistry laboratory—the AutoAnalyzer, a continuous-flow instrument that reacted specimen and reagents to produce a measurable color density recorded on a moving chart.
After briefly working alongside the photoelectric colorimeter and the single-channel AutoAnalyzer, the Duboscq-type visual colorimeter passed into history. Concern about insurance compensation and malpractice suits, blamed in part for the increase in the number of laboratory tests, is not a recent phenomenon. During the s, physicians were criticized for ordering laboratory procedures for the record or for protection Data that did not fit the clinical picture were either ignored or repeated until they did conform From the mids through the s, the ever-expanding role of the laboratory in clinical diagnosis and patient care was evident on the wards, in the records, in the building plans, and not least of all, in the finance office of every hospital The capability of automated devices to produce more chemistry test results at a lower cost gave rise to the almost universal identification of routine or baseline tests, an ever-expanding category, and patterns of physician ordering of packages, panels, profiles, screens, and surveys or other groupings named according to the instrument and its output, instead of making specific single test requests.
As expected, this increased the number of laboratory tests that were done. Diagnosis and follow-up that depended heavily on technology were equated with the practice of scientific medicine. Clinical application of blood chemistry determinations was especially abused This later perception of excessive laboratory testing occurred 25 years before the appearance of automated chemical analysis and its by-product, mass-produced laboratory data.
Physicians continually expressed their concern over the possible harm done to the practice of medicine and to medical education by overdependence on laboratory tests to the detriment of careful history taking and bedside examination of the patient. This was a call for technologic restraint and a patient-oriented approach to problems, rather than the problem-oriented approach to patients By , the widening application of chemical techniques to the quantitative estimation of many different constituents, chiefly in blood and urine, had made the practice of medicine and surgery increasingly dependent on the support provided by clinical chemistry There was increased awareness by clinicians of the value of chemical methods of diagnosis and that this was attributable to greater emphasis on functional concepts of disease with less emphasis on morphology and taxonomy We were warned in about the danger of dehumanization as a threat to the work of the clinical laboratory.
We were also urged to avoid a black box or pushbutton philosophy toward equipment This unwelcome dividend of the technical approach to modern medicine was nothing new. This survey of two centuries of change and development for clinical chemistry closes with a tribute to Ivar Christian Bang — There have been momentous advances in laboratory technology since these words were spoken, but they remain the essence of clinical chemistry. Skip to main content. Research Article History. Louis Rosenfeld. Published January Abstract The 19th and 20th centuries witnessed the growth and development of clinical chemistry.
Chemical Analysis of Body Fluids Applications of chemistry to medicine at the beginning of the 19th century were directed to the understanding of disease rather than to its relief. Diagnostic Signs The discoveries of new substances in the healthy and diseased body had spawned a wave of interest in clinical chemistry as a recognizable identity in the late s and s. Progress in America In the United States, as of , the average medical student or average practitioner had barely a nodding acquaintance with chemistry and could not use a microscope.
Clinical Pathology George Dock described his experiences in clinical pathology in the s and s when, during the 17 years that he was head of medicine at University Hospital in Ann Arbor, his office was the clinical laboratory A Fresh New Look In , Otto Folin proposed that American hospitals employ clinical chemists to advance their ability to differentiate between the physiologic and the pathologic. Location Is Everything The laboratory was not always accorded the respect its importance deserves. Clinical Chemistry Takes the Stage With the start of the 20th century, clinical chemistry emerged into its own space on the mosaic of medical practice.
Figure 1. Otto Folin. Figure 2.
Donald D. Van Slyke. Figure 3. Van Slyke volumetric carbon dioxide gas analysis apparatus. Figure 4.
Advances in Clinical Chemistry: v. 28: v. 30
Note light shield, fixed plungers, and glass bottom of sample cup. Overuse and Misuse of Testing Concern about insurance compensation and malpractice suits, blamed in part for the increase in the number of laboratory tests, is not a recent phenomenon. Renewal of the Partnership By , the widening application of chemical techniques to the quantitative estimation of many different constituents, chiefly in blood and urine, had made the practice of medicine and surgery increasingly dependent on the support provided by clinical chemistry The Complete Clinical Chemist This survey of two centuries of change and development for clinical chemistry closes with a tribute to Ivar Christian Bang — Fourcroy, chemist and revolutionary, — Cambridge, England: W.
The origin of clinical laboratories. Fourcroy AF , Vauquelin N. Ann Chim ; 32 : Liebig J. Animal chemistry or organic chemistry in its application to physiology and pathology [translated from German by William Gregory, ed. Cambridge: John Owen, ]. New York: Johnson Reprint Corp, Fruton JS. Molecules and life. Historical essays on the interplay of chemistry and biology : 97 Wiley-Interscience New York. Brock WH. The life and work of William Prout. Med Hist ; 9 : Jones HB. On animal chemistry in its application to stomach and renal diseases.
London: John Churchill, preface.. Prout W. An inquiry into the nature and treatment of diabetes, calculus, and other affections of the urinary organs, 2nd ed. Observations on the application of chemistry to physiology, pathology, and practice. London Med Gaz ; 8 : Inquiry into the origin and properties of the blood. Ann Med Surg ;—26,—57,—89 [see p.
Rosenfeld L. The chemical work of Alexander and Jane Marcet. Clin Chem ; 47 : Bostock J. Observations on the chemical properties of the urine in the foregoing cases. In: Bright R. Reports of medical cases, selected with a view of illustrating the symptoms and cure of diseases by a reference to morbid anatomy, Vol. Ober, ed.
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Wilks S. An account of some unpublished papers of the late Dr. Perfecting the world.
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