An old Yankee surgeon entertains a new idea

An old Yankee surgeon entertains idea Robb

H. Rutledge,

MD,

Fort

W&h,

Texas

JOHN COLLINS WARREX’s greatest surgical triumph occurred in the fall of 1846. Before this he had worked his entire surgical career without the benefit of anesthesia to relieve his patients’ pain during their dreaded operations. He was 68 years old and about to retire as professor of anatomy and surgery at Harvard Medical School and also as chief of surgery at Massachusetts General Hospital (Fig. 1). The previous year he had allowed Horace M’ells, a young Hartford dentist, the opportunity to demonstrate the prevention of pain from a dental extraction by the inhalation of nitrous oxide. This had failed miserably.‘, * Now Warren heard about William T. G. Morton, a young Boston dentist, who apparently had a new remedy to prevent pain during a surgical operation. On September 30, 1846, Morton had painlessly extracted a patient’s tooth by having the patient inhale a secret substance called Letheon. Henry Jacob Bigelow, one of Warren’s young assistants, read the successful report in the Boston Daily Jozwnal on the following &a~.~ During the next 2 weeks Bigelow not on&watched Morton perform numerous painless dental estractions, but he also may have performed several minor surgical excisions himself on patients in Morton’s office.’ He urged Warren to allow a public demonstration with the Letheon at the hospital (Fig. 2). Although Warren was on the verge of retirement, he was excited about the possibiliq of painless surgery. He was willing to entertain this new idea and risk his unblemished reputation on this untried method. Awangements were made, and the world’s most famous operation was performed in the amphitheater of the B&inch building at Massachusetts General Hospital on October 16, 1846, 150 years ago (Fig. 3). Morton administered his secret Letheon so that Warren could ligate a large vascular malformation on the neck of Edward Gilbert Abbott. Warren believed that the trial was only a partial success because Abbott moved, Presented in par-t at the Texas Surgical Society. Oct. 1, 1996, Corpus Chcisti, Texas. Accepted

for publication

Dec. 14, 1996.

Reprint requests: Robb H. Rutledge, Wonh. TX i61Oi. Surgery Coppight

MD. 5300 El Dorado

1997:121:575-80. Q 1997 bv Mosbv I?ar

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a new

Dr., Fort

Fig.

1. John

A. Counnvay

Collins

Ivan-en

L&ray

of

(1778-1856).

Courtesy

of Francis

Medicine.

moaned, and said he felt a scraping sensation but no actual ~ain.~ U’arren asked Morton to give another demonstration the next day. This time Warren carefully watched while George Hayward painlessly removed a lipoma from a patient’s arm. Although the Letheon had been tried on minor operations only, Warren was ecstatic with this new discovery. He was severelv disappointed when serious conflicts with hsforton arose almost immediately. Morton claimed that the Letheon was his invention and applied for a patent on it and his inhaler. He tried to capitalize on the discovery and monopolize the procedure. Warren beliered that Morton’s behavior was unethical and refused to use the secret product because of the risks and danSURGERY

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Fig. 2. Henw Jacob Bigelow, 2%year-old assistant of John Collins FVarren. Bigelow was a strong supporter of Norton, reported the original success, and urged acceptance of anesthesia. He never rook any credit for himself for the discoreq. Courtesy of Francis -1. Countway Library of Medicine.

to the patients. He told Morton that he could no longer use Letheon at the hospital unless he divulged its exact nature. On November 6 Morton finally admitted that Letheon was only rectified ether that he had disguised with red coloring and aromatic flavors. Warren immediately asked Morton to administer ether the next day for two major operations to prove its effectiveness. The amphitheater was packed and the atmosphere was electric as Hayward amputated a patient’s thigh and Warren removed a patient’s mandible. Both were total successes. After this there was no doubt that ether produced safe, reliable anesthesia.“” Hem-y Jacob Bigelow reported it to the world in the Boston hledical aud Sqical JournaLg John Collins Warren’s enthwiastic support was an essential factor in the immediate universal acceptance of ether anesthesia. He worked tirelessly to prove the efficacy and safety of etherization. Warren was a tough old autocratic Yankee well- suited to his role in this drama. -John Collins Warren, the oldest of 19 children, was born in 1778 during the American Revolutionary War. His ancestors came to the United States on the Magigers

