HISTORY

A Tale of Two Anticoagulants: Warfarin and Heparin

Charles E. Copeland, MD, and Cheryl K. Six, DO Department of Surgery, UPMC Mercy Hospital, Pittsburgh, Pennsylvania
This article relays the story of 3 men, Karl Paul Link, who is the discoverer of warfarin, and William Henry Howell and Jay McLean, who are the discoverers of heparin. (J Surg 66: 176-181. 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) Schoeld described a new disease in cattle caused by damaged sweet clover (Melilotus alba or Melilotus ofcinalis). Schoeld showed that Aspergillus mold was the cause of sweet clover spoilage but not the cause of a prolonged clotting time and bleeding in cattle.4 Roderick in 1931 clearly demonstrated that the prolongation of the clotting time was a result of a marked reduction in prothrombin.5 Both veterinarian authors recommended that farmers not feed damaged sweet clover to cattle and that the bleeding could be corrected with normal bovine blood transfusion.4,5 Two months after his visit to the University of Minnesota in February 1933, Ed Carlson, who was a farmer from Deer Lakes 305.7 km away, arrived as described by Link, In a howling blizzard and the mercury hovering near zero, with a dead heifer, a milk can containing nonclotted blood, and about 100 lbs of spoiled sweet clover. Link could only offer the advice recommended by Schoeld and Roderick to stop feeding the cattle spoiled sweet clover and transfuse sick cattle with normal bovine blood.1,3-5 For the next 6 years, Link and his graduate assistants worked on identifying the hemorrhagic agent present in spoiled sweet clover. On June 28, 1939, Harold A. Campbell viewed on a microscopic slide crystalline dicoumarin, and within 2 hours, he collected 6.0 mg.1-3 Mark A. Strahmann took over the project and in 4 months was able to crystalize 1.8 g of the anticoagulant.1-3 Three subsequent publications, which include The Isolation and Crystallization of the Hemorrhagic Agent and Identication and Synthesis of the Hemorrhagic Agent in 1941 as well as Anticoagulant Activity and Structure in the 4-Hydroxycoumarin Group in 1944, were a series of classic papers reprinted to celebrate the centenary of the Journal of Biological Chemistry in 2005.2,6-8 Link learned that spoilage of sweet clover resulted in oxidation of coumarin to 4-hydroxycoumarin, and the addition of formaldehyde, which is a product of additional decay, produced dicoumarin.3,9 On April 9, 1940, Professor Link wrote to C. L. Christensen, Dean of the College of Agriculture, on the research progress of his graduate assistants Harold A. Campbell, Mark A. Stahman, Ralph S. Overman, and Charles F. Huebner; he gave them credit for the work leading to the discovery of dicoumarin (di1931-7204/09/$30.00 doi:10.1016/j.jsurg.2009.03.035

KARL PAUL LINK (19011978)

Karl Paul Link was born in La Porte, Indiana, the 8th of 10 children to Frederika (Mohr) and George Link, who was a Missouri Synod Lutheran Minister. He received a bachelors and a masters degree at the University of Wisconsin and a doctorate while working with William Tottingham, who was a noted plant biochemist from Johns Hopkins University. Link received a 2-year postdoctoral fellowship at a time when fellowships were apparently difcult to obtain. He worked with Sir James Irvine, a distinguished carbohydrate chemist at St Andrews, Scotland; Fritz Pregl, a microchemist in Graz, Austria; and Paul Karrer, an organic chemist in Zurich, Switzerland. He returned to join the faculty at the University of Wisconsin and in 1930 and at the age of 29 became a professor of agricultural chemistry. By 1946, Link had an established reputation as a preeminent carbohydrate chemist and was elected to the National Academy of Sciences. The Academy presented him with the Kovalenko Award in 1967; this research award was established in 1952, and it is only given every 3 years. Link received several other prestigious awards, which include the Cameron Award in 1952 from the University of Edinburgh, the John Scott Medal in 1959 from the City of Philadelphia, the Lasker Award in 1955 from the American Public Health Association, and a second Lasker Award in 1960 from the American Heart Association.1,2 In December 1932, Link was invited by Ross A. Gortner to the University of Minnesota to consider a position there. Gortner supplied him with Lee Rodericks paper on Sweet Clover Disease of Cattle as a proposed project should he accept a position.3 Seven years before Rodericks paper, in 1924, Frank

