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Clin. Cardiol. 24, 93–94 (2001)
This section edited by J. Willis Hurst, M.D., and W. Bruce Fye, M.D., M.A.
W. Bruce Fye, M.D., M.A.
Mayo Clinic, Rocester, Minnesota, USA
| Fig. 1 John Collins Warren (1778–1856). From the personal collection of W. Bruce Fye. |
In 1809, John Collins Warren (Fig. 1) published the first monograph on heart disease in the United States.
Warren was born in Boston, Massachusetts, on August 1, 1778.1 His father, John Warren, was a surgeon during the Revolutionary War and a founder of the Harvard Medical School. After graduating from Harvard College in 1797, young Warren became his father's apprentice, reflecting the fact that there were no medical schools or hospitals in Boston at the time. In this era, the most ambitious young American doctors went to Europe for formal training. Warren sailed abroad in 1800 to spend two years traveling and studying medicine in London, Edinburgh, Leiden, and Paris.
In London, Warren served as an assistant to William Cooper, a senior surgeon at Guys Hospital. He also performed dissections at Guys and attended lectures delivered by Astley Cooper and other leading London physicians and surgeons. Warren next traveled to Edinburgh, then a magnet for American medical students.2 There he took courses from Charles and John Bell, Alexander Monro, John Gregory, and other popular medical teachers. On his way to Paris in 1801, Warren journeyed through Holland where he bought a large collection of medical books that included many classic anatomical and surgical texts. Paris was just recovering from the French Revolution, but Warren was pleased with the opportunities it afforded him for medical study. He attended lectures and clinics given by Guillaume Dupuytren, Raphael Sabatier, and other prominent medical professors. Warren also attended Jean Nicholas Corvisart's clinic at the Le Charié Hospital. Corvisart was a pioneer in the study of the diseases of the heart. His lectures on the subject, first published by a pupil in 1806, became the basis of his classic book, Essai sur les maladies et les lésions organiques du coeur et des gros vaisseaux.
After returning to Boston, Warren joined his father in medical practice and began seeing as many as 50 patients a day. Young Warren wanted to do more than just practice medicine, and he soon became a member of the medical and academic elite of that growing city. With James Jackson he helped found the New England Journal of Medicine and Surgery in 1812, and the Massachusetts General Hospital, which opened in 1821.3 Warren was also an active participant in the Massachusetts Medical Society. He delivered a paper on organic heart diseases at the February 1809 meeting of the society. Later that year he extended his observations and published the first monograph on heart disease written by an American. Published by Thomas Wait of Boston, the 61 page book reflected Corvisart's influence. The title, Cases of Organic Diseases of the Heart, with Dissection and Some Remarks Intended to Point out the Distinctive Symptoms of These Diseases, revealed Warren's interest in pathological anatomy and clinical pathological correlation.4
Warren informed his readers that his purpose, in part, was to convince them that
...derangements of the primary organ of the circulation cannot exist without producing so great disorder of the functions of that and of other parts, as to be sufficiently conspicuous by external signs; but, as these somewhat resemble the symptoms of different complaints, especially of asthma, phthisis pulmonalis [tuberculosis], and water in the thorax, it has happened, that each of these has been sometimes confounded with the former. The object of the following statement of cases is to shew [sic], that, whatever resemblance there may be in the symptoms of the first, when taken separately, to those of the latter diseases, the mode of connection and degree of those symptoms at least is quite dissimilar; and there are also symptoms, peculiar to organic diseases of the heart, sufficiently characteristic to distinguish them from other complaints.4 (pp. 1–2)
Warren's monograph included 11 case reports, one of which is of special interest: he described in detail the case of James Sullivan, the Governor of Massachusetts. In 1807, at the age of 63, Sullivan developed a permanently irregular pulse followed by symptoms consistent with an embolus to his right arm. Later that year, he developed a cough and began to complain of palpitations and progressive exertional dyspnea. When Warren examined Sullivan he discovered "the pulsation of the carotid arteries was uncommonly strong; the radial arteries seemed ready to burst from their sheaths; the veins, especially the jugulars, in which there was often a pulsatory motion, were every where turgid with blood." He characterized Sullivan's complexion as "livid." Sullivan also complained of occasional heaviness in his chest and "some nights . . . were passed in sitting up in bed, under a fit of asthma, as it was called."4 (p. 5) Sullivan's dyspnea, orthopnea, and other symptoms consistent with what we now term heart failure progressed during 1808.
It is noteworthy that Warren described the phenomenon of Cheyne-Stokes respiration a decade before Cheyne's classic paper was published.5 Warren explained,
The respiration was so distressing, as to produce a wish for speedy death; the eyes became wild and staring. No sleep could be obtained; for, after dosing [sic] a short time, he started up in violent agitation, with the idea of having suffered a convulsion. During the few moments of forgetfulness, the respiration was sometimes quick and irregular, sometimes slow, and frequently suspended for the space of twenty five, and even so long as fifty seconds.4 (p. 7)
Sullivan developed progressive edema and eventually anasarca. Warren concluded that he had "an organic disease of the heart" that included aortic valve calcification and probable cardiac enlargement. He felt that his patient would likely succumb to his heart disease within three months. Despite heroic measures that included the use of "much medicine," Sullivan's health declined progressively and he died in December. The autopsy revealed cardiac enlargement, marked left ventricular hypertrophy, aortic stenosis, mitral stenosis, and coronary arteries that were "considerably ossified." James Jackson was impressed with the book and concluded it would "lay before the American public much more knowledge respecting the diseases of the heart, and large vessels, than has hitherto been presented to them."4 (p. 22)
Warren concluded his book with a summary of the signs and symptoms that suggested the presence of heart disease. He believed that palpitations and an irregular pulse were often the first sign of heart disease. The earliest symptom was often dyspnea, followed by cough and orthopnea. Physical examination, especially of the heart, was still very limited when Warren's book appeared in 1809. Within the next decade, however, Corvisart would popularize percussion of the chest and Laennec would invent the stethoscope. So, Warren relied on the ancient practices of observation and palpation of the pulse. He noted that patients with heart disease often had evidence of venous distention and an irregular pulse. Certain signs and symptoms, if they occurred together, should alert the physician to the possibility of heart disease. For example, Warren explained that in cases of heart disease edema often developed in conjunction with exertional dyspnea and orthopnea. He explained that edema often started in the legs but would progress up to the abdomen, chest, and eventually the face. He emphasized that this was distinct from asthma and hydrothorax, diseases that were often confused with what we now term heart failure.6
Warren employed the standard therapeutic approaches of his day and prescribed blisters, cathartics, opium, and a simple diet. He believed that bloodletting was the most effective remedy for dyspnea and was an advocate of the use of digitalis. Warren extended his observations on heart disease in an article that appeared in 1812 in the first volume of the New England Journal of Medicine and Surgery. He applauded the recent publication of an English translation of Corvisart's book on heart disease and indicated that he planned to continue to publish interesting case reports of cardiovascular diseases.7
Warren was a proponent of clinicopathologic correlation, an approach championed by European physicians, because he was convinced this would lead to a better understanding of the pathophysiology of cardiovascular disease. Near the end of Warren's long and productive career, he performed an operation that would help to transform the practice of surgery. In 1846 he performed the first major operation in which ether anesthesia was used. Warren continued to see patients until two weeks before his death on May 4, 1856.
References
Address for reprints:
W. Bruce Fye, M.D., M.A.
Mayo Clinic, West 16A
200 First Street SW
Rochester, MN 55905, USA
Received: February 16, 2000
Accepted: February 16, 2000