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The Physician's Office Laboratory
Part I. OFFICE PROCEDURES
The Physician's Office Laboratory JOHN H. HODGES, M.D., F.A.C.P. Associate Professor of Medicine, The JejJerson Medical College and Hospital; StajJ Physician, The Lankenau Hospital; Attending in Internal Medicine, Veterans Administration Hospital, Philadelphia
THE performance of laboratory studies may be considered a specialized extension of the physical examination of the patient. There are many instances in which a simple procedure in a laboratory, which may require only a few minutes, may be sufficient to confirm a diagnosis which was suspected from the history and physical examination: for example, the detection of glycosuria in a suspected instance of diabetes mellitus, bilirubinuria in hepatitis, primitive cells in the blood film from a patient with lymphadenopathy, the detection of bacilluria and pyuria in a patient suspected of having pyelonephritis. The provision of a simple basic laboratory to extend the science of diagnosis, to provide a current appraisal of the effects of therapy and to detect the changes in the course of the patient's disease has become an important and requisite aid to the physician. HISTORICAL
The evolution of the laboratory to its important place in medicine has been amazingly slow. Until the past hundred years it was almost nonexistent. Clinical medieine, on the other hand, has had peaks of scientific grandeur followed by depressions into ignorance and mysticism paralleling the rise and fall of civilization throughout the world. The description of disease reached a zenith with the work of Hippocrates in the fifth century before Christ. There was little advancement
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in the science of diagnosis from that time until the descriptio]} of the URe of percm;sion by Aucnbrugger 1 in the eighteenth ccntury alld :tIlRcultatioll with the stethoscope by Laennec2 early in the nincteenth century. Before their time, the appraisal of the patient eonsisted of the history, the general appearance of the subject, the character of the pulse and the appearallce of the exeretionR, partieularly the urine. Aneient Hindu writings 3 describe what waR appanmtly diabeteR mellitus with "the attnwtioll of ants by the urine alld the urine limp alld as sweet as honey." Jo}mlllleR Aetuarius,4 court phYRieiull at Constantinoplc during the latter part of the thirteenth ccntury, wrote a treatise "On the Urillcs" ill which he distinguished fourtecn colol's of the urine, each one having a definite diagnostic meaning; however, it was not until the year 1695 that there appeared the first description of the demonstration of albumin in the urine by means of heat and acetic acid, credited to Frederik Dekkcrs,5 Professor of Medicine at Leyden. The science of morphologic hematology had its inception with the description of red blood cells by Anton Von Leeuwenhoek 6 in a letter to the Royal Society dated October 9, lm(i. Karl Vierordt7 published a paper in 1852 describing the first exaet method of counting the blood cells and recorded a count, performed on himself, which showed 5,010,000 red blood cells per cu. mm. Additiollal impetus to thc seience of hematology was obtained from the blood stain, devised in 1878 by Paul EhI'lieh,8 whieh permitted differcntiation of the polymorphonuclear leukocytes. The advancement of the sciences of bacteriology, chemi:-;try and physics in the latter part of the ninetcenth eentury and in the present century has enhanced the ability of the mcdical laboratory to make specific diagnoses when the history and physical examination illdicate possible syndromes of disease. Highly refined technical procedures requiring expensive, complieated equipment and highly specialized and train cd personnel, may, in some instanees, be requisite for a final diagnosis; however, a relatively inexpensive amount of equipment and chemicalR assembled in a small area adjacent to the physician's examining room will suffice, in most instances, to confirm a diagnosis. THE LABORATORY
The basic equipment for the laboratory eentcrs about the supplies needed to perform a routine blood count and a routine urinalYHis. Thi:-; is the minimum requirement for most physicians. Many additional simple procedures can then be added without much expense. The variety and usefulness of these added tests depend upon the needs of the physician as dietated by his type of practice aJl(1 also depend upon the foIkill and interpretative ability of the physician. The quantitative chemical tCRts are time-consuming and require mallY solutions and accurate equipmcnt; hence, the average physician usually finds it imperative to employ a
The j)hysician's o.Uice iAlbvm{or'Y
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kchllician if he intends to add these tests to the basic laboratory procedures. The following is a summary of suggested laboratory te"ts,9 with alternate procedures occasionally listed, the supplies and equipment needed and the a verage costs. BASIC LAm)l{ATOlty EQUIPMENT
1. Microscope
U sunlly acquired by the physician while he Binocular microscope preferred:
1S
in medical school.
a. Domestic 1. American Optical Co .. 2. Bausch and Lomh .. b. Foreign 1. Leitz ...... .
$(i42 $G45 $800
In choosing a microseope it is well to remember that no two scopetl are exactly the same. It is advisable, after a decision has been made as to type and model, to try several different microscopes so that an ideal ehoiee may be made in regard to lellses.
2. Microscope Lamp a. For monocular scope: An ordinary lamp with a blue filter such as Mieroscope Lamp (A.H.T. Co. No. G924-B) $G.50.* b. For binocular seope: It is necessary to have a stronger lamp, preferably one with a rheostat, sueh as: 1. Spencer (A.H.T. Co. No. li983-A) $G7. 2. Leitz Microscope Lamp and Transformer $85.50. 3. Centrifuge The ideal centrifuge is the InternatiOlml Clinical Centrifuge equipped with a four-place head. This is a good, durable apparatus which is suitable for many purposes from centrifuging urine for microscopic examination to performing procedures requiring speeds up to :moo r.p.m., sueh as the hematoerit. (A.H.T. Co. No. 297G) $134.50. 4. Colorimeter a. Klett-Summerson Colorimeter (Fig. 1): The work horse of colorimeters, which can tolerate rough usage. J t has two photoelectric cells and therefore its
* A partiailistillg of manufacturers will be found on page 1477.
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JOHN
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No. 800·3
(PATENTED)
Fig. 1. Klett-Summerson photoelectric colorimeter. (Courtesy of Klett Manufacturing Co.)
accuracy is maintained even though there are mild fluctuations in the current. The acid-hematin method of hemoglobin determination is accurately determined; however, the range is poor for the oxyhemoglobin method. Suitable for glucose and blood urea nitrogen determinations. Approximate cost $205. Klett Standardized Tubes (A.H.T. Co. No. 3788-D), $9.00 per dozen. b. Coleman Junior Spectrophotometer (Fig. 2): Highly accurate and very versatile because of the high range
Fig. 2. Coleman Junior spectrophotompter. (Courtesy of Coleman Instruments, Inc.)
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1467
of wave-length settings which are possible. Has only one photoelectric cell, so it requires a good voltage regulator to prevent alterations in the electrical supply. Approximate cost, $453. 5. Sterilizer
a. Instrument sterilizer (Castle): A good, reliable and popular device which can be used to sterilize various types of apparatus. Has a safety fuse to prevent overheating. Approximate cost, $85. (A.H.T. Co. No. 1715). 6. Refrigerator
a. Sears Roebuck Coldspot No. 46FM9000W: 8 cu. ft. with freezer top. Approximate cost, $189.95. b. Under-counter refrigerator: Acme (Acme National Refrigeration Co., Inc., 29-24 40th Ave., Long Island City 1, N.Y.). 24 inches wide, 23 inches deep, 34Y2 inches high, 5 cu. feet; $180. 7. Balance
Harvard Trip Balance (A.H.T. Co. No. 1919-C) $22.80. 8. Suction Pump
Faucet :;uction pump (A.H.T. Co. No. 5286); :;ize, 5 3/8 inche:;; $2.12. 9. Timer
Interval Timer (A.H.T. Co. No. 3(50) $1O.\.l5. 10. Counter
Hand Counter (A.H.T. Co. No. 4088) $9.15. 11. Staining Rack
Capacity 10 slides (Geo. H. Wahmann Mfg. Co., Baltimore, No. L-2508) $20.00. 12. Bunsen Burner (A.H.T. Co. No. 2553-B) $1.32. Rubber tubing, 3/8 inch bore, 3/32 inch wall (A.H.T. Co. No. 8832) $4.08 per 10 ft.
