TY - JOUR
AU - Robinson, Angela Tomei
AB - How does it make laboratory professionals feel when no one really knows what we do? Our career—the profession we chose for a living—where we spend most of our time? When all that we do for patient care, and our accomplishments every day, go unnoticed by the general public? How unsettling is it when very few grasp and understand the importance and significance of who we are? As practitioners in laboratory medicine, how often have we heard these questions? “You seem so smart. Why did you not become a doctor?” “You are important in healthcare. Are you a nurse?” “So—what do you do in pathology and laboratory medicine?” Do we really know how to respond? “I work in the laboratory” is not at all a sufficient response. It does not take into consideration the education, technical skills, body of knowledge, scope of practice, or independent judgment required of laboratory professionals. When we consider the fact that laboratory testing significantly and critically ‘aids in the detection, diagnosis and treatment of disease’ - a more respectful response is worth pursuing. To help ourselves and in turn help the general public (and maybe some colleagues) whom we serve to understand and appreciate pathology and laboratory medicine, we need to understand what pathology and laboratory medicine are and the people behind it. What Is Pathology? In essence, pathology is the study of disease with 2 main divisions: anatomic pathology (the study of body parts) and clinical pathology (the study of body fluids). The earliest application of pathology began and was rooted within the development of medicine—most early pathologists were also practicing physicians. Considering that today the laboratory professions are an underappreciated field, it is important to follow the history to the current day. This article sheds some light on how laboratory medicine evolved and observes that the history of pathology is complicated and convoluted. Historical Timeline of Laboratory Medicine: Early Laboratory Techniques Laboratory medicine began with the study of a natural byproduct of all humans that was easily obtained: urine. Urine specimens today can provide valuable information for a physician. Even if many current laboratory professionals hold opinions of urinalysis as perhaps not the most popular area assigned for work, urine testing in itself has been quite diverting and dramatic from the very beginning. Thousands of years ago, early providers relied on much different, primitive methods of analysis and depended heavily on assumptions based only on observations. 4000 BC Based on unearthed papyrus, Babylonian and Sumerian “physicians” were recording urine evaluations on clay tablets. Early Egyptian medical assessments were also recorded on scrolls and were considered to be advanced. However, the luxury of attaining a diagnosis of disease was originally predominantly allocated solely to members of the royalty and the wealthy. Rituals and sacrifices (ie, gods/demons) were generally used otherwise to determine the nature of disease. In either case, patient care was very much left to chance. 300–100 BC Ancient Hindu physicians conducted testing by pouring urine on the ground to observe whether ants would be attracted to the sweetness of urine. Classical Era 400–301 BC The Greek physician Hippocrates (460–370 BC), known as the “Father of Medicine,” had an indelible impact on Greek culture during the Hellenistic era that was exported directly to Roman medicine. Hippocrates was one of the first physicians to interpret body functioning based on urine. Professing that no other organ system of the human body provided so much information by its excretion as does the urinary system, he determined that urine could be used as a prognostic indicator for the examination of illness. He utilized human senses such as eyes and ears. For example, seeing sediment correlated with increased fever, and seeing bubbles floating indicated that the disease would be prolonged. Hippocrates also professed the importance of smell and even taste. His hypothesis followed that urine was a filtrate of 4 body fluids (humors), each originating from a different region of the body. Each humor needed to maintain balance for health. One of the first manual laboratory tests ever performed: the tasting of urine (confirming its sweetness). 101–200 AD Approximately 6 centuries later, Aelius (Claudius) Glenus (129–216 AD)—popularly known by the name Galen—was a Roman Empire physician born into a wealthy Greek family—who expanded on the ideals of Hippocrates. Considered as perhaps the greatest medical figure of that time, he clarified that urine was not a filtrate of the 4 humors (blood, phlegm, yellow bile, black bile) and proposed that urine was a filtrate of only the blood. He also suggested that liquid intake by a healthy patient was proportional to output. Galen’s writings were extensive, and his theories on anatomy (via living animals, because human dissections were prohibited by Roman law) directed medicine up until and throughout the Middle Ages. The undisputed acceptance of his views (ie, blood is created in the liver after ingesting food and flows to either the right or the left side of the heart) dominated medical thinking for approximately 1,500 years, which unfortunately did not promote new investigations with new ideas to challenge—and prolonged unproductive thinking. Early Middle (Medieval) Ages (500–1300 AD) Medicine during these years was influenced mainly by Arab and Byzantine physicians (mostly monks) and held to the basic theory that disease was an inevitable outcome of deemed punishment—symbolic of sinning and/or witchcraft. The 7th-century Byzantium physician Theophilus Protospatharius (610–641) authored the first manuscript published solely on urine. Held in high esteem, “De Urinis” reviewed the subject according to the ancient classical conditions attributed to urine but concentrated on its characteristics to define disease, migrating from a theory of disease to clinical application. The study of urine remained the main source of laboratory testing for centuries, as did recognizing that the combination of clinical symptoms with