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Tales of Yore

James Wardrop

Science of deduction

Sen, Mrittika; Honavar, Santosh G

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Indian Journal of Ophthalmology: January 2021 - Volume 69 - Issue 1 - p 5-6
doi: 10.4103/ijo.IJO_3566_20
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James Wardrop (1782–1869)[1]

If anyone should imagine that it is in his generation that wisdom arose, let him read in the older writers; if he feels pessimistic, as one is apt to do, regarding our poor advance in the knowledge of disease, let him study them further, and he will find that till he comes to the deductions to be drawn from the observations there is little indeed to add except the particular points of precise mensuration which can only be supplied by modern instruments and tests, and these in truth form an advance which affords us great and solid advantages as compared with our ancestors; but for all that, within their possible area the older observers were not easy to beat.

William Sym

In a small town in Scotland, Linlithgow, not too far from Edinburgh, on August 14, 1782, was born a child who would go on to become one of the leading figures of his time in matters of the heart and horses…and also the eyes. James Wardrop, when he decided to join the medical profession, became an apprentice to his uncle Andrew Wardrop, an eminent surgeon in Edinburgh. He spent a few years studying medicine in London and some time in Paris before he escaped Napoleon's secret police to Vienna. It was here that he had his tryst with ophthalmology. He attended the cliniques by the illustrious Dr. Georg Jospeh Beer and found his calling in the diseases of the eye. In 1804, he returned to Edinburgh and set up his practice. He was actively involved in the establishment and was the curator of the museum of the College of Surgeons and many of his preparations still adorn the shelves. But soon he found himself back in London, where he continued his surgical practice and lived till his death in 1869. In 1818, he was appointed surgeon-extraordinary to the Prince Regent, who subsequently acceded the throne as King George IV.[1]

In 1823, Wardrop, along with Sleigh, founded his own hospital, the West London School of Surgery, to attend to poor patients and lecture and demonstrate surgical techniques. This was free for any practitioner who wanted to come and learn and join in discussions on cases and treatment.[1]

As a general surgeon, he did considerable work on and published a book, Diseases of the Heart, in 1837. He described an innovative treatment for aneurysms by ligating the branches of the diseased vessel distal to the aneurysm in an attempt to reduce blood flow through it, development of a thrombus within the aneurysm and, consequently, diminished risk of rupture or progressive expansion.[2] His understanding of horses went beyond the breed, hide, and flesh. He published a book on the treatment of diseases of the eye in horses. He was the first to describe in great detail specific inflammation in horse eyes including recurrent inflammation, cloudy anterior chamber, cataract, synechiae, and potential blindness. Today, in veterinary practice, it is better known as equine recurrent uveitis. In connection to this, he also described the sympathetic involvement of the other eye with the inflamed eye and proposed early enucleation as a prevention for this. Interestingly, he even suggested the use of glass eyes to prevent deformity in horses that have lost an eye.[3] It was later understood that it was not sympathetic ophthalmia that he described, but he definitely proposed a novel idea of the good eye responding to the inflammation in the affected one.

Wardrop, in his book Essays on the Morbid Anatomy of the Human Eye, presented extensive details with accompanying colored diagrams based on his experiences with dissection of cadavers. It is in this book that he coined the word keratitis.[3]“And as no attempt has yet been made in this country to treat of the pathology of this organ (eye), little apology seems necessary for the present undertaking,” he enunciates the need of the book in its preface.