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It\SIC LABOIL\'1'Ol{Y '1'1<;::;'1'::; AND SUPPLIES
Urinalysis
Equipment
Examination A. Color B. Clarity C. Specific gravity D.pH Chemical Examination A. Protein I. Heat and acetic acid (Purdy's) test Phy~ical
2. Hulfosalieylic ar:id test, B. lledueing substances 1. Benedict's qualitative tcRt 2. Tes-Tape (tests only for g;lucoH<') C. Acetone bodics 1. Powdcr test
2. Acetest D. Phenylketonuria E. Bilirubin l. Harrison test
U rinc bottlPs and eaps
Urinometer Nitrazine paper Test tubes, Pyrex, average size 125 X Hi mm. Hodium chloride, 35% aq\WOIIS solutioll Acetic acid, 50% aqueous solution Bunsen burner with rubber tubing Sulfosalicylie acid, :1% aql[(:ous solution Bt'Jledict's r[ualitative reag('!lt Pipets, 5 and 1 ml. Tes-Tape (Lilly) Sodium nitropru:,;sidr), 1 gram Sodium carbonate: (anhydrous), 20 grams Ammonium suJfatt', 20 grams Ae:etest (AIlH's) Fe:rric cliloride: 10% aqueolls solution Filter paper (;lass funnel BariuJll chloride, 1or;;" :Ll[IWOUS sulution FOllchct's reagent: Trichloraeetic aciel, 25 ~ralllS ill 100lll!. water
2. let()k~t F. llcllloglobill I. Benzidine
Fl'lTie ehloridl', lO Ill!. of a 10% aqU(,OUH :-iolution letotest (Amps) tc~t
Microfwopic Examination
Blood Studies Cutaneous blood A. llcllloglolJi 11 I. Haden-HauHscr
Benzidine reagent: Dissolve: 1 gram bl'llzidine dihydroe:hloride in 20 Ill!. glaeial acetic aeid, tlH'n add 30 1111. distilled watt-r and 50 ml. !l5o/r, ethyl alcohol. Centrifuge tU1)(,N J\IieroscopC' slirkR Covl'rglasses
Equipment DisposaLlc lane:ets CottOIl hall:-; or ~auze squart·s JI;thyl alcohol, 70% Itqlwous N/lO Hydrochloric acid
The Physie£an's O.lli.ce LahoratoTY 2. Photoelectric methods a. Oxyhemoglobin
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lI:1ckn-1:Iausser hf'lYlllglobinollll'tl'r TA~ukocytc pi pet
Ammonium hydroxide, O.04(;{), aqueous solution 0.02 rnl. pipet Cyanrnethernoglohin standard reagent b. Cyanllwthellloglobin 0.02 Illl. pi pet Speetrophotometer B. Erythr(wyk count IIernacytometer ehamber Erythrocyte pipet Cower's solution: Sodium sulfate, 2.5 grams Acetic acid, 33.3 ml. Distilled water, 200 ml. C. LPllkoc.yte ('ount llemacytometer chamlwr Lcukocyte pipet Acetic acid, 1% aqueous solution with 1 ml. aqueous crystal violet PCT 100 Illl. D. Hlood films Wright's stain Wright's buffer Class slides :Eo Erythmeytc smlin]()lltatioll mte 5 ml. syringes Needles No. 20 gauge, 172 inches I. Cutler method Cutler sedimentation tube ::";odium citrate, 3% aqueous solution 2. Wintrobc method Wintrobe sedimentation tube Heller & Paul oxalate tubes Clean~ing of Pi pets Faucet suction pump Acetone Rubber tubing
AIHlTTHINAT, OPTIONAL TF~STS
Kidney Function A. Specific gravity 1. Concentration 2. Dilution B. l'henosulfontllall'in
Equipment llrillOlneter
r.s.p.
ampules Dunning Colorimeter Of Hellige Kichwy Tester ::";odiurn hydroxide, 10% aqueous solution Porcelain graduate, 1000 ml.
Sputum Organisms 1. (:ram's stain
Equipment Platinum loop violet, 1% aqlleolls solutioll 80dillm bicarbonate, rl10 nqlwlJlll' solution (;ram's iodine (~rystal
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JOHN H. HODGES
Safranine, 1% aqueous solution Staining rack 2. Acid-fast (Ziehl-Neelsen) Stain Carbo I fuchsin Acid-alcohol mixture, 3% HCl in 95% ethyl alcohol
Gastric Analysis Acidity 1. Tube method
2. Diagnex method (tubeless)
Stool A. Blood I. Benzidine
2. Guaiac
B.
n robilin and urobilino?;()J1
C. Microscopic examination
Equipment ltehfuss tube or Levin tube Histamine solution 'ropfer's solution Sodium hydroxide, N/lOO aqueous solution Phenolphthalein, 1% aqueous solution Porcelain evaporating dish Burette Glass stirring rod Diagnex Kit (Squibb)
Equipment Benzidine solution: 1 gram benzidine dihydrochloride 20 m!. glacial acetic acid 30 m!. distilled watcr 50 m!. 95% ethyl alcohol Hydrogen peroxide, 3% Filter paper Guaiac, 20% solution 111 95% ethyl alcohol Glacial acetic acid Hydrogen peroxide, 3% Filter paper Zinc acetate, saturated alcoholic (ethyl) solution Ehrlich's reagent Sodium acetate, saturated aqueous solution Funnel Filter paper Sudan III Acetic acid, 30% aqueous solution Gram's iodine or D' Antoni's iodine
Blood Chemistry Blood glucose and blood urea nitrogen determinations are the two more important chemical tests. They can be performed on the KlettSurnmerson colorimeter or Colernan spectrophotometer. The preliminary step for each is the preparation of a protein-free filtrate.
'l'he
Phys~cian' s
Office Laboratory
1471 Equipment
Protein-free Filtrate
A. Blood glueose (Benedict)
B. Blood urea nitrogen (Gentzkow)
Benedict's precipitant Sulfuric acid, 0.62 N Whatman No. 2 filter paper Sulfuric acid, 10% solution Oxalate tubes Copper reagent (Benedict) Sodium bisulfite solution Color reagent Alkaline copper solution Standard glucose solution Folin-Wu sugar tubes Water bath Erlenmeyer flasks Funnels Filter paper Squibb's double-strength urease powder Nessler's solution Potassium persulfate, 2.5% aqueous solution Potassium gluconate, 1% aqueous solution Standard nitrogen solution Erlenmeyer flasks, 125 m!.
Hemostatic Tests A. Tourniquet test Requires only blood pressure apparatus, which is standard equipment in any physician's office. B. Lee and White coagulation time Requires only three Wassermann type (size 100 X 13 mm.) test tubeR, which cost approximately $3.87 per 100 (A.H.T. Co. No. 9446). C. Skin bleeding time Best performed with an automatic lancet to give a uniform cut of 3 mill. in depth. Approximate cost of lancet, $4.97 (A.H.T. Co. No. 3644A). D. Platelet count Routine hemacytometer equipment plus Rees and Ecker solution at approximate cost of $2.40 per 16 oz. (Harleco No. 2796). Bone Marrow Requires only the routine blood-staining equipment plus bone marrow needles such as the Rosenthal needle (Becton, Dickinson), approximate cost $1.89; and 2% Xylocaine solution. (Astra Pharmaceutical Products, Inc.), cost $0.50 per 20 ml. vial. Erythrocyte Sickling Coverglass and slide, petrolatum and a 2% aqueous solution of sodium bisulfite (Harleco No. B-2212 at $1.55 per lb.). Hematocrit Wintrobe pipet (A.H.T. Co. No. 3150F at $0.31) and hematocrit tube (A.H.T. Co. No. 3150-B at $1.75) with Helier and Paul dried oxalate tubes. Cerebrospinal Fluid Requires lumbar puncture needles (Becton, Dickinson, 18 gauge, $0.76 each) and a manometer (Becton, Dickinson Kit No. 5027 at $12.00). Thp ordinary hemacytometer chamber is adequate for the cell count, and a saturated ammonium sulfate solution CRoss-Jones) is sufficient for a qualitative test for protein.
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Stool
D' Alltolli'~ iodine Holution for pam;;itol()!!;i(~ ~tlldi('~. ZiJle KlIlfak 8olutioll with a Kp('(·ifie !!;ravity of 1.0~0 for examinatioll for panLsitt's by the zinc Kulfak f1otatioll eon('cntratioll kehnique.
Urine Urobilinogen and Porphobilinogen
Ehrlieh'K 1'<':L!!;('nt and saturated sodium aeetatc I'<'a!!;('ut as listed above pIu:; chlorofo],1ll for the vVatson-Sehwartz test.