standardized laboratory measurements could determine clinical disease. One of the first actual laboratory techniques ever performed was 500 years after Galen: precipitating protein with heat, causing urine cloudiness. Urine had become the primary diagnostic tool for laboratory testing. The 10th-century Egyptian/Jewish practitioner Isaac (Ben Solomon) Judaeus Israeli (850–950) was the founder of the origins of nephrology. He widened both the writings of Protospatharius and the ideas of Galen and was an enormous contributor to Arab-Jewish medicine— history records him to have lived 100 years. Israeli also originated the concept that fluid and sediment from blood seeped into the kidney and from the kidney to the bladder. The analysis of urine became a complex procedure used for both prognostic and diagnostic purposes with disease. Under the Jerusalem Code of 1090, urine became the exclusive diagnostic tool of legal necessity. If a physician failed to examine a patient’s urine, then public beating or fining were the punishment outcomes. The 12th-century royal Islamic Persian physician Zan al-Din Sayyed Isma’il ibn Husayn Gorgani (al-Jurjani; 1040–1136) required his patients to collect 24 hours of urine into a clean vessel on an empty stomach after a good night’s rest (this was not inordinately difficult or burdensome, despite the fact that laboratory staff were not available to advise on the preanalytical variables of proper collection and storage of specimens). The 13th-century Byzantine physician Johannes Zacharias Actuarius (1275–1328) authored a comprehensive 7-volume manuscript on just urine. This manuscript was the most complete work on this subject matter and remained so until the chemical developments of the 19th century. He detailed how to collect 24-hour urine: using a clean, transparent, very large bladder-shaped bottle protected against heat, cold, and sunlight. This medical practice of urine testing (visually examining urine) was collectively known as uroscopy (“water casting”) and eventually became associated with the Urine Wheel, a diagram linking the color of urine to disease. The variations of urine smells and tastes were also displayed. The medieval physician held up a glass flask (a matula) of the patient’s urine and would compare it to the colors on the wheel. The urine flask mimicked the shape of the bladder to preserve the urine in its familiar environment and became the symbol of the physician in medieval medicine (Figure 1). The Urine Wheel became well established and was an immensely popular quick reference chart for 20 different types of urine. Almost every urinary characteristic of color, smell, and taste was directly related to the disease state of the patient. Of course, the urine had to be examined immediately to maintain the warmth from urination, and various lighting had to be considered. What is most perplexing is how urine remained such a viable body fluid throughout the Middle Ages. Figure 1 Open in new tabDownload slide Medieval Uroscopy Figure 1 Open in new tabDownload slide Medieval Uroscopy An entertaining sidebar is that as an instructional aid for students in Salernes, France, a poem was written by French royal physician Gilles de Corbeil (1140–1224) to sing along with to help with memorizing the 20 types of urine and became a classic. Most of the testing performed in medieval days by today’s standards would be considered a fad or mockery (eventually referenced satirically in Shakespearean plays during the 1600s). Yet what transformed into urinalysis today still withstands the validity of direct observation, ie the color of urine (red, indicating the presence of red blood cells [RBCs]), and brown (indicating the presence of bilirubin) and a foul odor (indicating infection). Fortunately, tasting is no longer required, although collection still involves urinating into a cup in place of a flask. How far have we really come? 13th century (1201–1300) These early “laboratory tests” developed were performed by physicians, who were predominantly men, until Modino de’ Luzzi (1270–1326) at the University of Bologna employed Alessandra Giliani as a medical/surgical assistant to perform laboratory testing such as surgical dissections. Using the cadavers of criminals, he “supervised” autopsies and incorporated them into medical training, gaining the title “Restorer of Anatomy.” Meanwhile, as those times would have it, a young woman involved in medical testing was not considered acceptable, and historians are hard pressed to find definitive evidence of Giliani’s work, which is assumed to be either lost or destroyed. Distinguished as the first female anatomist, she ironically died of a septic wound—a laboratory-acquired infection—at the very young age of 19. Late Middle Ages to The Renaissance (1301–1600) AD —A Time of Rebirth After the Crusades (1095–1492), the monasteries were where ancient medicine continued under monks who became physicians, and this practice did not alter significantly until the 14th century and the revival of interest in Bologna universities. Although this century was an impressive period with advanced artistic, cultural, literary, and philosophical revelations and political and economic growth, there is no mention of pathology and laboratory medicine in historical records, and for good reason. Those advances were not yet forthcoming. Learning was primarily for the sake of knowledge, and none existed in application of the laboratory. There were some advances in pathology noted—but again, predominantly through academia—with a renewed interest in ancient Greek and Roman medicine along with Arabic/Persian medicine. However, some key medical discoveries did pave the road for modern medicine. Swiss/German physician/alchemist Theophrastus von Hohenheim, or Paracelsus (1493–1541), referred to the balance of minerals and chemical remedies in medicine (pre-chemistry/pre-pharmaceutical) and is sometimes called the “Father of Toxicology.” He advocated fasting instead of bloodletting/purges and anticipated early germ theory: illnesses were the outcome of outside agents attacking the human body. He discovered that using vinegar (acid) resulted in cloudiness in urine hundreds of years