The Warrens and Other Pioneering Clinician Pathologists of the Massachusetts General Hospital During its Early Years

An Appreciation on the 200th Anniversary of the Hospital Founding

Robert H Young; David N Louis

Disclosures

Mod Pathol. 2011;24(10):1285-1294. 

In This Article

The Development of Surgical Pathology: J. Collins Warren

The development of surgical pathology at the hospital can be traced most clearly to another distinguished member of the Warren family: John Collins Warren (1842–1927) (Figure 10), grandson of the first John Collins Warren. He styled his name J Collins Warren to distinguish himself from his grandfather (generally styled as John C Warren) and appears to have been referred to as 'Coll' by close friends. After graduation from HMS in 1866, J Collins Warren studied in Vienna in Rokitansky's laboratory and under Billroth, the famed surgeon who had a major interest in pathology and wrote an influential text on the topic. Warren himself greatly credited the time he spent studying histological techniques and microscopy with Alfred Biesiadecki (a protégé of Rokitansky).[17] He also studied in Berlin under Cohnheim (remembering later this experience with strong positive feelings) and in Paris under Ranvier and Cornil, and completed his European travels in Glasgow with Joseph Lister, whose concepts he accepted. He fought vigorously to have them instituted at the MGH, against strong opposition. Notably the last chapter of his book (see below) is entitled 'Aseptic and Antiseptic Surgery'.

Figure 10.

(Left) Dr J Collins Warren. (Right) Spine and frontispiece of Dr Warren's 1895 book.

In 1870, back at the MGH, Warren began to record pathologic observations in a private ledger entitled 'Microscopic Examination of Tumors.' The ledger was based on his own specimens as well as those submitted to him by other surgeons; the diagnoses were copied into the patients' records by the surgical house pupils (residents). Such diagnoses constituted early examples of anatomical pathology diagnoses at the hospital.

Warren made important contributions to the pathology literature. His first pathology paper, written in Europe, was on the development of keloids. After his return to Boston, he won the Boylston prize in 1872 for his paper on 'The Anatomy and Development of Rodent Ulcer,' what is now known as basal cell carcinoma being poorly understood at that time. Warren authored a book 'Surgical Pathology and Therapeutics,' published in 1895[18] (Figure 10). The second sentence of the preface states that 'no young practitioner can be considered thoroughly equipped for surgical work who is not both a good pathologist and bacteriologist.' The book, which runs to 810 pages, is based largely on gross observations made in the operating room, but it also includes a microscopic classification of breast tumors with drawings reflecting his particular interest in breast disease. There is also significant coverage of bacteriology. Indeed the majority of the illustrations are related to that area rather than anatomic pathology, hence according to the usage of today the title of his book is a little misleading. His interest in infections likely dates back to his service in 1864 as an assistant surgeon in the Civil War. He and several others of his medical school class volunteered for service after a call for volunteers by the governor of Massachusetts. Interestingly, in his reminiscences[17] Dr Warren makes essentially no comment on his work on the book. He does mention working in the North Grove Street medical school building with Dr Fitz and others and the editor of his reminiscences notes, in reference to his microscopic work, that 'apparently his services in this regard supplemented those of a duly appointed hospital microscopist, then Calvin Ellis.' Dr Warren's publications on breast disease include one entitled 'The Diagnosis and Treatment of Cancer of the Breast' published in 1889[19] and a paper 16 years later based on a study of 758 cases.[20]

Dr Warren was a pioneer of the use of the needle biopsy in evaluating breast disease and in his book comments 'the diagnosis of cancer of the breast often presents great difficulties…the use of the Mixter punch (a fine cannula sharpened on the inner edge) is most valuable in such cases, and in fact, in all doubtful cases of cancer. The operation, when performed with cocaine injections, is painless and harmless, and secures a specimen amply sufficient for microscopic diagnosis.' At that time, the suggestion that one would biopsy a breast tumor in advance of a resection was controversial. The Mixter punch cannula, invented by an innovative surgical associate of Warren, Samuel Jason Mixter, may have been the first instrument devised for needle biopsy of tumors. Warren also has a claim to priority in utilization of frozen section in tumor diagnosis, having written in 1889 that specimens were sometimes examined immediately 'with the freezing microtome;' this was 6 years before the more detailed report of frozen section technique by the Hopkins gynecologist pathologist, Thomas S Cullen,[21] who is generally credited with devising the technique.[22] Warren worked at a time when German investigators dominated pathology but it is noteworthy that one medical historian considered him one of the five most significant American contributors to the growth of clinical microscopy in the United States in the nineteenth century.[23] Dr Warren also had a major role in the move of HMS to its new (and current) location, on Longwood Avenue in 1906[24] and was the first Moseley Professor of Surgery at the medical school.

Given the legacy of the Warren family to the hospital and the study of pathology, it is fitting that their name is commemorated in the name of the building that houses a significant part of the department to this day (Figure 11). The new building dates to the mid-1950s, and was built in part to house the new pathology laboratories. Originally dubbed the Medical Science Building, it soon was named the 'Warren Building' to honor this remarkable family.

Figure 11.

Commemorative marble wall honoring the contributions of the Warren family to Massachusetts General Hospital and Harvard Medical School, Lobby of Warren Building.

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