A('('Lt'st (AIII('8): $;Ui(j (HO ksts) A(·(·tie acid, !!;I:i('ial, (Baker, analyzed): $~.!J(i I)(~r 5 11)8. Aecto]I(' (Baker): $~.55 pe!" 5lbs. Alcohol, ethyl, 95%: $5.79 per gal. Ammonium hydroxide, 0.04%, (Harleeo No. ~2.'\S): $~.15 per ;)~ oz. Ammonium l-mlfate (Harleeo B-l:316): $0.79 per ~ lb. AmIllonium Imlfate, saturated (Harleeo No. 1414): *,:3.(i5 Pt']' Hi oz. Bariulll chloride, 10% aqueous, (Harleco No. 141 (i) : $;).15 pet' :32 oz. 13!'ak(']'s (A.H.T. Co. No. 2110): 100 ml., $0.:37 !'ach 150 ml., 0.:35 " 250 m!., 0.:35 " 400 ml., 0.4~ " 600 m!., 0)52 " 800 ml., 0.64 " 1000 ml., 1. 02 " Benedict's qualitative solution (Harleeo No. 2:316): $2.45 per :32 oz. Benzidine dihydroehloride (Coleman &: Bell) : $:3.00 per 4 oz. Blood urea nitrogl'n tube (A.H. T. Co. No. :3552-C): $1.:32 each Bottle, screw top (A.H.T. Co. No. 2207-B, 8 oz.): $0.19 each Bottle, dropper (A.H.T. Co. No. 2257, 125 m!. eapaeity): $1.06 ea eh Burette (A.H.T. Co. No. 2404, 25 ml. capaeity): $7.24 each Cm'hol fuchsin (Harleco No. 6051X): $2.10 per 16 oz. Chloroform (Baker): $0.87 per lb. Color reagent, Benedict (Harleeo No. 2400): $5.:35 per Hi oz. Copper alanine rea!!;ent, Benediet (Harleco No. 240~): $5.KO pCI' Hi oz. Cotton balls, medium: $:3.15 per case Cover glasses (Coming): $1.90 per oz. Crystal violet (Harleco No. 192): $2.:30 per 25 grams Cyanmethemoglobin Standard (Hycel, Inc.): $7 ..50 pcr 6 vials Cyanmethemoglobin Reagent (Hycd, Inc.): $7.50 pcr 6 vials D' Antoni's iodine (lIarleco No. 25(8): $2.40 per 8 oz. Diagnex Blue (Rquibb): $27.00 per .50 test kits Dunning ColorinlPtlor (phenolsulfonthalein) (A.H.T. Co. :\'0. ;)48G): $1.5.00 Ehrlich's reagent (Harleco No. 2454): $:3.:35 pPI' Hi oz. Erlenmeyer flask, 125 m!. capacity (A.H.T. Co. :\0. 5;)42): $0.4:3 eaeh Ferric chloride, 10% solution (Harleco No. 1428): $2.15 pCI' :32 oz. Filter paper, Whatman No. 1, 110 mm. (A.H.T. Co. No. 5200): $0.44 pCI' 100 Folin-Wu sugar tubes (A.H.T. Co. No. :3554-A): $21.17 pm 24 Fouehet's reagent (Harleco No. 2502): $5.25 per S oz. Funnel, glass, 65 mm. (A.H.T. Co. No. 5573-B2): $0.62 each Gauze squares «(2" X 2"): $:3.10 per 10 packages
7'hc Physician's Offi·ce Laboratory ,;olution (Harleeo No. 253~): $2.20 per 10 oz. Graduuk, enamel, 1000 m!. (A.H.T. Co. No. (ill~): $2.1 [j Graduated cylinders (A.H.T. Co. No. 440~): 100 m!., $2.71 [jOOm!., 5.13 LOOO Ill!., 7.17 Gram',; iodine (Harleeo No. (j24): $1.30 per 8 oz. Hadlm-lIausser Hemoglobinollletl-r (A.H.T. Co. N o. ;~43[j): $22.~O Hemaeytometer ehambm', Spenccr Bright Line (A.H.T. Co. No. 333(j-A): $12.[j0 Hemacytorneter chamber COVl~r glass (A.H.T. Co. No. ;~:n(i): $0.50 Histamine :,;olution, 5 Ill!. vial: $1.25 Hydrochloric acid (lVlerck Reagent): $0.7.5 per lb. Hydrog(~n peroxide, 3%: $O.;~[j ]ler S oz. Ictotest (Ames): $3.60 per 90 Labels (A.H.T. Co. No. 6302): $0.35 per box Lancets, disposable (Redi-Lance Co.): $15.00 per 1000 Lens tissue (A.H.T. Co. No. G32.5): $0.20 per book Levin tubes: Hubiler (Pilling): $2.00 Plastic disposable (Pharmaseal): $0.40 Mierm;cope slides (A.H.T. Co. Ko. 7mO-B): $2.[j7 (approximately GO per box) Needks, 1~2" No. 20 gauge (Beeton, Dickinson): $2.50 pCI' doz. Needle holder (A.H.T. Co. No. 7432): $0.61 Nessler's solution (Harleco No. 2(33): $3.05 per 16 oz. Nitrazine paper (Squibb) (A.H.T. Co. No. 52(2): $l.G9 ]lcr roll Nitrogen standard, 1 m!. = 0.015 mg. N (Harleco No. 26(2): $3.05 per 16 oz. Oxalate tubes, Vacutailwr (Beeton, Dickinson): $13.50 per lOO Phenolphthalein, 1% in 95% alcohol (Harleco No. 1127X): $1.20 per 4 oz. Phenolsulfonthalein ampules: $20.00 per lOO Pipets: Glass, measuring (A.H.T. Co. No. 8171A): 5 m!., $1.34 each I m!., $1.35 each Erythrocyte, diluting (A. H.T. Co. No. 3390): $lG.[jO per doz. Leukocyte, diluting (A.H.T. Co. No. 3392): $1G.[j0 pet" doz. Hemoglobin, 0.02 m!. (A.ILT. Co. No. 3453-E2): $1:3.2X per doz. Platinlllllloop (A.H.T Co. No. 7433): $4.41 Porcelain evaporating dish, diameter 95 mm., depth 2:3 mm. (A.H.T. Co. No. 44S2): $1.07 Potassiulll gluconate, 1% solution (lIarleco Ko. 27712): $3.05 per Hi oz. Potassium persulfate, 2.5% Rolution (Harleco No. 27821): $Ul5 per 8 oz. Rehfuss tube (Pilling): $4.00 Safranin counterstain (Harleeo No. 726X): $1.55 per 8 oz. Sodium acetate, saturated solution (Harleco No. 28491): $;~.9.'i per 16 oz. Sodium hicm'bonate (Baker): $0.73 per lb. Sodium carbonate (Harleco 132227): $0.90 per 74 lb. Sodium chloride, saturated solution (Harleco No. l1!}O): $2.40 per 16 oz. Sodium hydroxide, K/I00 (Harleco No. 3914): $2 .•50 per 16 oz. Sodium hydroxide pellets (Merek): $0.92 per lb. Sodium nitroprusside (Hatleeo No. B22(8): $2.38 per 74 lb. Standard glucose solution (Harlec:o No. 2516): $2.40 per IG oz. Sudan III solution (Harleco No. 728X): $4.00 per 16 oz. Sulfnric acid, normal (to make 0.62N) (Harleco No. a927): $2 . .'i0 1](']' 16 oz.
(;O\vl~r's
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.10HN R. RODGES
Syringes: Glass: 5 ml., interchangeable, metal tip: $1.40 eaeh 10 ml. (Omega Precision Medical Instrument Co., Passaic, N. ,L): $1.80 ('ach Disposable (Pharmaseal): No. 724, 5 ml., 20 gauge, 1:1" needle: $25.00 per 100 No. 720, 5 ml., without needle: $17.00 per 100 Tes-Tape (Lilly): $1.9H per roll Test tube,; (Pyrex), average ~ize (125 X 15 mm.) (A.H.T. Co. No. 9450): $0.57 per 10 tube» Test tube bnlHh, 9 in. (A.H.T. Co. No. 2380-N): $0.40 each Test tube clamp (A.H.T. Co. No. 3246): $0.24 eaeh Test tube rack (A.H.T. Co. No. 9481-A): $2.30 each Test tube rack, Neoprene, for colorimeter tubes (A.H.T. Co. No. 3788-S): $3.35 each Topfer reagent (Harleco No. 2997X): $1.20 per 4 oz. Tripod (A.H.T. Co. No. 9731): $1.37 each Tube, Cutler, Sedimentation (A.H.T. Co. No. 3(46): $0.68 each Tube, centrifuge, ungraduated (A.H.T. Co. No. 2993): $0.29 each Urease tablets, 25 mg. (Harleco No. 64:30): $3.60 per 100 Urine bottles with 100 caps (A.H.T. Co. No. 3507-L): $1.85 ppr dOJ:. Urine bottle caps (A.H.T. Co. No. 3507M): $0.41 per 100 Urinometer with glass cylinder (A.H.T. Co. No. 3517): $4.07 Volumetric flasks (glass) (A.H.T. Co. No. 54(1): 100 ml., $2.92 500 ml., 4.44 1000 ml., 5.46 Wax marking pencil (A.H.T. Co. No. 79(4): $0.22 each Wire gauze square with asbestos cenk!", 6 inch square (A.H.T. Co. No. 9995): $0.19 each Wright's buffer, pH 6.4 (Harleco No. 4020): $0.90 per 25 grams Wright's stain (Harleco No. 740): $5.30 per 16 oz. Zinc acetate, saturated alcoholic (Harleco No. B2435): $3.60 Zinc sulfate, specific gravity 1.080 (Harleco No. 3073): $3.60 per ]() OJ:.