after Protospatharius used heat (early studies of proteinuria). Leonardo da Vinci’s (1452–1519) contributions are lesser known in the medical field. This multitalented renaissance man never ventured into the enticing world of laboratory medicine, but he did recognize the need for scientific knowledge and afforded anatomical techniques and detailed human anatomy sketches (anatomic art), which greatly enhanced knowledge of the human body. Although today the dissection of bodies, organs, tissues to study disease is a vital component of pathology laboratory medicine, slow progress was made over the centuries because of the Hippocratic and Galenic influences and the periodic prohibition of dissections. An early Arabian physician known by one name (Avenzoar), Abu Marwan Abd al Malik Ibn Zhr (1091–1161) reportedly made the first postmortem dissections. The 15th-century Florentine physician and skilled diagnostician Antonio di Paolo Benivieni (1443–1502) published “The Hidden Causes of Disease,” which was one of the first works proposing anatomic pathology as a separate specialty. His skilled autopsy techniques set him apart as the “Founder of Pathology.” The 16th-century French surgeon Ambroise Pare (1510–1590), who moonlighted as a barber, served 4 kings and became noted as the “Father of Surgery and Forensic Pathology,” inventing several surgical instruments and techniques. The greatest advancement in anatomic pathology finally came with Bologna’s Giovanni Batista Morgagni (1682–1771), who became known as the “Father of Pathologic Anatomy.” As the most famous of the early gross pathologists, he raised standards and improved existing knowledge in every area of pathology. The mostly clandestine postmortem examinations of the past centuries now became open-to-the-public theaters. Morgagni directly recorded and correlated the underlying diseased anatomy of organs with clinical symptoms and illnesses in over 640 autopsies; this labor is considered the beginning of modern medicine and pathology. However, pathology was not yet dignified as a separate science and so remained part of clinical medicine. 17th Century (1601–1700) Many practitioners continued using ancient and superstitious rituals and cures during the 17th century. The use of “medical equipment” for bloodletting and purging became acceptable practice, which turned patients away from medicine. Physicians could render a diagnosis without ever seeing a patient in person by just examining the urine. Uroscopy became available to the common person at home, including self-diagnosis. Amateur laymen became the new healers. Chlorosis (referring to lovesickness) and chastity were also diagnosed long before the immunoassay measurement of glycoprotein hormones such as human chorionic gonadotropin. “Uromancy” or “urimancy” followed as the analysis of one’s urine for fortune-telling and witch-hunting. A common practice was to place iron nails or needles or pins in a bottle of urine with a secured cork. It was taken as a sign of guilt if the suspect (or patient) became ill or if the cork popped out. Of satirical interest today would be the very popular book “The Pisse-Prophet,” written by Colchester (England) physician Thomas Brian in 1637 decrying the contemporary medical practice of uroscopy. He advised practitioners to simply place the urine flask on a windowsill to allow for sedimentation while asking the courier who transported the flask questions about the sick patient. Basically, without any scientific or real clinical testing, he advised practitioners to exaggerate the extent of disease. If patient lived - skilled practitioner; but if patient died - then claim the correct prediction had been made. Laboratory testing definitely needed to be developed. The most notable advancement perhaps was English physician Thomas Willis (1621–1675), who coined the term “mellitus” (diabetes), basically to describe what had been perceived for centuries—that certain patients’ urine had a different taste. Uroscopy eventually lost its solo appeal by the end of the 17th century, opening the door for another major body fluid to become the main focus of study and leading to more noteworthy and pertinent laboratory testing: blood. Practitioners of ancient medicine realized that blood was a notable “fluid of life”: phlebotomy (bloodletting) was practiced, Hebrews drained animals’ blood before consuming them, and Romans drank the blood of their enemies. There were, however, no specific scientific laboratory blood tests throughout the centuries until the microscope was created to examine blood beyond the naked eye (detailed in the following section). Of interest are some impressive digressions from past accepted theories, finally moving forward toward modern laboratory medicine. For example, Syrian Muslim anatomist Ibn al-Nafis (1210–1288) is believed by many historians to be the first to challenge Galen’s findings by proposing the existence of pulmonary circulation. How al-Nafis arrived at this hypothesis has been controversial because dissections were prohibited by Islamic law. Unfortunately, his medical encyclopedia manuscripts were incomplete and unpublished and many volumes were lost. Spanish physician Michael Servetus (1511–1553) was the first European who incidentally referred to pulmonary circulation but within theological writings and unorthodox teachings of religion. For this he was executed (burned alive) in 1553. The extraordinary breakthrough with pulmonary circulation is often credited to English scientist William Harvey (1578–1657). He refuted the allegations of witchcraft and purging and bleeding. In 1628, Harvey revolutionized the concept of disease in his groundbreaking detailed description of systemic circulation—the property of blood being pumped from the heart to the organs of the body (although he erred by not noting the capillaries). Harvey’s published writings finally disputed Galen’s long-established accepted theory of separate arteries (vital) and venous (natural) systems. Despite facing much skepticism during the 17th century (his practice encountered much criticism), he chose a diverged road for others to travel—a paved road that was enhanced with the development of