Correspondence: Inquiries to Charles E. Copeland, MD, Department of Surgery, UPMC Mercy Hospital, 1400 Locust St, Pittsburgh, PA 15219; fax: (412) 232-2096; e-mail: copelandc@upmc.edu

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cumarol) and referred to them as a worthy quartet of station workers.1 In his 1943 Harvey Lecture on The Anticoagulant from Sweet Clover Hay, Link again acknowledged his graduate assistants and their contributions to the discovery of dicoumarin. He referred to Campbell as a universal laboratory joint: he can do almost anything and related that Stahmann had developed a relentless zeal.9 Link referred to himself as the spokesmanthe reporterfor those who made the discoveries.3 He later characterized Huebner as sensitive, brilliant and deft.3 In 19411942, Karl Paul Link lectured at the Wisconsin General Hospital and at the Mayo Clinic on the anticoagulant properties of dicumarol and on vitamin K. Vitamin K was discovered by Henrik Dam in 1935 in Denmark and was synthesized by Edward Doisy in 1939 in St Louis, Missouri; for this work, they jointly received the Nobel Prize in Physiology or Medicine in 1943. Link recognized the similarity between the biochemical structure of dicumarol and vitamin K and conducted experiments to demonstrate that vitamin K reversed the hypothrombic state of dicumarol.3,9,10 Within a few days of the 1941 publication on the synthesis of dicumarol, a request came to Link from the Mayo Clinic for the anticoagulant, and in 3 months, physicians there published a report on the prolongation of coagulation and prothrombin times in 6 humans.9,11 Link was hospitalized in September 1945 for 2 months in Wisconsin General Hospital and then transferred to Lakeview Sanatorium for 6 months because of reactivated tuberculosis, which he had acquired as a fellowship student in Switzerland.1,3 During the 6 months in the sanatorium, he studied laboratory records and read about the history of rodent control.3 In 1942, Link conducted eld trials on dicumarol and found that its activity was not high enough to make it practical for rodent control.3 Link assigned Mark Stahmann and Lester Scheel the responsibility of reappraising 4-hydroxycoumarin analogs numbers 40 through 65, and they found that analog number 42 was more potent than dicumarol.1,3 As with dicumarol, they patented number 42, and in 1948, Link named the product warfarin by combining the rst letters of the Wisconsin Alumni Research Foundation and promoted it as a rodenticide.1,3,12 In 1950, Link recommended the use of warfarin in clinical medicine.3 The transition of a substance promoted to exterminate rats was generally met with clinical reluctance. Two events, however, 1 in 1952 and the other in 1955, added impetus to the adoption of warfarin for clinical use. The rst was a report in the Journal of the American Medical Association, by Lieutenant Roy Holmes and Captain Julian Love, United States Navy, on an inductee who had taken 567 mg of warfarin in 6 days in a suicide attempt; the patient was treated with 2 blood transfusions and 2 injections of vitamin K and recovered without a complication.12 The second was a presentation at the American College of Angiology that was published in the November 12 issue of the Journal of the American Medical Association by Colonel Byron Pollock, who was stationed at Fitzsimons Army Hospital, Denver, Colorado, on the clinical experience of 100 patients with myocardial infarction or deep venous thrombosis