THE LABORATORY FURNITURE
A sink with running water, a table top, gas and electrical outlets are the basic requisites for a laboratory and are sufficient to contain the equipment for the simplest needs. The ideal laboratory should occupy its own room. It must have ventilation; this is insured by use of a ventilating fan or ducts of an airconditioner, with adequate space between the outlet and the proposed site for use of a Bunsen burner. A window is usually insufficient for ventilation because of the necessity of closing it during cold or inelemellt weather. An unobstructed window is ideal for the provision of daylight, the best light source for the interpretation of the color of specimens and the end points of chemical reactions. A laboratory without a window tends to cause claustrophobia if the technician is occupied in the area for long periods of time. A ceiling higher than eight feet is desirable to
The Physician's Office Laboratory
1475
allow for the rapid dissipation of odors. A glossy finish paint which can be washed is ideal for the walls. The floor covering should be of inlaid linoleum, asphalt tile or rubber tile which has the color or pattern throughout its depth; otherwise, the first accidental spilling of caustic material will permanently scar the flooring. This type of covering is relatively waterproof, can be waxed and easily cleaned and allows some resilience to ease the footsteps of the worker, in contrast to the fatiguing resistance of concrete, tile or even wooden floors. The sink should have a well at least nine inches deep and should be provided with a removable elongated stopper to allow for almost complete filling of the sink well before the water escapes into the open overflow top of the stopper. This permits the rinsing of glassware preparatory to washing. A double-well sink is ideal. A mixing spigot for hot and cold water should be centrally placed and should be of the moving type so that the water can be directed into either sink well. A second tap, for cold water, should be placed near the lateral margin of one of the sink wells. This can be fitted with a simple suction device which will supply suction when the spigot is turned on with sufficient force to be useful for cleaning ordinary glass pipets or hematologic pipets. It also serves as an auxiliary when the central tap is being used. A draillboard, on olle or on both sides of the sink, is useful. An ordinary metal kitchen sink covered with porcelain can be used; however, it becomes quickly stained and cracks in the porcelain permit caustics to attack the defenseless underlying metal. The metal drain and the connection to the sink are other vulnerable sites for chemical attack. The most nearly ideal material for sinks and drainboards is synthetic stone. Drains and traps in the drains are usually made of lead, so that acid or caustic solutions should be diluted by having the water running in the sink when they are discarded. Mercury, such as is found in thermometers and various types of manometers, should never be allowed to go down a drain because it will very quickly cause erosion through a lead trap. Stainless steel sinks are expensive, but apparently quite durable. A wooden peg-type drainboard may be fastened to the wall above the sink. The laboratory table is the working center of the unit. The most important feature is its height. There has been a trend to the use of tables of desk height, but this is a prac:tical mistake. The ordinary busy physician or technician does not sit down to perform a urinalysis or other quick, simple procedure. The laboratory table should be at working height when Ol1e is standing. This makes for much more ease in working and eliminates the tiring motion of leaning over a low table to work. The ideal height for most persons is :-lli inches. If it is desired to sit at such a table, a stool can be used, preferably one with an adjustable height. Synthetic stone is an ideal material for the table top. The undcr portion of the table, preferably made of metal, can be used for storage with drawers under one end and doors for bulky equipment under the
1476
JOHN H. HODGJ
other. Two important considerations should be obscrved: onc, a kneespace extending the depth of the table and at least two feet, preferably two and one-half feet, in width so that one can sit comfortably at the table; second, the lower five inches of the storage space on either side should be recessed so that the toes of anyone standing at the table can project unobstructed under the tahle. Lined against the back of the table should hn a centrally placed and double-pronged gas outlet alld double electrical outlets at either end. The center of the laboratory table can be used for tests requiring a BUllsen hUl"ller or for microscopic work. Additional storage may be obtained by bolting cabinets to the walls. These may be attanhed to free walls or above the laboratory table. In the latter instance, the base should be 12 to 18 inches above the table top to clear the gas and electrical outlets adequately and to prevent infringement on the working space of the table top. The most satisfactory cabinets are those made of metal, and they can be obtained in a kitchen supply store or from laboratory supply companies. They should be about nine inches deep and should hav<: adjustable metal shelves and sliding glass doors. A flmall desk is a useful additional piece of equipment. A double electrical flocket on the wall jUflt above the level of the desk top provides an outlet for a desk lamp and for a microscope lamp. A desk chair on casters allows a qui<:k change of position from the center of the desk to the side of the desk, which would he an ideal position for a comfortable armchair for seatillg the patient for blood counts al\(I for venipuncture. This chair should be fitted with flat armR three to four inches wide for good positioning and support of the patient's arms. The back legs should be onc-quarter to one inch shorter than the front legs. This tel\(is to contain the patient in the chair should he become faint. The chair ::;hould have a headrest or should be backed against a wall to serve the same purpose. A luxury item is a chair of the type used for blood bank donors, which, with the pulling of a lever, places the patient completely horizontal. A low table with a firm mattress or a divan is useful for taking electrocardiograms. Overhead white fluorescent fixtures, if properly positioned, provide a difTuRP, even light. 8hort rods of fluorescent lights may be placed under the wall eabillets if auxiliary light is needed. A toilet should be positioned as close as possible to the laboratory to facilitate collection of Rpeeimens. A refrigerator can Rerve many purposes, including the storage of perishable solutions, medications, biologicals and specimens. Compact 4 to 5 cubic foot refrigerators which will fit under the laboratory table are particularly useful when conservation of space is important. These sell from $lti5 to $200. Somewhat larger upright models can be purchased at prices starting at $200.
The Phys£c£an's Office Laboratory
1477
l\IAN1TFAC'l'URERS AKD DTSTlnBUTORS*
American Optical Co., Instrument Divisioll, Buffalo 15, N. Y. Becton, Dickinson and Co., ltutherforcl, :N . .T. Fisher Seientific Co., ();~;i Grccnwich St., New York 14, N. Y. Hartman-Leddoll Co., Ine. (lTarleeo), 58~1 j\Iarket St., Philadelphia ;)9, Pa. Laboratory Apparatus, Ceorge H. \Vahm:wn Mfg. Co., 18 and 20 N. Green St., Baltimore 1, Md. Laboratory Furniture Co., Inc., Mineola, L. I., N. Y. Macalaster Bicknell Co., 24;3 Broadway, Cambridge, Mass. Mathesoll Coleman and Bell, Inc., East Rutherford, N. J. GeOl'ge P. Pilling and Son Co., ;3451 Walnut St., Philadelphia 4, 1'a. E. H. Sheldon Equipment Co., Muskegon, Mich. Arthur H. Thomas Co., S.W. Cor. 3rd and Vine Sts., Philadelphia 5, Pa. Will Corporation and Subsidiaries, Rochester 3, N. Y.
* This list has been formulated from among those manufacturers and suppliers of whom I have pcrsonal knowledge. It is not a preferential list. It is prescntcd with the understanding that there are many others of equal merit and that a complete list would be prohibitive in the space here allotted. Acknowledgment AppreciatioIl is extended to Miss Jane E. Kirk, who aided in the compilation of the tables of pri(~es for the laboratory reagents and cquipment, and to Mrs. Geraldine O. Vang, who typed the manuscript.
REFERENCES 1. Major, Ralph H.: A History of Medicinc. Springfield, Ill., Charlcs C Thomas, 1!J54, p. 583. 2. Ibid., p. 662. 3. Ibid., p. 74. 4. Ibid., p. 217. 5. Ibid., p. 561. 6. Ibid., p. 534. 7. Ibid., p. 802. 8. Ibid., p. !J34. !J. Hodges,.J. H. (ed.): Manual for the Laboratory of Clinical Medicine. Philadelphia, The Jefferson Medical College Library, HHIO.