the microscope. The Invention and Use of the Microscope The microscope was actually what intrigued many future laboratory professionals—the author included—about a career in the laboratory and the world beneath the microscope. Although the microscope was somewhat limited in use during the 17th and 18th centuries, the creation of optically corrected lenses and objectives augmented microscopy. Although lenses were used for eyeglasses dating as far back as the 13th century, they now had a higher purpose. From the mid-19th century and thereafter, what occurred in vivo could actually be appropriately studied in vitro: no more guessing, no more assuming, and much less speculating. The ancient premise relating disease found in from nature to sin or worse, witchcraft, was finally replaced with scientific measurements and anatomic autopsies, which viewed the body in both harmony and disease using localized processes. A level of controversy exists as to exactly who invented what and when. Galileo Galilei (1564–1642) was an Italian astronomer who has been associated with the invention of the telescope, which led the way to the invention of the microscope. However, many historians credit the first telescope to German-Dutch glassmaker Hans Lippershey (1570–1619), who in 1608 actually acquired the first patent. Lippershey is also alternatively suspected to be the inventor of the first microscope in 1590. Meanwhile, father-and-son team Hans Janssen (1605–1633) and Zacharias Janssen (1580–1630) were Dutch spectacle lens makers who later designed devices used to magnify objects. Zacharias (still a teenager) has more often been credited with creating the first so-called compound microscope (more than 1 lens) by placing a lens on the top and bottom of a tube and noting that objects on the other side were suddenly magnified in size, although the images were blurry and the device had no resolution capabilities. The first to actually utilize the microscope for laboratory testing was Jesuit German priest Athanasius Kircher (1602–1680), declared the “last Renaissance Man.” As early as 1646, he examined the blood of plague victims (one of the first to do so). In 1658, he recorded the origin of disease via “worms” in the blood—although note that a low-powered microscope could not possibly discern the Yersinia pestis bacteria at that time, so he may have actually observed increased numbers of white blood cells (WBCs). Of particular interest, Kircher also proposed hygienic measures to prevent the spread of disease, such as isolation, quarantine, and wearing face masks to prevent the inhalation of “germs.” Dutch scientist Jan Swammerdam (1637–1680) is respected as one of the most accurate of classical microscopists, having cultivated new techniques for examining/preserving/dissecting specimens specifically to view blood vessels. In 1658, he was the first to observe RBCs under the microscope by researching insects. He never practiced human medicine despite completing his medical studies. Marcello Malpighi (1628–1694) studied animals and for the first time in 1661 observed “very small red particles” as blood composition. Referred to as the “Founder of Microscopical Anatomy/Histology,” this Italian physician discovered the link between arteries and veins (capillaries) and discovered a human blood clot in 1666. English scientist Robert Hooke (1635–1703) made contributions in many fields of science, including refining the compound microscope and introducing the iris diaphragm (Figure 2). Using a microscope in 1665, he coined the first use of the word “cell” (reminiscent of the small rooms where monks lived) while observing microscopic cavities in cork. His research also focused on microorganisms as the etiological agent of infectious disease. Figure 2 Open in new tabDownload slide 17th century microscope Figure 2 Open in new tabDownload slide 17th century microscope By 1830, the English amateur opticist and physicist Joseph Jackson (JJ) Lister (1786–1869) had designed a lens combination reducing achromatic aberration (where objects appear colored) and spherical aberration (where objects appear circular), improving image resolution for minute detailed identification. This development solidified the microscope as a superior performance piece of laboratory equipment. Lister did all this during his spare time from his main occupation in the wine business. Over the years, with advancements made to the optical abilities of the microscope, cellular and bacterial knowledge along with laboratory testing broadened tremendously and pathology found its origins within clinical microscopy, but it was still a long way from the advanced superior fluorescent and electron microscopes of today. Beginnings of the Clinical Laboratory 18th century (1701–1800) During the 18th century, internal medicine practitioners developed new drugs and precision equipment for the doctor. Textbooks of pathology diagnostic testing were being published, but much information still needed to be assimilated into clinical laboratory testing. With the studies of illnesses now centered around the microscope as the key piece of laboratory equipment, the concept of diseases soon developed from organ-based to cell-based and cellular components. Microbiology There was ultimately a correlation of symptoms with underlying disease: the birth of the new “pathology”. Microbiology is probably the oldest known of all laboratory areas with tapeworm infections being recognized as one of the earliest parasites - discovered by Egyptians from 1500 BC. However, Dutch textile merchant, businessman, and self-taught microscopist Antonie van Leeuwenhoek (1632–1723) is generally regarded as the “Father of Microbiology”. He pioneered microscopy with his hobby of grinding lenses to study objects. Ironically, in 1676, unsatisfied with the magnifying lens available, he designed his own lens to examine the quality of thread in his draper shop. Much to his amazement (and that of the scientific community), he was the first to “accidentally” observe “animalcules” (microbes, or unicellular organisms) in water. These were among the first bacteria discovered, laying the foundation for the widespread detection of bacteria, which