Petrus Pawius of Amsterdam was the first to describe, in medical literature, a tumor resembling retinoblastoma. In 1805, William Hey of Leeds coined the term “fungus hematodes” for an extremely vascular and fungating tumor presenting on the limbs or breast.[4] Wardrop, in his monograph, “Observations on fungus hæmatodes or soft cancer in several of the most important organs of the human body”, he described retinoblastoma for the first time as a distinct entity originating from retinal cells [Fig. 1]. He presented cases, ophthalmic pathologic findings and some autopsies of 15 children, between the age of 9 months to 13 years, with an intraocular tumor, some of which he had seen himself, some which were communicated to him by peers. The tumors were described as “white in color and brain-like substance.” Before this, only a few case reports were available, some of which may not even have been retinoblastoma. The testament to the value of the book lies in the fact that it was translated in German and Dutch and followed in other countries of Europe. Incidentally, Wardrop's old mentor, Dr Beer coined the term “amaurotic cat's eye reflex”! Although Wardrop and his colleagues were unsuccessful in preventing orbital recurrence or metastasis, he went as far as to predict that enucleation, while the tumor was still intraocular, would help in saving the lives of children. “But as we know of no instance of the operation being performed at a very early period of the disease or in any case where the optic nerve was found in a healthy state, there is still room to hope for success under such circumstances. It is an experiment, at all events, which still merits trials; and were I in any case to be assured of the existence of the disease in the early stage, I would have no hesitation in urging the performance of the operation. Past experience proves the impropriety of attempting any operation, when the disease has advanced so far that the posterior chamber is filled with the diseased growth.” This, at that time, was not only a radical proposition, but more of a preposterous idea and denounced by most. For others, the main problem lay somewhere else, neither general, nor any form of local anesthesia was discovered till then. Unfortunately, the bleak outlook towards enucleation persisted for decades to come and, even around the time of his death in 1869, Ernst Knapp in Germany was still trying to propagate the same principle in vain.[5] But, it is not difficult to understand why young Wardrop would have liked to cut out the eye with the tumor if the cases had come to him before reaching an advanced stage with a large fungating mass protruding from the eye. Scotland, at that time, was the nurturing ground for early modern surgery. Anatomy and surgery were taught as one and students had to get bodies themselves to learn and dissect. These young lads would go scavenging after surgeons and in graveyards at night. Once armed with the skill of the scalpel, they were eager to try it in real scenarios to cure diseases.[5] Nonetheless, Wardrop's book on retinoblastoma in 1809 did initiate a search for its cure, and in the next 200 years, the treatment evolved, with enucleation being accepted as standard of care, to radiation and finally the dawn of chemotherapy with a current cure rate of 96%–98%.

Figure 1
Figure 1:
First two pages of chapter on the tumour of the eyeball from the treatise "Observations on Fungus Haematodes", the first classical description of retinoblastoma as a separate entity.[7]

There was, however, a sixteenth case reported in his treatise, which was different from the rest. It was a seven-page description of the case of a 41-year-old lady,who presented to another Scottish surgeon, Allan Burns, with diminution of vision in one eye. Burns noted early, complicated cataract, which over time progressed to an inflamed, painful blind eye. After a few months, she came back with a dark brown mass breaking out through the inferior portion of the sclera. Burns invited Wardrop, to assist him in enucleating the eye. They did extirpate the eye but found the tumor adherent to the surrounding bone and also extending on to the optic nerve. They described the mass, the optic nerve, and the involved bone to be black as ink. The tumor recurred in the orbit and the patient in question passed away after a few months. A postmortem performed by Burns after exhuming the body showed similar affliction of the liver. This was possibly the first description of the natural course of uveal melanoma in medical literature beginning with painless vision loss, followed by extraocular extension, local recurrence, and later distant metastasis.[6]

James Wardrop may not be a name oft mentioned in ophthalmology books, possibly because his influence extended beyond just one speciality. To fully appreciate his skills, it is worth remembering that he described diseases, proposed ideas and recommended management advise in the absence of any tools that are considered essential for ophthalmic practice today. In the words of William Sym, “The older writers possessed none of the extraneous means of investigations: No ophthalmoscope, for example, no tonometer; no Wassermann had yet appeared, no perimeter was invented, the microscope was in its infancy. Yet the clinical descriptions of the naked eye aspect of their cases, it is oftentimes a joy to study.”[1]

1. Sym WG. British masters of ophthalmology series: 6.—James Wardrop, FRCS (1782-1869) Br J Ophthalmol. 1918;2:nil2–406
2. Fye WB. James Wardrop Clin Cardiol. 1998;21:308–9
3. Paglia DT, Miller PE, Dubielzig RR. James Wardrop and equine recurrent uveitis Arch Ophthalmol. 2004;122:1218–23
4. Albert DM. Historic review of retinoblastoma Ophthalmology. 1987;94:654–62
5. Kivelä T. 200 years of success initiated by James Wardrop's 1809 monograph on retinoblastoma Acta Ophthalmol. 2009;87:810–2
6. Kivelä TT. The first description of the complete natural history of uveal melanoma by two Scottish surgeons, Allan Burns and James Wardrop Acta Ophthalmologica. 2018;96:203–14
7. https://archive.org/details/observationsonfu00ward/page/10/mode/2up last visited on 9/12/20
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