1025 Walnut Street Philadelphia 7, Pennsylvania
The Physician's Office Laboratory JOHN H. HODGES, M.D., F.A.C.P. Associate Professor of Medicine, The JejJerson Medical College and Hospital; StajJ Physician, The Lankenau Hospital; Attending in Internal Medicine, Veterans Administration Hospital, Philadelphia
THE performance of laboratory studies may be considered a specialized extension of the physical examination of the patient. There are many instances in which a simple procedure in a laboratory, which may require only a few minutes, may be sufficient to confirm a diagnosis which was suspected from the history and physical examination: for example, the detection of glycosuria in a suspected instance of diabetes mellitus, bilirubinuria in hepatitis, primitive cells in the blood film from a patient with lymphadenopathy, the detection of bacilluria and pyuria in a patient suspected of having pyelonephritis. The provision of a simple basic laboratory to extend the science of diagnosis, to provide a current appraisal of the effects of therapy and to detect the changes in the course of the patient's disease has become an important and requisite aid to the physician. HISTORICAL
The evolution of the laboratory to its important place in medicine has been amazingly slow. Until the past hundred years it was almost nonexistent. Clinical medieine, on the other hand, has had peaks of scientific grandeur followed by depressions into ignorance and mysticism paralleling the rise and fall of civilization throughout the world. The description of disease reached a zenith with the work of Hippocrates in the fifth century before Christ. There was little advancement
1463
.J OHN H. HODcms
1464
in the science of diagnosis from that time until the descriptio]} of the URe of percm;sion by Aucnbrugger 1 in the eighteenth ccntury alld :tIlRcultatioll with the stethoscope by Laennec2 early in the nincteenth century. Before their time, the appraisal of the patient eonsisted of the history, the general appearance of the subject, the character of the pulse and the appearallce of the exeretionR, partieularly the urine. Aneient Hindu writings 3 describe what waR appanmtly diabeteR mellitus with "the attnwtioll of ants by the urine alld the urine limp alld as sweet as honey." Jo}mlllleR Aetuarius,4 court phYRieiull at Constantinoplc during the latter part of the thirteenth ccntury, wrote a treatise "On the Urillcs" ill which he distinguished fourtecn colol's of the urine, each one having a definite diagnostic meaning; however, it was not until the year 1695 that there appeared the first description of the demonstration of albumin in the urine by means of heat and acetic acid, credited to Frederik Dekkcrs,5 Professor of Medicine at Leyden. The science of morphologic hematology had its inception with the description of red blood cells by Anton Von Leeuwenhoek 6 in a letter to the Royal Society dated October 9, lm(i. Karl Vierordt7 published a paper in 1852 describing the first exaet method of counting the blood cells and recorded a count, performed on himself, which showed 5,010,000 red blood cells per cu. mm. Additiollal impetus to thc seience of hematology was obtained from the blood stain, devised in 1878 by Paul EhI'lieh,8 whieh permitted differcntiation of the polymorphonuclear leukocytes. The advancement of the sciences of bacteriology, chemi:-;try and physics in the latter part of the ninetcenth eentury and in the present century has enhanced the ability of the mcdical laboratory to make specific diagnoses when the history and physical examination illdicate possible syndromes of disease. Highly refined technical procedures requiring expensive, complieated equipment and highly specialized and train cd personnel, may, in some instanees, be requisite for a final diagnosis; however, a relatively inexpensive amount of equipment and chemicalR assembled in a small area adjacent to the physician's examining room will suffice, in most instances, to confirm a diagnosis. THE LABORATORY
The basic equipment for the laboratory eentcrs about the supplies needed to perform a routine blood count and a routine urinalYHis. Thi:-; is the minimum requirement for most physicians. Many additional simple procedures can then be added without much expense. The variety and usefulness of these added tests depend upon the needs of the physician as dietated by his type of practice aJl(1 also depend upon the foIkill and interpretative ability of the physician. The quantitative chemical tCRts are time-consuming and require mallY solutions and accurate equipmcnt; hence, the average physician usually finds it imperative to employ a
The j)hysician's o.Uice iAlbvm{or'Y
1405
kchllician if he intends to add these tests to the basic laboratory procedures. The following is a summary of suggested laboratory te"ts,9 with alternate procedures occasionally listed, the supplies and equipment needed and the a verage costs. BASIC LAm)l{ATOlty EQUIPMENT
1. Microscope
U sunlly acquired by the physician while he Binocular microscope preferred:
1S
in medical school.
a. Domestic 1. American Optical Co .. 2. Bausch and Lomh .. b. Foreign 1. Leitz ...... .
$(i42 $G45 $800
In choosing a microseope it is well to remember that no two scopetl are exactly the same. It is advisable, after a decision has been made as to type and model, to try several different microscopes so that an ideal ehoiee may be made in regard to lellses.
2. Microscope Lamp a. For monocular scope: An ordinary lamp with a blue filter such as Mieroscope Lamp (A.H.T. Co. No. G924-B) $G.50.* b. For binocular seope: It is necessary to have a stronger lamp, preferably one with a rheostat, sueh as: 1. Spencer (A.H.T. Co. No. li983-A) $G7. 2. Leitz Microscope Lamp and Transformer $85.50. 3. Centrifuge The ideal centrifuge is the InternatiOlml Clinical Centrifuge equipped with a four-place head. This is a good, durable apparatus which is suitable for many purposes from centrifuging urine for microscopic examination to performing procedures requiring speeds up to :moo r.p.m., sueh as the hematoerit. (A.H.T. Co. No. 297G) $134.50. 4. Colorimeter a. Klett-Summerson Colorimeter (Fig. 1): The work horse of colorimeters, which can tolerate rough usage. J t has two photoelectric cells and therefore its
* A partiailistillg of manufacturers will be found on page 1477.
1466
JOHN
H.
HODGES
No. 800·3
(PATENTED)
Fig. 1. Klett-Summerson photoelectric colorimeter. (Courtesy of Klett Manufacturing Co.)
accuracy is maintained even though there are mild fluctuations in the current. The acid-hematin method of hemoglobin determination is accurately determined; however, the range is poor for the oxyhemoglobin method. Suitable for glucose and blood urea nitrogen determinations. Approximate cost $205. Klett Standardized Tubes (A.H.T. Co. No. 3788-D), $9.00 per dozen. b. Coleman Junior Spectrophotometer (Fig. 2): Highly accurate and very versatile because of the high range
Fig. 2. Coleman Junior spectrophotompter. (Courtesy of Coleman Instruments, Inc.)
The Physician's Office Laboratory
1467
of wave-length settings which are possible. Has only one photoelectric cell, so it requires a good voltage regulator to prevent alterations in the electrical supply. Approximate cost, $453. 5. Sterilizer
a. Instrument sterilizer (Castle): A good, reliable and popular device which can be used to sterilize various types of apparatus. Has a safety fuse to prevent overheating. Approximate cost, $85. (A.H.T. Co. No. 1715). 6. Refrigerator
a. Sears Roebuck Coldspot No. 46FM9000W: 8 cu. ft. with freezer top. Approximate cost, $189.95. b. Under-counter refrigerator: Acme (Acme National Refrigeration Co., Inc., 29-24 40th Ave., Long Island City 1, N.Y.). 24 inches wide, 23 inches deep, 34Y2 inches high, 5 cu. feet; $180. 7. Balance
Harvard Trip Balance (A.H.T. Co. No. 1919-C) $22.80. 8. Suction Pump
Faucet :;uction pump (A.H.T. Co. No. 5286); :;ize, 5 3/8 inche:;; $2.12. 9. Timer
Interval Timer (A.H.T. Co. No. 3(50) $1O.\.l5. 10. Counter
Hand Counter (A.H.T. Co. No. 4088) $9.15. 11. Staining Rack
Capacity 10 slides (Geo. H. Wahmann Mfg. Co., Baltimore, No. L-2508) $20.00. 12. Bunsen Burner (A.H.T. Co. No. 2553-B) $1.32. Rubber tubing, 3/8 inch bore, 3/32 inch wall (A.H.T. Co. No. 8832) $4.08 per 10 ft.
1468
JOHN
H.