were not fully understood until 200 years later. Leeuwenhoek further observed sperm in fish, mammals, and humans. His unique lens design techniques were not reproduced until the late 1950s; this accomplishment was not bad for a businessman with no medical background. Hematology British physiologist William Hewson (1739–1774) is often referred to and distinguished as the “Father of Hematology” for his many considerable discoveries in all hematological areas of study. He described the RBC, one of the most intriguing of the body’s cells, as discoid, refuting the spherical shape originally described by Leeuwenhoek, who had detailed observations and illustrations of “red particles” in blood in 1695. Hewson incorrectly supposed that RBCs started as the rare “colorless cells” (WBCs) and that the center of the RBC was a nucleus. It is important to note that at this time, lenses were nowhere near perfected. Furthermore, Hewson’s belief in the presence of cell membranes was largely ignored. However, his isolation of the protein fibrin and his discoveries that fibrinogen (not cells) leads to the coagulation process and that lymph vessels exist (at least in animals) greatly advanced knowledge about the lymphatic system. Hewson died of sepsis infection at age 35 after cutting himself. Chemistry Originally referred to as “alchemy” (defined as the transmutation of elements; practitioners were primarily attempting to convert metals to gold) and based on mystical beliefs and not the scientific method, chemistry began initially as a qualitative testing of chemicals and minerals. Some documents refer to the first chemical test as the one used to determine pregnancy. Egyptian women in 1350 BC urinated on seeds of wheat and were deemed pregnant if the seeds sprouted. French chemist Antoine-Laurent de Lavoisier (1743–1794) was, according to historians, a pivotal influence on the chemical revolution. He suggested the law of the conservation of mass (a substance may change in form but retains the same mass); this idea began the conversion in science from qualitative to quantitative analysis. Identifying oxygen and hydrogen, de Lavoisier laid the foundation for the fundamentals of chemical reactions and is called the “Father of Modern Chemistry.” He constructed the metric system, wrote the first list of elements, and reformed chemical nomenclature. Unfortunately, because he had political adversaries because of his economic funding for scientific research, he was charged and sent to the guillotine, becoming a victim of the French Revolution. Because of the limited analytical development of equipment, only simple chemical tests were available until the early 19th century. These simple tests, such as the examination of stones and urine, could be performed at the bedside. One might say that they were the first point-of-care tests. Immunology English country doctor Edward Jenner (1749–1823) is attributed with the discovery of the immune system and is hence referred to as the “Father of Immunology.” Coincidentally, because of his familiarity with farm work (in particular, dairy cows), in 1796 he inoculated a 13-year-old boy with the first vaccine for cowpox, which made the boy immune to smallpox. Histology French pathologist Marie Francois Xavier Bichat (1771–1802) was an army surgeon during the French Revolution who used freshly guillotined bodies to investigate tissues. By 1801—and supposedly without the use of the fundamental microscope—he identified 21 types of tissues. He redirected the study of pathology from focusing on organs to the concept that disease occurred as the result of pathological alterations in tissue. Long after his untimely work-related death, he came to be known as the “Father of Histology.” The German word Histologie was coined almost 20 years later in an 1819 book by anatomist August Franz Josef Karl Mayer (1787–1865). Although histological progression moved slowly and it was not until the 19th century that histology became an independent discipline, the following tools and practices utilized in histology remain critical pieces of equipment. Microtome Czech physiologist Jan Evangelista Purkinje (1787–1869) was one of the most highly regarded scientists of his time. This Bohemian professor was the founder of laboratory training in connection with university teaching in Germany. Although microscopes with advanced magnifications and resolutions were in use by the 18th century, the process of tissue cuttings lagged far behind, producing only thick sections. Manual preparation using razor blades and knives evolved by the 1770s into the use of hand-operated “compressing” devices devised to create thinner sections, which basically crushed the tissue. By the early 1830s, Purkinje was the first to appropriately slice/compress thin tissue sections to prepare specimens for acute microscopic examination. Swiss Swiss anatomist Wilhelm His (1831–1904) is generally acknowledged with the invention of the rotary microtome in 1865 - a mechanical device enabling very thin slices (sections) of tissue to enhance microscopic level study. Embedding German/Swiss microbiologist Theodor Albrecht Edwin Klebs (1834–1913), renowned predominantly for pioneering modern bacteriology and the study of infectious diseases (he identified the bacterium causing infection with diphtheria), introduced paraffin wax embedding around 1869. Formaldehyde In 1859, Russian chemist Alexander Mikhaylovich Butlerov (1828–1886) accidentally produced formaldehyde while synthesizing methylene glycol. In 1868, German chemist (originally a law student) August Wilhelm von Hofmann (1818–1892) conclusively identified and laid the foundation for the modern manufacturing process of formalin in preparation and fixation of soft tissues. German physicians Ferdinand Blum (1865–1959) and his father Isaac Blum (1833–1903) advocated the use of formaldehyde in laboratory medicine due to its effectiveness for maintaining the color and shape of tissues with no change to the microscopic structures. Although an essential improvement in both anatomical and histological laboratory studies, as the toxicity became more evident, formalin became (and remains so today) one of the most highly regulated safety concerns. 