jlower. His father, John Warren, founded Harvard Medical School in 1782 and was the first professor of anatomy and surgery. lo His uncle, Joseph 1i\iarren, a good friend of Paul Revere, was also a physician, but he was better known as the hero of Bunker Hill, where he was killed at the age of 34 years.” John Collins Warren graduated from Boston Latin School in 1792 and showed his own academic promise early when he was the fira recipient of the Franklin prize. Under the terms of Benjamin Franklin’s will this prize was given to encourage scholarship in high school graduates.” Warren graduated from Harvard in 1797 and pursued a mercantile career. Finding no suitable position, he apprenticed with his father in surgery instead. In 1799 he went to Europe to recover from an unrequited love affair and spent 3 years in the medical centers of London, Edinburgh, and Paris. His most valuable experience was at Guy’s Hospital in London where he worked as a dresser for Sir Astley Cooper. Much later Warren dedicated his own book, Surgical Obseruations 0~2 Tumors, to Cooper. They remained devoted friends.‘” In 1802 Warren returned to Boston and worked again with his father. He married Susan Powell Mason, and they had seven children. During the next 50 years he became the outstanding New England, if not American, surgeon (Fig. 4). In 1818 he declined the chiefship at the University of Pennsylvania, and about 15 years later he declined a similar offer in New York.” In 1849 he became the third president of the L\merican Medical ,%ssociation.15 Warren was thought by many to be cold, haughty, rigid, and unfeeling. He was greatly admired but not warmly liked. He had few close friends. An essential exception was Dr. James Jackson, a peaceful man with whom he developed a deep personal friendship and professional association. Together they acquired the charter for Massachusetts General Hospital in 1811. Jackson was the hospital’s first chief physician, and Warren was the first chief surgeon. Later Warren’s children dedicated their father’s biography to Jacks0n.l” In 1812 Warren was the originator and first editor of the New En.gla.nd Journal of Medicine and Su7-gwy. This started as a quarterly and is the oldest journal with uninterrupted publication in the United States. In 1828 Warren changed it to a weekly and renamed it the Boston Medical and Suyical Journal. In 1928 the journal assumed its current name The New England Journal of Medicine.“* ‘* After his father’s death in 1515 John Collins \Varren became the second professor of anatomy and surgery at Harvard Medical School. He was made dean from lS16 to 1819 and supervised the medical school’s move from Cambridge to Boston. He continued his anatomy dis-

Fig. 3. Close-up photograph of Robert C. Hinckley painting, “The First Operation Under Ether.” Patient is Edward Gilbert Abbott. FirleJgurcs surrounding him are, lpft to right, i$‘illiam T. G. Morton holding the inhaler, Jonathan Mason Warren, John Collins Warren \.vith the scalpel, Eben Frost, Morton’s first patient who successfully took ether for a dental extraction, and Charles F. Hewood, the house surgeon. Mason U’arren, John Collins Warren’s son, was not present at the actual operation. sections and lectures faithfullv for 32 veal-s until his retirement iii 1847. Warren was always prepared and left nothing to chance. He had a positive fear of idleness and avoided all light reading or amusements that merely passed time or were for entertainment only.lg He was intolerant of weakness or mistakes either in himself or in others. He was proud of his son Jonathan Mason Warren, who followed him in practicing surgery, but he totally disavowed another son John, who became mentally unsound.” Warren’s leisure time was spent in religious, literary, or scientific pursuits outside of the medical field. Some of his interests included the Natural Philosophy Society, the Public Library and Athenaeum, the Monthlv ,~ithology Club, the Friday Evening Society, the Natural History Society, and a gynnasium for physical fitness. In 1820 he-joined the newly formed St. Paul’s Episcopal Church and was the person most responsible for keeping it from becoming Unitarian. He supplied the music, taught Sunday School, and convinced the bishop to send them a strong rector. He served on the vestry for 29 years and was the senior warden for 17 years.21 In 1823 in memory of his uncle he purchased 3 acres of land on top of Bunker Hill and donated this land to the Bunker Hill Monument Association for their monument. He was chairman of the building committee until the monument was completed, and he also served as the association’s vice president.‘” In 1827 he joined the Massachusetts Temperance So-

Fig. 4. The Gilbert Stuart painting of John Collins Warren when he was in his late twenties. Courtesy of Francis A. CounLibrary of Medicine.