HODGES
It\SIC LABOIL\'1'Ol{Y '1'1<;::;'1'::; AND SUPPLIES
Urinalysis
Equipment
Examination A. Color B. Clarity C. Specific gravity D.pH Chemical Examination A. Protein I. Heat and acetic acid (Purdy's) test Phy~ical
2. Hulfosalieylic ar:id test, B. lledueing substances 1. Benedict's qualitative tcRt 2. Tes-Tape (tests only for g;lucoH<') C. Acetone bodics 1. Powdcr test
2. Acetest D. Phenylketonuria E. Bilirubin l. Harrison test
U rinc bottlPs and eaps
Urinometer Nitrazine paper Test tubes, Pyrex, average size 125 X Hi mm. Hodium chloride, 35% aq\WOIIS solutioll Acetic acid, 50% aqueous solution Bunsen burner with rubber tubing Sulfosalicylie acid, :1% aql[(:ous solution Bt'Jledict's r[ualitative reag('!lt Pipets, 5 and 1 ml. Tes-Tape (Lilly) Sodium nitropru:,;sidr), 1 gram Sodium carbonate: (anhydrous), 20 grams Ammonium suJfatt', 20 grams Ae:etest (AIlH's) Fe:rric cliloride: 10% aqueolls solution Filter paper (;lass funnel BariuJll chloride, 1or;;" :Ll[IWOUS sulution FOllchct's reagent: Trichloraeetic aciel, 25 ~ralllS ill 100lll!. water
2. let()k~t F. llcllloglobill I. Benzidine
Fl'lTie ehloridl', lO Ill!. of a 10% aqU(,OUH :-iolution letotest (Amps) tc~t
Microfwopic Examination
Blood Studies Cutaneous blood A. llcllloglolJi 11 I. Haden-HauHscr
Benzidine reagent: Dissolve: 1 gram bl'llzidine dihydroe:hloride in 20 Ill!. glaeial acetic aeid, tlH'n add 30 1111. distilled watt-r and 50 ml. !l5o/r, ethyl alcohol. Centrifuge tU1)(,N J\IieroscopC' slirkR Covl'rglasses
Equipment DisposaLlc lane:ets CottOIl hall:-; or ~auze squart·s JI;thyl alcohol, 70% Itqlwous N/lO Hydrochloric acid
The Physie£an's O.lli.ce LahoratoTY 2. Photoelectric methods a. Oxyhemoglobin
14G9
lI:1ckn-1:Iausser hf'lYlllglobinollll'tl'r TA~ukocytc pi pet
Ammonium hydroxide, O.04(;{), aqueous solution 0.02 rnl. pipet Cyanrnethernoglohin standard reagent b. Cyanllwthellloglobin 0.02 Illl. pi pet Speetrophotometer B. Erythr(wyk count IIernacytometer ehamber Erythrocyte pipet Cower's solution: Sodium sulfate, 2.5 grams Acetic acid, 33.3 ml. Distilled water, 200 ml. C. LPllkoc.yte ('ount llemacytometer chamlwr Lcukocyte pipet Acetic acid, 1% aqueous solution with 1 ml. aqueous crystal violet PCT 100 Illl. D. Hlood films Wright's stain Wright's buffer Class slides :Eo Erythmeytc smlin]()lltatioll mte 5 ml. syringes Needles No. 20 gauge, 172 inches I. Cutler method Cutler sedimentation tube ::";odium citrate, 3% aqueous solution 2. Wintrobc method Wintrobe sedimentation tube Heller & Paul oxalate tubes Clean~ing of Pi pets Faucet suction pump Acetone Rubber tubing
AIHlTTHINAT, OPTIONAL TF~STS
Kidney Function A. Specific gravity 1. Concentration 2. Dilution B. l'henosulfontllall'in
Equipment llrillOlneter
r.s.p.
ampules Dunning Colorimeter Of Hellige Kichwy Tester ::";odiurn hydroxide, 10% aqueous solution Porcelain graduate, 1000 ml.
Sputum Organisms 1. (:ram's stain
Equipment Platinum loop violet, 1% aqlleolls solutioll 80dillm bicarbonate, rl10 nqlwlJlll' solution (;ram's iodine (~rystal
1470
JOHN H. HODGES
Safranine, 1% aqueous solution Staining rack 2. Acid-fast (Ziehl-Neelsen) Stain Carbo I fuchsin Acid-alcohol mixture, 3% HCl in 95% ethyl alcohol
Gastric Analysis Acidity 1. Tube method
2. Diagnex method (tubeless)
Stool A. Blood I. Benzidine
2. Guaiac
B.
n robilin and urobilino?;()J1
C. Microscopic examination
Equipment ltehfuss tube or Levin tube Histamine solution 'ropfer's solution Sodium hydroxide, N/lOO aqueous solution Phenolphthalein, 1% aqueous solution Porcelain evaporating dish Burette Glass stirring rod Diagnex Kit (Squibb)
Equipment Benzidine solution: 1 gram benzidine dihydrochloride 20 m!. glacial acetic acid 30 m!. distilled watcr 50 m!. 95% ethyl alcohol Hydrogen peroxide, 3% Filter paper Guaiac, 20% solution 111 95% ethyl alcohol Glacial acetic acid Hydrogen peroxide, 3% Filter paper Zinc acetate, saturated alcoholic (ethyl) solution Ehrlich's reagent Sodium acetate, saturated aqueous solution Funnel Filter paper Sudan III Acetic acid, 30% aqueous solution Gram's iodine or D' Antoni's iodine
Blood Chemistry Blood glucose and blood urea nitrogen determinations are the two more important chemical tests. They can be performed on the KlettSurnmerson colorimeter or Colernan spectrophotometer. The preliminary step for each is the preparation of a protein-free filtrate.
'l'he
Phys~cian' s
Office Laboratory
1471 Equipment
Protein-free Filtrate
A. Blood glueose (Benedict)
B. Blood urea nitrogen (Gentzkow)
Benedict's precipitant Sulfuric acid, 0.62 N Whatman No. 2 filter paper Sulfuric acid, 10% solution Oxalate tubes Copper reagent (Benedict) Sodium bisulfite solution Color reagent Alkaline copper solution Standard glucose solution Folin-Wu sugar tubes Water bath Erlenmeyer flasks Funnels Filter paper Squibb's double-strength urease powder Nessler's solution Potassium persulfate, 2.5% aqueous solution Potassium gluconate, 1% aqueous solution Standard nitrogen solution Erlenmeyer flasks, 125 m!.
Hemostatic Tests A. Tourniquet test Requires only blood pressure apparatus, which is standard equipment in any physician's office. B. Lee and White coagulation time Requires only three Wassermann type (size 100 X 13 mm.) test tubeR, which cost approximately $3.87 per 100 (A.H.T. Co. No. 9446). C. Skin bleeding time Best performed with an automatic lancet to give a uniform cut of 3 mill. in depth. Approximate cost of lancet, $4.97 (A.H.T. Co. No. 3644A). D. Platelet count Routine hemacytometer equipment plus Rees and Ecker solution at approximate cost of $2.40 per 16 oz. (Harleco No. 2796). Bone Marrow Requires only the routine blood-staining equipment plus bone marrow needles such as the Rosenthal needle (Becton, Dickinson), approximate cost $1.89; and 2% Xylocaine solution. (Astra Pharmaceutical Products, Inc.), cost $0.50 per 20 ml. vial. Erythrocyte Sickling Coverglass and slide, petrolatum and a 2% aqueous solution of sodium bisulfite (Harleco No. B-2212 at $1.55 per lb.). Hematocrit Wintrobe pipet (A.H.T. Co. No. 3150F at $0.31) and hematocrit tube (A.H.T. Co. No. 3150-B at $1.75) with Helier and Paul dried oxalate tubes. Cerebrospinal Fluid Requires lumbar puncture needles (Becton, Dickinson, 18 gauge, $0.76 each) and a manometer (Becton, Dickinson Kit No. 5027 at $12.00). Thp ordinary hemacytometer chamber is adequate for the cell count, and a saturated ammonium sulfate solution CRoss-Jones) is sufficient for a qualitative test for protein.
1472
JOHN
H.
HODGES
Stool
D' Alltolli'~ iodine Holution for pam;;itol()!!;i(~ ~tlldi('~. ZiJle KlIlfak 8olutioll with a Kp('(·ifie !!;ravity of 1.0~0 for examinatioll for panLsitt's by the zinc Kulfak f1otatioll eon('cntratioll kehnique.
Urine Urobilinogen and Porphobilinogen
Ehrlieh'K 1'<':L!!;('nt and saturated sodium aeetatc I'<'a!!;('ut as listed above pIu:; chlorofo],1ll for the vVatson-Sehwartz test.