19th Century (1801–1900) Along with the transformation to political, social, and industrial revolutions replacing societies previously dominated by religion and aristocracy, the advancements in the microscope, the introduction of standards of measurement, and knowledge about hematology, microbiology, immunology, histology, and chemistry paved the way for a number of significant and useful laboratory tests during the 19th century. The 1800s marked the beginning of the usefulness of newly evolved laboratory testing as specific chemical, bacteriological, and hematological diagnostic tools. Even the study of urine was rediscovered as urinalysis. Pathology until this century still played no direct role in patient care. Most pathologists were segregated to teaching/research and performing autopsies. However, with advancements to the microscope. a new era of pathology and laboratory medicine as distinct disciplines evolved. The cross-training and multitasking involved in the various laboratory disciplines meant that each were better appreciated and understood for their contributions. French professor Gabriel Andral (1797–1876) was a pioneer of blood pathology and was considered the “Founder of Clinical Hematology.” He studied the blood of both animals and humans and was the first to describe the constituent proportions of normal blood. His opposition to bloodletting as a practice performed by many physicians was a direct result of noting that disease affects the blood. Referring to “pus” in the blood, in 1843 he detected an increased number of “globules” (which were WBCs) and a decreased number of “another globular element” (which were RBCs). Andral was essentially describing leukocytosis and anemia. Simultaneously, English practitioner William Addison (1802–1881) reported in 1843 the first description of “white globules” (leukocytes), concluding that both known blood elements—RBCs and WBCs—were markedly altered in infections. Curiously, almost 2 centuries passed from the discovery of RBCs to the discovery of WBCs, but one must consider that RBCs outnumber WBCs by millions to thousands per cubic millimeter and the transparency of WBCs. French physician Alfred Francois Donne (1801–1878) is acknowledged for expanding the use of the microscope to all human body fluids, notably discovering the parasite Trichomonas vaginalis. In 1842, he reviewed the microscopic appearance of blood smears, noting the existence of a total of 3 blood elements: red “globules” (RBCs) and elevated white “globules” (WBCs) along with “little globules” (not yet named). By 1844, the excess of WBCs in sick patients convinced him to suspect the maturation arrest of intermediate cell development. Donne linked abnormal blood pathology for the first time in medical history to what would become known as leukemia. By 1845, he was the principal proponent of a new, cutting-edge technology: photography with microscopy. Scottish physician and pathologist John Hughes Bennett (1812–1875), a student influenced by Donne, published a text on the use of the microscope for diagnostic purposes in 1841, defining it as a clinical instrument. He opposed bloodletting and supported the admission of women to medical schools. He also offered the first published description in 1845 of “leucocythemia” as a systemic blood disorder resulting from purulent “colorless corpuscles—leucocytes.” He also detailed the pathogenic fungus in human lungs (Aspergillus sp). Although there is much ado in medical history regarding the origin of platelets, several physicians share the credit for discovering them. Italian pathologist Giulio Bizzozero (1846–1901) is generally credited in 1882 with the microscopic comprehensive description of living animals having “little plates,” having been inspired by German anatomist Max Schultze (1825–1874), who in 1865 came upon what he referred to as “spherules” that were smaller than RBCs and WBCs and sometimes clumped together. Notably, Schultze was educated in music and in medicine and preferred a laboratory research career over the practice of medicine. German Prussian-born pathologist Rudolf Carl Virchow (1821–1902) was one of the most prominent “laboratory” physicians in the 19th century. He was the first to study disease from organs all the way down to the cellular level, using the microscope routinely in autopsies. He brought a scientific basis to medicine and pioneered the application of the cell theory, that all cells arise from pre-existing cells. He wrote more than 2000 scientific papers and coined more than 50 medical terms such as “thrombus,” “embolism,” and “chromatin.” Although he erroneously dismissed the idea of the migration of leukocytes, in 1847 he detected reversed WBCs and RBCs, naming the blood condition “leukamie” originating from previously normal cells and thereby contributing to the theory of cancer. He has been coined the “Father of Modern Pathology.” Another strong advocate of microscopy was British scientist Lionel Smith Beale (1828–1906). In 1854, Beale reported on his cell classifications that were based on shape and body origin and in particular his descriptive discovery of the cell’s nucleus and nucleolus. He also described sputum cancer cells in 1860. But of all the extraordinary laboratory testing advances, it was German physician Paul Ehrlich (1854–1915) who probably made the most substantial discoveries for the most laboratory areas—histology, hematology, immunology (for which he received the Nobel Prize), microbiology, and chemistry—by inventing a repository of stains. He experimented progressively with aniline chemical dyes and in 1877 created his “triacid” stain, which enabled the detailed staining of tissue, bone marrow, and blood cells. Acidophils (now known as eosinophils), basophils, and neutrophils were clearly shown as were mast cells and nucleated RBCs. In fact, at age 25 Erlich published the technique of staining blood films for differential counting. Unfortunately, the pigment solution (Ehrlich’s reagent), interrelating chemistry with the other laboratory disciplines in laboratory medicine, was rejected at the time because of the lack of chemistry knowledge in the medical