treated with warfarin.13 President Dwight D. Eisenhower was treated for a heart attack at Fitzsimons that year (ie, September November 1955). Link received a card from a Wisconsinite working at the Fitzsimons Hospital who related that the president was being treated with one of your drugs and it is not Dicumarol. Link knew of Colonel Pollocks experience with warfarin and surmised that the most important man in the world today was being anticoagulated with warfarin.3 Robert H. Burris, who was a student, then a colleague, and nally the department chairman of Karl Paul Link, wrote in Links biographic memoir that Link was a talented and gifted teacher, that he taught with a air, and that he was the best lecturer of the group.1 Burris also noted that Karl Paul Link was an accomplished biochemical researcher and mentor, that he established a student legal defense fund, and that he was noted on campus for nontraditional dress, large bow ties, annel shirts, shorts, work shoes, knickers, and sometimes a cape1,2 (Fig. 1). The University of Wisconsin established a posthumous Karl Paul Link Fellowship for any student whose area of study is concerned with the application of scientic research in the evolution and encouragement of a peaceful and just international order.1

FIGURE 1. Karl Paul Link. Photograph taken by Edwin Stein and courtesy of the Wisconsin State Journal, Madison, Wisconsin. 177

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WILLIAM HENRY HOWELL (1860 1945)

From 1899 to 1911, William Howell also served as the dean of the Johns Hopkins Medical School.16 In 1909, 2 years before his retirement as dean, Howell expressed the conviction during an address on education at the Harvard Medical School, that the heads of major clinics, should be made, as the preclinical chairmen already were, full-time university professors. This achievement was accomplished 2 years later at the Johns Hopkins Medical School (Fig. 2).15 In 1918, William Howell and Emmet Holt published a paper on heparin and proantithrombin. In that paper, Howell coined the name heparin as an anticoagulant obtained from the liver.14,18 Howell acknowledged Jay McLeans publication in 1916 in which McLean briey described a hepatophosphatid anticoagulant.18,19 Howell had asked McLean if he would like to have his name added as an author to the HowellHolt paper, and McLean declined, feeling that he had participated so little in that work that he was not entitled to the offer.17 In Howells 1917 Harvey Lecture on The Coagulation of Blood, he again acknowledged Jay McLeans contribution to the discovery of an anticoagulant on 4 occasions during the presentation.20

Howell continued his work on purifying heparin, and 10 years later in 1928 he published in the Bulletin of the Johns Hopkins Hospital an article titled The Purication of Heparin and Its Chemical and Physiological Reactions. In that paper, Howell had clearly established that heparin was not a phosphatide but a sulfur-containing complex carbohydrate.21 On February 1, 1941, 250 friends and admirers gathered for a dinner in the Welch Library to celebrate the 60th anniversary of William Henry Howells graduation from the Johns Hopkins University. Dr. Edward A. Park served as the toastmaster.22 Dr. Park was a professor of pediatrics at Johns Hopkins from 1927 until his retirement in 1946. He received the rst John Howland Award from the American Pediatric Society, which is the most prestigious award given by the society.23 Three keynote speakers addressed the audience. First, Dr. Joseph Erlanger spoke, who was 1 of Howells foremost pupils, then Dr. William MacCallum, and nally Dr. Simon Flexner. Additionally, 11 letters and telegrams were read. Erlanger emphasized Howells human attributes noting that he was gracious, sympathetic, approachable, helpful, thoughtful, and that he had an instinctive comprehension of his fellow men and his no less certain affection for them.22 In Howells response to the occasion, he related that what success I have had in teaching, I nd it difcult to appraise. In such matters one cannot well gather precise data . . . . I have given thousands of lectures to students but I do not really know to what extent I have inuenced their actions or their ideals. He told of a trustee who visited his department and posed a direct question What discoveries have you made Dr. Howell? . . . I found it very embarrassing. I could not think of any really important discovery that I could claim as my own. He concluded his remarks by saying, this good fortune has come to me, and I thank you out of a full heart.22 William Henry Howell died in 1945, and Joseph Erlanger wrote his obituary emphasizing that he was an accomplished and meticulous investigator, an inspiring teacher, an able and considerate administrator, and that he had a calm, simple philosophy of life and the ability to live in the light of that philosophy.16

JAY MCLEAN (1890 1957)