Fig. 5. Warren home at #2 Park Street as seen from across the Boston Common. Countway Library of Medicine.

Fig. 6. Parr of his libraq

Courtesy of Francis 4.

in family area of Warren home. Courtesy of Francis A. Countway Library of Medicine.

ciety and served as its president for 20 years. As a show of faith in his beliefs he gave away his extensive wine cellar and abstained from all alcohol.‘3 On his sixty-third birthday, 2 months after his wife, Susan, died he wrote, “The question occurs, whether, during the short period remaining to me, I can lead a better life than I have done. Of this there is no doubt, and it must be my object to discover in what respects I can improve. . .” One and one-half years later he wrote, “I am a lonely being but the sense of this leads me to

look higher than earth.“‘4 He married -&me Winthrop shortly thereafter. They were happy for 7 years until her death in 1850 left him desolate once more. He lived nearly all of his adult life in a dark, gloomy mansion at #2 Park Street near the Boston Common (Fig. 5). The upstairs family area was well appointed and held his personal library of 6000 volumes (Fig. 6). The downstairs area was taken over by his students and apprentices. It had sand floors to allow anatomic dissections. He assembled a giant mastodon skeleton down-

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Fig. 7. Mastodon skeleton assembled in Warren’s home. The skeleton, 25 feet long and 10 feet high, is the largest, most perfect mastodon skeleton in existence. It is currently displayed in the -American Museum of Natural History. This mastodon lived about 30,000 years ago in its Hudson River habitat in upstate New York. Courtesy of Francis h Countway Library of Medicine.

stairs and collected manv other skeletons and fossils (Fig. 7). After his death his daughter--in-law refused to move into the home until all of these collections had been removed.‘” He retired from Harvard at 68 years of age, and his interests turned more and more to mastodons and fossils. He quit hospital work 6 years later, but he continued his natural histoq studies and published his classic book ibktodon Gigm7tcm.‘6 He was active until his death in 1856. His fi-iend Oliver U’endell Holmes said, “During his last several years his professional austerity diminished, and his pleasant social qualities found their natural expression.“” In other words he finally mellowed. John Collins Warren began his career during the time of the “body snatchers.” In 1830 he was responsible for the Massachusetts Legislature’s passing of the world’s first anatomy act that made dissection legal.” He always remembered the difficulties of getting specimens for dissection, and in his will he requested that his own hod) should be given to Harvard Medical School to be examined or dissected. Then the bones should be carefLdly preserved, whitened, articulated, and placed in the lecture room near his bust as a usefiA lesson for moralit! and science.2g Warren’s wishes were carried out except that the family understandably did not want his skeleton to be on public display. After his funeral at St. Paul’s Episcopal Church an autopsy was performed. The hod) was cremated, and the remains were buried at Forest

Fig. 8. Bust ofJohn tains his skeleton.

Collins

Warren

with

the closet

that con-

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Hills Cemetery. His skeleton was hung in a locked closet near his bust in the Warren Museum at Harvard hiledical School, where it is still viewed by a family member once a year (Fig. 8). John Collins Warren was unique in many ways. Like all of us, he had his faults, but his integrity and persistent desire for knowledge are rarely matched. Many senior surgeons become conservati\,e and are unwilling to take risks or entertain new ideas. This has always been true. None of William Harvey’s contemporaries older than middle age accepted his doctrine of the circulation of blood in 162K3’ When Henry Jacob Bigelow was a young man, he encouraged Warren to tn ether anesthesia. Thirty years later when Bigelowwas the older chief, he was very reluctant to embrace the new listerism.“l Warren \ias different. In spite of the risks to his career he eagerly pushed the new etherization. His role in the development of anesthesia made him the outstanding American surgeon of his time and transformed Massachusetts General Hospital into a hospital of international acclaim. In Warren’s obituary Olirrer Wendell Holmes said it best, “We confess it to have been a noble sight when an old man was found among the foremost to proclaim the great fact-that pain was no longer the master but the servant of the body.“30 I appreciate all the help that I have received from Richard J. i$‘olfe and his staff in the Rare Books and Manuscripts Division at the Frances A. COLlnhVay Library of Medicine. I am also indebted to Peter Drumme? and his staff at the library of the Massachusetts Historical Society for their help and advice. REFERENCES 1. Wolfe eration Francis 2. Nuland

and the recreation The Boston Medical

of the first opLibrary in the

.-2 Countwa~ Libray of Medicine, 1993: 146. SB. The origins of anesthesia. Birmingham: The Classics

of Surgery LibraIT, 1988237-45. 3. Nuland SB. The origins of aoesrhesia. of Surgery Libra?, 1988279. 4. Morton WJ. Discussion of paper 1911;56:1677. 5. Warren JC. Etherization

Russell,

1858:88-90.