A('('Lt'st (AIII('8): $;Ui(j (HO ksts) A(·(·tie acid, !!;I:i('ial, (Baker, analyzed): $~.!J(i I)(~r 5 11)8. Aecto]I(' (Baker): $~.55 pe!" 5lbs. Alcohol, ethyl, 95%: $5.79 per gal. Ammonium hydroxide, 0.04%, (Harleeo No. ~2.'\S): $~.15 per ;)~ oz. Ammonium l-mlfate (Harleeo B-l:316): $0.79 per ~ lb. AmIllonium Imlfate, saturated (Harleeo No. 1414): *,:3.(i5 Pt']' Hi oz. Bariulll chloride, 10% aqueous, (Harleco No. 141 (i) : $;).15 pet' :32 oz. 13!'ak(']'s (A.H.T. Co. No. 2110): 100 ml., $0.:37 !'ach 150 ml., 0.:35 " 250 m!., 0.:35 " 400 ml., 0.4~ " 600 m!., 0)52 " 800 ml., 0.64 " 1000 ml., 1. 02 " Benedict's qualitative solution (Harleeo No. 2:316): $2.45 per :32 oz. Benzidine dihydroehloride (Coleman &: Bell) : $:3.00 per 4 oz. Blood urea nitrogl'n tube (A.H. T. Co. No. :3552-C): $1.:32 each Bottle, screw top (A.H.T. Co. No. 2207-B, 8 oz.): $0.19 each Bottle, dropper (A.H.T. Co. No. 2257, 125 m!. eapaeity): $1.06 ea eh Burette (A.H.T. Co. No. 2404, 25 ml. capaeity): $7.24 each Cm'hol fuchsin (Harleco No. 6051X): $2.10 per 16 oz. Chloroform (Baker): $0.87 per lb. Color reagent, Benedict (Harleeo No. 2400): $5.:35 per Hi oz. Copper alanine rea!!;ent, Benediet (Harleco No. 240~): $5.KO pCI' Hi oz. Cotton balls, medium: $:3.15 per case Cover glasses (Coming): $1.90 per oz. Crystal violet (Harleco No. 192): $2.:30 per 25 grams Cyanmethemoglobin Standard (Hycel, Inc.): $7 ..50 pcr 6 vials Cyanmethemoglobin Reagent (Hycd, Inc.): $7.50 pcr 6 vials D' Antoni's iodine (lIarleco No. 25(8): $2.40 per 8 oz. Diagnex Blue (Rquibb): $27.00 per .50 test kits Dunning ColorinlPtlor (phenolsulfonthalein) (A.H.T. Co. :\'0. ;)48G): $1.5.00 Ehrlich's reagent (Harleco No. 2454): $:3.:35 pPI' Hi oz. Erlenmeyer flask, 125 m!. capacity (A.H.T. Co. :\0. 5;)42): $0.4:3 eaeh Ferric chloride, 10% solution (Harleco No. 1428): $2.15 pCI' :32 oz. Filter paper, Whatman No. 1, 110 mm. (A.H.T. Co. No. 5200): $0.44 pCI' 100 Folin-Wu sugar tubes (A.H.T. Co. No. :3554-A): $21.17 pm 24 Fouehet's reagent (Harleco No. 2502): $5.25 per S oz. Funnel, glass, 65 mm. (A.H.T. Co. No. 5573-B2): $0.62 each Gauze squares «(2" X 2"): $:3.10 per 10 packages
7'hc Physician's Offi·ce Laboratory ,;olution (Harleeo No. 253~): $2.20 per 10 oz. Graduuk, enamel, 1000 m!. (A.H.T. Co. No. (ill~): $2.1 [j Graduated cylinders (A.H.T. Co. No. 440~): 100 m!., $2.71 [jOOm!., 5.13 LOOO Ill!., 7.17 Gram',; iodine (Harleeo No. (j24): $1.30 per 8 oz. Hadlm-lIausser Hemoglobinollletl-r (A.H.T. Co. N o. ;~43[j): $22.~O Hemaeytometer ehambm', Spenccr Bright Line (A.H.T. Co. No. 333(j-A): $12.[j0 Hemacytorneter chamber COVl~r glass (A.H.T. Co. No. ;~:n(i): $0.50 Histamine :,;olution, 5 Ill!. vial: $1.25 Hydrochloric acid (lVlerck Reagent): $0.7.5 per lb. Hydrog(~n peroxide, 3%: $O.;~[j ]ler S oz. Ictotest (Ames): $3.60 per 90 Labels (A.H.T. Co. No. 6302): $0.35 per box Lancets, disposable (Redi-Lance Co.): $15.00 per 1000 Lens tissue (A.H.T. Co. No. G32.5): $0.20 per book Levin tubes: Hubiler (Pilling): $2.00 Plastic disposable (Pharmaseal): $0.40 Mierm;cope slides (A.H.T. Co. Ko. 7mO-B): $2.[j7 (approximately GO per box) Needks, 1~2" No. 20 gauge (Beeton, Dickinson): $2.50 pCI' doz. Needle holder (A.H.T. Co. No. 7432): $0.61 Nessler's solution (Harleco No. 2(33): $3.05 per 16 oz. Nitrazine paper (Squibb) (A.H.T. Co. No. 52(2): $l.G9 ]lcr roll Nitrogen standard, 1 m!. = 0.015 mg. N (Harleco No. 26(2): $3.05 per 16 oz. Oxalate tubes, Vacutailwr (Beeton, Dickinson): $13.50 per lOO Phenolphthalein, 1% in 95% alcohol (Harleco No. 1127X): $1.20 per 4 oz. Phenolsulfonthalein ampules: $20.00 per lOO Pipets: Glass, measuring (A.H.T. Co. No. 8171A): 5 m!., $1.34 each I m!., $1.35 each Erythrocyte, diluting (A. H.T. Co. No. 3390): $lG.[jO per doz. Leukocyte, diluting (A.H.T. Co. No. 3392): $1G.[j0 pet" doz. Hemoglobin, 0.02 m!. (A.ILT. Co. No. 3453-E2): $1:3.2X per doz. Platinlllllloop (A.H.T Co. No. 7433): $4.41 Porcelain evaporating dish, diameter 95 mm., depth 2:3 mm. (A.H.T. Co. No. 44S2): $1.07 Potassiulll gluconate, 1% solution (lIarleco Ko. 27712): $3.05 per Hi oz. Potassium persulfate, 2.5% Rolution (Harleco No. 27821): $Ul5 per 8 oz. Rehfuss tube (Pilling): $4.00 Safranin counterstain (Harleeo No. 726X): $1.55 per 8 oz. Sodium acetate, saturated solution (Harleco No. 28491): $;~.9.'i per 16 oz. Sodium hicm'bonate (Baker): $0.73 per lb. Sodium carbonate (Harleco 132227): $0.90 per 74 lb. Sodium chloride, saturated solution (Harleco No. l1!}O): $2.40 per 16 oz. Sodium hydroxide, K/I00 (Harleco No. 3914): $2 .•50 per 16 oz. Sodium hydroxide pellets (Merek): $0.92 per lb. Sodium nitroprusside (Hatleeo No. B22(8): $2.38 per 74 lb. Standard glucose solution (Harlec:o No. 2516): $2.40 per IG oz. Sudan III solution (Harleco No. 728X): $4.00 per 16 oz. Sulfnric acid, normal (to make 0.62N) (Harleco No. a927): $2 . .'i0 1](']' 16 oz.
(;O\vl~r's
1474
.10HN R. RODGES
Syringes: Glass: 5 ml., interchangeable, metal tip: $1.40 eaeh 10 ml. (Omega Precision Medical Instrument Co., Passaic, N. ,L): $1.80 ('ach Disposable (Pharmaseal): No. 724, 5 ml., 20 gauge, 1:1" needle: $25.00 per 100 No. 720, 5 ml., without needle: $17.00 per 100 Tes-Tape (Lilly): $1.9H per roll Test tube,; (Pyrex), average ~ize (125 X 15 mm.) (A.H.T. Co. No. 9450): $0.57 per 10 tube» Test tube bnlHh, 9 in. (A.H.T. Co. No. 2380-N): $0.40 each Test tube clamp (A.H.T. Co. No. 3246): $0.24 eaeh Test tube rack (A.H.T. Co. No. 9481-A): $2.30 each Test tube rack, Neoprene, for colorimeter tubes (A.H.T. Co. No. 3788-S): $3.35 each Topfer reagent (Harleco No. 2997X): $1.20 per 4 oz. Tripod (A.H.T. Co. No. 9731): $1.37 each Tube, Cutler, Sedimentation (A.H.T. Co. No. 3(46): $0.68 each Tube, centrifuge, ungraduated (A.H.T. Co. No. 2993): $0.29 each Urease tablets, 25 mg. (Harleco No. 64:30): $3.60 per 100 Urine bottles with 100 caps (A.H.T. Co. No. 3507-L): $1.85 ppr dOJ:. Urine bottle caps (A.H.T. Co. No. 3507M): $0.41 per 100 Urinometer with glass cylinder (A.H.T. Co. No. 3517): $4.07 Volumetric flasks (glass) (A.H.T. Co. No. 54(1): 100 ml., $2.92 500 ml., 4.44 1000 ml., 5.46 Wax marking pencil (A.H.T. Co. No. 79(4): $0.22 each Wire gauze square with asbestos cenk!", 6 inch square (A.H.T. Co. No. 9995): $0.19 each Wright's buffer, pH 6.4 (Harleco No. 4020): $0.90 per 25 grams Wright's stain (Harleco No. 740): $5.30 per 16 oz. Zinc acetate, saturated alcoholic (Harleco No. B2435): $3.60 Zinc sulfate, specific gravity 1.080 (Harleco No. 3073): $3.60 per ]() OJ:.