Jay McLean was born in San Francisco in 1890. His father, John T. McLean, who was a surgeon, died in 1894 when Jay was 4 years old. Several years later, his mother remarried. The earthquake and re in 1906 destroyed his familys home and his stepfathers business. McLean attended the University of California, Berkeley for 2 years and then took 15 months off to work in a Mojave gold mine at 25 an hour.24,25 He devoted spare time to a variety of part-time jobs. McLean worked in the college inrmary doing blood counts and urinalyses; he also worked at the museum of invertebrate zoology and campus bookstores. McLean scrubbed ferry boat decks and served as a railroad mail clerk from Oakland to Denver. McLean related that he worked at various odd jobs since age 12.25 His nal year

FIGURE 2. William Henry Howell (1860 1945). Photograph courtesy of the Alan Mason Chesney Medical Archives, Johns Hopkins University. 178

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at Berkeley commenced in 1913, which was concurrently the rst year as a medical student, and he received a Bachelor of Science degree in 1914.24 McLean applied to the Johns Hopkins Medical School and was rejected. He worked for 15 months in the oil elds and paid off a senior year loan to the University of California25 (Fig. 3). McLean moved to Baltimore even though rejected for the second-year classes at Johns Hopkins; he decided that he could work there as well as in California and complete an organic chemistry course requirement at Johns Hopkins University. Shortly after he arrived in Baltimore, he learned of an unexpected vacancy in the second year and that he would be admitted to that class. He paid his medical school fees for the year and called on Dr. William Henry Howell, who was chairman of the Department of Physiology.25 He informed Dr. Howell of his desire to prepare for an academic career in surgery and that he wanted a problem that he could reasonably hope to nish and publish in 1 academic year entirely by himself. He was given the problem of determining what portion of the crude extract of cephalin from the brain was an accelerator of clotting.25 He observed that an ether-soluable, alcohol-insoluable extract of cephalin, would accelerate the coagulation of blood and that when saved batches of cephalin had lost their thromboplastic

FIGURE 3. Jay McLean (1890 1957). Photograph courtesy of Alan Mason Chesney Medical Archives, Johns Hopkins University.