DD. The Scribners

with

Co, 1848:1-8. of a public

surgical benefactor.

Birmingham:

The Classics

by Babcock, remarks. Next

\V. \V. J.WLA Boston: York:

William

Pudne!;

and

first capital 1892;12:515-24.

operation

under

the

influence

of

8. Warren JC. The influence of anaesthesia on the surge? of the nineteenth century. Transactions of American Surgical .Issociadon 1897;16:1-55. 9. Bigelow HJ. Insensibility by inhalation. Boston 309.17. 10. Truax R. The doctors

during Medical

surgical operations and Surgical Journal

produced 1846;35:

M’arren

of Boston.

Boston:

Houghton

hIif-

flin Cornpan!, 1968:67-l 11. 11. Truax R. The doctors Warren

of Boston.

Boston:

Houghton

hlif-

flin

Cornpan>,

12. Churchill cences

1968:17-64.

M. To work in the vineyard of J. Collins Warren (1842-19%).

setts: Harvard

University

Press.

of surgeq, Cambridge,

Maryland Medical Journal 15. TVarren JC. John Collinr 1926;46:142-7. 16. Warren journals. 17. Garland N Engl 18. Garland

1901;11:45-54. 1Vatren.

E. The life ofJohn C. Warren vol I. Boston: Ticknor and J. The Boston

medical

J Med 1928;198:1-13. J, The New England

the reminic hlassachu-

1958:9.

13. Warren JC. Surgical observations on turnours. and Brewster, 1837:iii.iv. 14. Warren JC. Reminiscences of an old New

and

Boston:

Cracker

England

Surg

surgeon.

Gynecol

Obsret

with his autobiograph) Fields. 1859:iii. surgicaljournal

(1828.1928). and

the Masand

journals. vol I. Boston: Ticknor and Fields, 1859:17. 20. Tmas R. The doctors Warren of Boston. Boston: Houghton

Mif-

flin Company, 1968: 133-5. 21. Warren E. The life ofJohn C. Warren

with his autobiography

and

journals. 22. Wal-ren journals.

vol I. Boston: Ticknor and E. The life ofJohn C. Warren vol I. Boston: Ticknor and

Fields, 1859:155-67. with his autobiography Fields, 1859:209-19.

and

23. WalTen journals.

E. The life ofJohn C. Warren vol I. Boston: Ticknor and

with his autobiography Fields. 1859:22&35.

24. Warren journals. 25. Churchill

E. The life ofJohn C. Warren with his autobiography and vol I. Boston: Ticknor and Fields. 1859:363-4. EA. To work in the vineyard of surgery, the reminisofJ.

Collins

Warren

Journal

and

sachusetts Medical Society. N Engl J Med 1992;246:801-6. 19. Warren E. The life of,John C. Warren with his autobiography

cences

RJ. Robert C. Hinckley under ether. Boston:

D Ticknor and 6. Rice NP. Trials

7. Slade ether.

of Medicine

(184%19271.

setts: Harvard University Press, 26.1Varren JC. Mastodon Giganteus.

1958:140. Boston:

Cambridge, John

and

hlassachu-

Wilson

and

Son,

1852. 27. Warren E. The life ofJohn C. \$‘amen with his autobiography journals. vol II. Boston: Ticknor and Fields, 1859:298-9. 28. Truax R. The doctors \\rarren of Boston. Boston: Houghton

and hlif-

flin Company, 1965:152-4. 29. \$‘arren JC. Personal letter to John Mason Warren, dated 7,/14, 1842. Original at Massachusetts Historical Society. Boston. 30. Warren E. The life ofJohn C. \Varren with his autobiography and journals. rol II. Boston: Ticknor and Fields, 1859:301. 31. Truss R. The doctors WalTen of Boston. Boston: Houghton flin

Company,

1968:253-6.

Mif-