THE LABORATORY FURNITURE
A sink with running water, a table top, gas and electrical outlets are the basic requisites for a laboratory and are sufficient to contain the equipment for the simplest needs. The ideal laboratory should occupy its own room. It must have ventilation; this is insured by use of a ventilating fan or ducts of an airconditioner, with adequate space between the outlet and the proposed site for use of a Bunsen burner. A window is usually insufficient for ventilation because of the necessity of closing it during cold or inelemellt weather. An unobstructed window is ideal for the provision of daylight, the best light source for the interpretation of the color of specimens and the end points of chemical reactions. A laboratory without a window tends to cause claustrophobia if the technician is occupied in the area for long periods of time. A ceiling higher than eight feet is desirable to
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allow for the rapid dissipation of odors. A glossy finish paint which can be washed is ideal for the walls. The floor covering should be of inlaid linoleum, asphalt tile or rubber tile which has the color or pattern throughout its depth; otherwise, the first accidental spilling of caustic material will permanently scar the flooring. This type of covering is relatively waterproof, can be waxed and easily cleaned and allows some resilience to ease the footsteps of the worker, in contrast to the fatiguing resistance of concrete, tile or even wooden floors. The sink should have a well at least nine inches deep and should be provided with a removable elongated stopper to allow for almost complete filling of the sink well before the water escapes into the open overflow top of the stopper. This permits the rinsing of glassware preparatory to washing. A double-well sink is ideal. A mixing spigot for hot and cold water should be centrally placed and should be of the moving type so that the water can be directed into either sink well. A second tap, for cold water, should be placed near the lateral margin of one of the sink wells. This can be fitted with a simple suction device which will supply suction when the spigot is turned on with sufficient force to be useful for cleaning ordinary glass pipets or hematologic pipets. It also serves as an auxiliary when the central tap is being used. A draillboard, on olle or on both sides of the sink, is useful. An ordinary metal kitchen sink covered with porcelain can be used; however, it becomes quickly stained and cracks in the porcelain permit caustics to attack the defenseless underlying metal. The metal drain and the connection to the sink are other vulnerable sites for chemical attack. The most nearly ideal material for sinks and drainboards is synthetic stone. Drains and traps in the drains are usually made of lead, so that acid or caustic solutions should be diluted by having the water running in the sink when they are discarded. Mercury, such as is found in thermometers and various types of manometers, should never be allowed to go down a drain because it will very quickly cause erosion through a lead trap. Stainless steel sinks are expensive, but apparently quite durable. A wooden peg-type drainboard may be fastened to the wall above the sink. The laboratory table is the working center of the unit. The most important feature is its height. There has been a trend to the use of tables of desk height, but this is a prac:tical mistake. The ordinary busy physician or technician does not sit down to perform a urinalysis or other quick, simple procedure. The laboratory table should be at working height when Ol1e is standing. This makes for much more ease in working and eliminates the tiring motion of leaning over a low table to work. The ideal height for most persons is :-lli inches. If it is desired to sit at such a table, a stool can be used, preferably one with an adjustable height. Synthetic stone is an ideal material for the table top. The undcr portion of the table, preferably made of metal, can be used for storage with drawers under one end and doors for bulky equipment under the
1476
JOHN H. HODGJ
other. Two important considerations should be obscrved: onc, a kneespace extending the depth of the table and at least two feet, preferably two and one-half feet, in width so that one can sit comfortably at the table; second, the lower five inches of the storage space on either side should be recessed so that the toes of anyone standing at the table can project unobstructed under the tahle. Lined against the back of the table should hn a centrally placed and double-pronged gas outlet alld double electrical outlets at either end. The center of the laboratory table can be used for tests requiring a BUllsen hUl"ller or for microscopic work. Additional storage may be obtained by bolting cabinets to the walls. These may be attanhed to free walls or above the laboratory table. In the latter instance, the base should be 12 to 18 inches above the table top to clear the gas and electrical outlets adequately and to prevent infringement on the working space of the table top. The most satisfactory cabinets are those made of metal, and they can be obtained in a kitchen supply store or from laboratory supply companies. They should be about nine inches deep and should hav<: adjustable metal shelves and sliding glass doors. A flmall desk is a useful additional piece of equipment. A double electrical flocket on the wall jUflt above the level of the desk top provides an outlet for a desk lamp and for a microscope lamp. A desk chair on casters allows a qui<:k change of position from the center of the desk to the side of the desk, which would he an ideal position for a comfortable armchair for seatillg the patient for blood counts al\(I for venipuncture. This chair should be fitted with flat armR three to four inches wide for good positioning and support of the patient's arms. The back legs should be onc-quarter to one inch shorter than the front legs. This tel\(is to contain the patient in the chair should he become faint. The chair ::;hould have a headrest or should be backed against a wall to serve the same purpose. A luxury item is a chair of the type used for blood bank donors, which, with the pulling of a lever, places the patient completely horizontal. A low table with a firm mattress or a divan is useful for taking electrocardiograms. Overhead white fluorescent fixtures, if properly positioned, provide a difTuRP, even light. 8hort rods of fluorescent lights may be placed under the wall eabillets if auxiliary light is needed. A toilet should be positioned as close as possible to the laboratory to facilitate collection of Rpeeimens. A refrigerator can Rerve many purposes, including the storage of perishable solutions, medications, biologicals and specimens. Compact 4 to 5 cubic foot refrigerators which will fit under the laboratory table are particularly useful when conservation of space is important. These sell from $lti5 to $200. Somewhat larger upright models can be purchased at prices starting at $200.
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l\IAN1TFAC'l'URERS AKD DTSTlnBUTORS*
American Optical Co., Instrument Divisioll, Buffalo 15, N. Y. Becton, Dickinson and Co., ltutherforcl, :N . .T. Fisher Seientific Co., ();~;i Grccnwich St., New York 14, N. Y. Hartman-Leddoll Co., Ine. (lTarleeo), 58~1 j\Iarket St., Philadelphia ;)9, Pa. Laboratory Apparatus, Ceorge H. \Vahm:wn Mfg. Co., 18 and 20 N. Green St., Baltimore 1, Md. Laboratory Furniture Co., Inc., Mineola, L. I., N. Y. Macalaster Bicknell Co., 24;3 Broadway, Cambridge, Mass. Mathesoll Coleman and Bell, Inc., East Rutherford, N. J. GeOl'ge P. Pilling and Son Co., ;3451 Walnut St., Philadelphia 4, 1'a. E. H. Sheldon Equipment Co., Muskegon, Mich. Arthur H. Thomas Co., S.W. Cor. 3rd and Vine Sts., Philadelphia 5, Pa. Will Corporation and Subsidiaries, Rochester 3, N. Y.
* This list has been formulated from among those manufacturers and suppliers of whom I have pcrsonal knowledge. It is not a preferential list. It is prescntcd with the understanding that there are many others of equal merit and that a complete list would be prohibitive in the space here allotted. Acknowledgment AppreciatioIl is extended to Miss Jane E. Kirk, who aided in the compilation of the tables of pri(~es for the laboratory reagents and cquipment, and to Mrs. Geraldine O. Vang, who typed the manuscript.
REFERENCES 1. Major, Ralph H.: A History of Medicinc. Springfield, Ill., Charlcs C Thomas, 1!J54, p. 583. 2. Ibid., p. 662. 3. Ibid., p. 74. 4. Ibid., p. 217. 5. Ibid., p. 561. 6. Ibid., p. 534. 7. Ibid., p. 802. 8. Ibid., p. !J34. !J. Hodges,.J. H. (ed.): Manual for the Laboratory of Clinical Medicine. Philadelphia, The Jefferson Medical College Library, HHIO.
1025 Walnut Street Philadelphia 7, Pennsylvania