action, they possessed a strong anticoagulant activity.24,25 McLean related the story that into a small beaker full of cats blood, I stirred all of the proven batch of heparphosphatide and placed this on Dr. Howells laboratory table and asked him to tell me when it clotted. It never did.25 In 1916, Jay McLean published his work The Thromboplastic Action of Cephalin in the American Journal of Physiology.26 He had realized his hope to publish in 1 academic year by himself. In his publication, he noted that the heparphosphatid on the other hand when puried by many precipitations in alcohol at 60 degrees has no thromboplastic action and in fact shows a marked power to inhibit coagulation. The anticoagulating action of this phosphatid is being studied and will be reported upon later.26 Apparently, Howell often permitted research assistants to publish papers without his name on the work.27,28 Howell offered McLean the opportunity to have his name added to the 1918 Howell and Holt publication in the American Journal of Physiology on Heparin and Pro-antithrombin; however, McLean declined feeling that he had participated to such a small extent in this later work that I did not feel I was entitled to the privilege offered.17 McLean in later years most certainly regretted that decision. After graduation in 1919, McLean began a surgical residency with William Stewart Halsted, and in 1924, he served as a full-time assistant attending surgeon with Alan O. Whipple, who was Professor of Surgery at Columbia University and Chief of Surgery at the Presbyterian Hospital. The next year, 1925, McLean left Columbia and entered the private practice of surgery in New York City.28 In July 1939, McLean moved from New York to Columbus, Ohio, and joined a short-lived practice with Edward Reinhart. His practice consisted of radiology, oncology, and electrocoagulation at Grant Hospital.28,29 In 1943, McLean was certied by the American Board of Radiology.24McLean had become aware in the 1940s that most physicians in the academic medical community recognized William Henry Howell as the discoverer of heparin.28 While in Columbus, McLean began a campaign to receive appropriate credit for the discovery of heparin.17 On November 14, 1940, McLean wrote to Charles H. Best in Toronto, Canada, describing his work on heparin. Six months later, he wrote to Best again giving him permission to use the information in his prior letter for presentation in Bests Harvey Lecture on Heparin and Thrombosis. Best replied that the lectures time constraints would not permit the addition of a history of the discovery of heparin.28 During his lecture, however, Best did acknowledge McLeans presence in the audience and referred to McLeans 1916 work.30 In a 1959 publication on the preparation of heparin and its use in the rst clinical cases, Best referred to Jay McLean as the discoverer of heparin 3 times.31 On June 22, 1945, several months after William Henry Howells death on February 6, McLean was interviewed on national radio by celebrity Milton Cross on The Doctors Talk it Over. McLean was introduced as the discoverer of heparin and discussed the evidence for the use of heparin in acute coronary thrombosis.28,29
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In 1947, McLean moved to Washington, DC, to become the Director of the Bureau of Cancer Control. Two years later, in 1949 he moved to Savannah, Georgia, as director of radiation therapy and consultant in malignant disease at the Savannah Tumor Clinic until his death in November 1957.27,29 In 1959, 2 years after Jays death, an unnished manuscript on the Discovery of Heparin authored by Jay McLean was published. McLean opened by stating The discovery of heparin came as a result of my determination to accomplish something by my own ability.25 In 1985, Conrad Lam published an article titled The Strange Story of Jay McLean, the Discoverer of Heparin, Lam related that the only honor Jay ever received came six years after his death . . . . I wish fate had been kinder to my friend Jay when he was alive.29 The honor was in the form of a 2 ft 4 ft brass plaque presented to the Johns Hopkins Medical School by the Conference on Bleeding in the Surgical Patient from the New York Academy of Science. Erik Jorpes, who was a Swedish biochemist involved in the early development of heparin, proposed the original inscription on the plaque to read Jay McLean, while a rst year medical student working in William H. Howells laboratory at the Johns Hopkins Medical School in 1916, discovered heparin. The inscription was unacceptable to Thomas B. Turner, dean of the medical school, and he wrote to D. I. Weisblat of Upjohn and strongly suggested that the inscription should in some way recognize Dr Howells role in the discovery of heparin.17,28 The nal inscription reads, Jay McLean, 1880 1957. In recognition of his major contribution to the discovery of heparin in 1916 as a second-year medial student in collaboration with Professor William H. Howell, this plaque is presented to the Johns Hopkins Medical School at the Conference on Bleeding in the Surgical Patient held by the New York Academy of Science, May 3, 1963.17,27,28 A monetary award of $6000 was given to Jay McLeans widow.27,32 Karl Paul Link and William Henry Howell were brilliant researchers and outstanding mentors. Link openly acknowledged the work of his graduate students, and generally the discovery of warfarin is considered a product of the Wisconsin Alumni Research Foundation. William Henry Howell permitted McLean, as he had done with other students, to publish a research project under his name only. Jays publication sealed his wish to accomplish something entirely by himself. McLeans observation led Howell to change course and to focus on an anticoagulant and later name the anticoagulant heparin. It is appropriate that they share in the recognition for that discovery. McLean, however, never attained the goal of becoming an academic surgeon, and in fact, during the last 14 years of his life, he practiced radiologic oncology.

2. Kresge N, Simoni RD, Hill RL. Hemorrhagic sweet clover

disease, Dicumarol and warfarin: the work of Karl Paul Link. J Biol Chem. 2005;280:e5.
3. Link KP. The discovery of Dicumarol and its sequels.