profession. Modifications of the Ehrlich staining methods made by Russian physician Dimitri Leonidovich Romanowsky (1861–1921), German chemist/bacteriologist Gustav Giemsa (1867–1948) in 1905, and American pathologist James Homer Wright (1869–1928) in 1906 advanced blood film staining as it is utilized today. A laboratory medicine area also ascribed to Romanowsky for the general staining of cytopathologic specimens is now known as Cytology. In 1887, Ehrlich’s tuberculosis was confirmed using his own stain to identify tubercle bacilli in his own sputum. He also researched antitoxins and discovered the “autoantibodies against oneself” and attempted to find a chemical capable of killing the microbe but avoiding the rest of the body’s healthy cells. Erlich’s stains distinguishing cells enabled differentiation and the identification of different hematological disorders, including anemia and leukemia. Although Ehrlich has been painted as an indifferent student who disliked formal exams and sometimes had an unpleasant relationship with medical leadership, his staining of blood films brought hematology into a new era and left an everlasting impression on Laboratory Medicine. 20th Century (1901–2000) Two additional distinct clinical laboratories historically were not developed as disciplines in laboratory medicine until much later in timelines: Blood Bank/Immunohematology It was not until 1901 that Viennese pathologist Karl Landsteiner (1868–1943) introduced the modern blood typing concept and described the ABO blood group classifications. He later contributed to the Rh factor discovery relating human blood to the rhesus monkey blood. Charles R. Drew (1904–1950) was a prominent African-American surgeon who worked closely with the first American Red Cross Blood Bank in 1941 - becoming the first director. He developed blood banks early in WWII saving thousands of Allied forces and shipped ‘bloodmobiles’ (trucks with refrigerators of stored blood) to mobilize quickly. He also utilized a cream separator devised by the British to separate plasma from RBCs and mass produce plasma. Special Hematology - Coagulation The blood coagulation advances by English physiologist William Hewson in 1770 did not proceed with any momentum. The classical theory mechanism for converting prothrombin using tissue (extrinsic pathway) continued but the blood clotting without tissue (intrinsic pathway) was not pursued for approximately another 40 years. It was not until 1905 when Paul Morawitz (1879–1936) a 26 yr old German physician became the ‘Founder of Classical Coagulation Theory’ by discovering that tissue extracts did not coagulate fibrinogen and introduced the clotting theory. This laid the foundation of the coagulation cascade. And despite one of the most frequently ordered test for haemostatis - PT - was not developed until 1935 and APTT was not measured until 1953. Special hematology as we know it today was not a separate laboratory science until the 1950s when complex interactions and coagulation factors were studied and utilized. Chemistry This laboratory area requires another mention again due to noted particular advancements in the 20th centuries from simple qualitative to quantitative analysis of urine and blood. Of particular mention is German pathologist Max Jaffe (1841–1911) who discovered the principle that color changes directly proportional to concentration - and introduced the Jaffe reaction in 1886 as a colorimetric method This analytical method remains one of the oldest methodologies still in use after 134 years. But is wasn’t until Swedish-born chemist Otto Knut Olof Folin (1867-1934) that groundbreaking advancements were noted. In 1882 he migrated as a 15 yr old to USA and by 1907 was appointed to Harvard Medical School. He was intrigued by the advancing area of chemistry and incorporated and adapted the Jaffe reaction from research - the first reaction of uric acid with picric acid. Even more remarkable - he was responsible for developing several methods for quantifying human waste produces in urine including creatinine, uric acid, urea, ammonia, creatine - and introduced the principles of protein metabolism. He was able to precipitate proteins in blood without adsorbing the non-protein. From 1920, he collaborated with China-born biochemist Hsien Wu (1893–1959) to produce several micro methods for quantifying non-protein constituents suas as the first assay for blood sugar (Folin-Wu method). Many laboratorians consider this “American” the “Father of the subspeciality of Laboratory Medicine - Modern Clinical Chemistry.” The Earliest Laboratories From Teaching and Research to Analysis Initially, laboratories were used predominantly for teaching and research, which progressed to the study and investigation of public health diseases. With the great London cholera outbreak in 1854, English physician John Snow (1813–1858) studied water pumps as the source of contaminated water and analyzed the disease patterns, which can be seen as beginning the application of laboratory methods (chemical and microscopic examination of water) for patient safety. This reliance on the laboratory to determine etiological agents continued with the groundbreaking work of Louis Pasteur (1822–1895). Pasteur discovered the existence of aerobic and anaerobic bacteria, the partial heat sterilization of microbes, and the vaccines against anthrax and rabies. A French biologist, microbiologist, and chemist and the “Father of Bacteriology,” he was a noteworthy contributor with significant breakthroughs in sterilization, vaccination, and pasteurization. His work has saved countless lives via laboratory testing. Robert Koch (1843–1910) was a brilliant bacteriologist and is considered the “Founder of Bacteriology.” He advanced the culturing of microorganisms, establishing a direct relationship between microbe germs and principal infectious diseases. In 1882 he isolated the tuberculosis bacillus pathogen responsible for numerous deaths in the 19th century, winning the Nobel Prize in 1905. He also identified the causative bacillus of anthrax and the bacterium of cholera. Notably, Koch originally began growing bacterial colonies using slices of potato. However, because this was not a suitable medium for growth, he switched to another nutrient: gelatin. In 1881, German microbiogist Walther Hesse (1846–1911), Koch’s laboratory assistant, suggested agar as a favorable medium. It was his wife Fannie Hesse (1850–1934), working as an unpaid laboratory assistant, who discovered this phenomenal nutrient of the microbiology laboratory. She was using it at home to make puddings and jellies and became acutely aware of its properties maintained at heated temperatures. Some historians distinguish her as the ‘Mother of Microbiology.’ In 1887, another assistant in the laboratory, German microbiologist Julius Richard Petri (1852–1921), invented the Petri dish. A substantive component of the microbiology laboratory, it prevented contamination and could slide under a microscope. This old laboratory tool remains the same and is still in use in modern microbiology laboratories. Dutch microbiologist Martinus Willem Beijerinck (1851–1931) furthered the work of Edward Jenner and Louis Pasteur by developing vaccines as protection against infections, at a time when viruses were not yet identified. After studying the work of Russian botanist Dmitri Ivanovsky (1864–1920), who in 1892 demonstrated that there was ‘something’ not being filtered with bacteria from infected tobacco plants, Beijerinck called the infectious substance ‘virus- beginning the field of virology. Laboratory Equipment What did the original clinical laboratories look like (Figure 3)? Where were the first clinical laboratories located? Any laboratories associated with teaching institutions were used purely for the purposes of experiments and for teaching. Early clinical laboratory procedures were performed by physicians within the confines of an office or home. Figure 3 Open in new tabDownload slide The Earliest Laboratory Figure 3 Open in new tabDownload slide The Earliest Laboratory Although the various types of “laboratories” would be dependent on the designated testing being conducted—the laboratory techniques related to the procedures in use—the typical elementary laboratory room may have had some of the following key pieces of simple equipment or tools (depending on the nature of the study). Microscope Glass slides (originally pieces of ivory bone placed between the stage and the objective until the Royal Microscopical Society of London created the standardized 3 × 1 inch glass slides in 1840) Test tubes (invented by Swedish chemist Jons Jacob Berzelius in 1814 and refined by English chemist Michael Faraday in 1827) Beakers and flasks (invented by German chemist Emil Erlenmeyer in 1860). There has been some speculation that wine glasses were used before the invention of specialized glassware. Incubator (ancient Egyptian models that were used to keep chicken eggs warm were revised in the 16th century by Italian inventor Jean Baptiste Porta and in the 17th century by French scientist Rene-Antoine Ferchault de Reaumur. Notably, 19th-century practitioners predominantly relied on a simple bell jar that contained a single candle so that cultures could be placed near the flame on the underside of the jar’s lid and placed in a dry heated oven. Scale or balance (invented by Richard Salter [England] in 1770) Bunsen burner (invented by Robert Bunsen [Germany] in 1855) Thermometer (invented by Daniel Gabriel Fahrenheit Germany in 1710) Petri dishes (invented by Julius Petri [Germany] in 1887) Forceps (invented by English Clergyman Stephen Hales who lacked formal medical training in the 18th century and originally used to remove urinary stones Tongs - (created by eldest son of the Chamberlen family of French surgeons who escaped religious persecution to England in the 16th century and originally used as an obstetric device for delivery of infants. The secrecy of this tool was not revealed until the 18th century.) Water Bath (used for heating and suspected to have been created by alchemist Maria the Jewess in 200 AD) The laboratory “room” probably also had a table, a chair, and a stand - along with trays, lamps, and perhaps shelves for any chemical fixatives or stains in use. This was the simplest earliest laboratory, which is far different from today’s highly modernized, automated, complex, and computerized instruments. Two additional laboratory equipment of historical interest but which emerged much later in timeline are: Refrigerator (ancient Persians in 400 BC are credited by historians with the ice pit dome but not until 1748 with Scottish physician/inventor William Cullen was the first articial refrigeration system created. By 1805, US inventor Oliver Evans gave more practical uses for refrigeration and patents were granted in 1835 to American inventor Jacob Perkins who became the “Father of Refrigerator”. Gloves (Not in use until the 1980s with John Hopkins’ Hospital surgeon Dr. William Steward Halsted who created the disposable latex gloves as a regulatory compliance.) In review, although initially the various early laboratories were developed for early scientists to perform experimental study and scientific research, none were specifically medically oriented for testing for direct diagnosis for patient care. Diagnostic laboratories would become the offspring to these early research facilities. This summarized history of pathology and laboratory medicine is just the beginning. The next installment to be published discusses how pathology and laboratory medicine laboratories found their way into hospitals, who managed these facilities, and perhaps most importantly, who finally worked in these laboratories, and the development and emergence of the laboratory professional. Abbreviations Abbreviations RBC red blood cell WBC white blood cell. Suggested Reading 1. Akmal M , Zulkifle M, Ansari AH. Ibn Nafis—a forgotten genius in the discovery of pulmonary blood circulation. Heart Views 2010 ; 11 ( 1) : 26–30. 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TI - Pathology—The Beginnings of Laboratory Medicine
JO - Laboratory Medicine
DO - 10.1093/labmed/lmaa098
DA - 2021-03-06
UR - https://www.deepdyve.com/lp/oxford-university-press/pathology-the-beginnings-of-laboratory-medicine-tXPEx7M76R
SP - e66
EP - e82
VL - 52
IS - 4
DP - DeepDyve
ER -