Circulation. 1959;19:97-107.
4. Schoeld FW. Damaged sweet clover: the cause of a new

disease in cattle simulating haemorrhic septicemia and blackleg. J Am Vet Med Assoc. 1924;64:553-575.
5. Roderick LM. A problem in the coagulation of blood:

sweet clover disease of cattle; North Dakota Agricultural Experimental Station. Am J Physiol. 1931;96:413-425.
6. Campbell HA, Link KP. Studies on the hemorrhagic

sweet clover disease iv. The isolation and crystallization of the hemorrhagic agent. J Biol Chem. 1941;132:21-33.
7. Stahmann MA, Huebner CF, Link KP. Studies on the

hemorrhagic sweet clover disease v. identication and synthesis of the hemorrhagic agent. J Biol Chem. 1941;138: 513-527.
8. Overman RS, Stahmann MA, Huebner CF, et al. Studies

of the hemorrhagic sweet clover disease xiii. Anticoagulant activity and structure in the 4-hydroxycoumarin group. J Biol Chem. 1944;153:5-24.
9. Link KP. The anticoagulant from spoiled sweet clover

hay. Harvey Lect. 1943;34:162-216.

10. Last JA. The missing link: the story of Karl Paul Link.

Proles in toxicology. Toxicol Sci. 2002;66:2-4.

11. Butt HR, Allen EV, Bollman JL. A preparation from spoiled

sweet clover [3, 31-methylene-bis-(4-hydroxycoumarin)] which prolongs coagulation and prothrombin time of blood: preliminary report of experimental and clinical studies. Proc Staff Meet Mayo Clin. 1941;16:388-395.
12. Holmes RW, Love J. Suicide attempt with warfarin, a

bishydroxycoumarin-like rodenticide. JAMA. 1952;148: 935-937.

13. Pollock BE. Clinical experience with warfarin (coumadin)

sodium, a new anticoagulant. JAMA. 1955;159:10941097.

14. Fye WB. Heparin: the contributions of William Henry

Howell. Circulation. 1984;69:1198-1203.

15. Harvey AM. Fountainhead of American physiology: H

Newell Martin and his pupil William Henry Howell. Johns Hopkins Med J. 1975;136:38-46.
16. Erlanger J. Obituary: William Henry Howell (1860-

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17. Baird RJ. Presidential address: Give us the tools . . . the

Karl Paul Link, vol. 64. Washington, DC: National Academy of Sciences; 1994:176-195.
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William Henry Howell, Jay McLean, Charles Best, and Gordon Murray. J Vasc Surg. 1990;11:4-18.
18. Howell WH, Holt E. Two new factors in blood

24. [No authors listed]. Jay McLean (1890-1957), discoverer

of heparin. JAMA. 1967;201:144.

25. McLean J. The discovery of heparin. Circulation. 1959;

coagulationHeparin and pro-antithrombin. Am J Physiol. 1918;47:328-341.

19. Marcum JA, Howell WH, McLean J. The experimental

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26. McLean J. The thromboplastic action of cephalin. Am J

Physiol. 1916;41:250-257.
27. Couch NP. About heparin, or . . . whatever happened to

context for the discovery of heparin. Perspect Biol Med. 1990;33:214-230.

20. Howell WH. The coagulation of blood. Harvey Lect.

jay McLean? J Vasc Surg. 1989;10:1-8.

28. Marcum JA. The origin of the dispute over the discovery

1917;12:273-324.
21. Howell WH. The purication of heparin and its chemical

of heparin. J Hist Med Allied Sci. 2000;55:37-66.

29. Lam CR. The strange story of Jay McLean, the discoverer

and physiological reactions. Bull Johns Hopkins Hosp. 1928;42:199-206.

22. Park EA. The celebration of the sixtieth anniversary of Dr

of heparin. Henry Ford Hosp Med J. 1985;33:18-23.

30. Best CH. Heparin and thrombosis. Harvey Lect. 1940;36:

William H Howells graduation from the Johns Hopkins University. Bull Johns Hopkins Hosp. 1941;68:291-308.
23. Strain JE. Biographical sketches of the rst editorial

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clinical cases. Circulation. 1959;19:79-86.

32. Ulin AW, Gollub S. Posthumous award commemorating

board of those who edited pediatrics. Pediatrics. 1998; 102(suppl):191-193.

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