Jonas Friedenwald, Eugene Wolff, and the Two Books That Helped Bridge the Specialty Gap

The relationship of ophthalmology and traditional medicine is complicated. There was never any guarantee that their integration that is now taken for granted would last. It could have turned out differently as it did for dentistry or podiatry were it not for the efforts of many visionaries. Among these were two ophthalmologists, Eugene Wolff (1896–1954) of England and Jonas S. Friedenwald (1897–1955) of America, who recognized the critical role that anatomic pathology has in anchoring ophthalmology to the scientific foundations of medicine. Their most tangible effort to maintain the relevance of the rapidly developing specialty of anatomic pathology to ophthalmology was the publication of two textbooks of ophthalmic pathology in 1929 and 1934. This paper describes the roles that Friedenwald and Wolff played in preventing ophthalmology from inadvertently neglecting the emerging field of surgical pathology.

Anatomic pathology steadily strengthened its position as a core discipline among the basic sciences of medicine since Virchow introduced the cellular theory of disease [3‒7]. Knowledge of anatomic pathology was essential for pursuing research in almost every area of medicine. After the Flexner Report, medical schools increasingly relied upon anatomic pathology to give their curriculums scientific legitimacy [3, 8, 9]. Despite the acceptance of anatomic pathology in medical education and research, it still had a tentative connection with the clinical practices of medicine and surgery through much of the first decades of the 20th century.

The fine distinction between anatomic pathology and surgical pathology started to emerge when tissue diagnoses could positively influence medical and surgical decision-making [8‒11]. Once diagnosis by biopsy was reliable in predicting the behavior of disease, it was no longer confined to the province of research and the deliberations of postmortem examinations. Diagnosis by microscopic examination of surgically sampled tissue was systematically incorporated into routine patient care in the USA during the third and fourth decades of the 20th century, as the technological obstacles in the preparation of tissue for microscopic examination were overcome. Anatomic pathology with its roots in the postmortem examination would witness surgical pathology emerge as its progeny, proficient in the art of prognostication (through biopsy and later cytology). Obtaining this technical proficiency, however, took time.

Most early 20th century surgical pathologists were surgeons. Given how few were formally trained in microscopy, the inability to correctly interpret many specimens impeded the acceptance of surgical biopsy [10, 11]. Distinguished pathologist James Ewing (1866–1943) wrote in 1925 that “egregious blunders” were still being made in rendering diagnoses [12]. Noted medical historians have in retrospect described the lack of physicians adequately trained in histopathology in the USA as a major cause of under-utilization of surgical biopsies [13]. By 1932, there were approximately 350 full or part-time pathologists in the USA, serving over 6,000 hospitals [13]. According to medical historian William Rothstein, most physicians in the 1930s simply did not have confidence in the specialty [13].

William Halsted (1852–1922), the chief of surgeon at Johns Hopkins, in need of reliable tissue diagnoses encouraged his resident Joseph Colt Bloodgood (1867–1935) to set up a laboratory of surgical pathology in 1897 [14]. Over the ensuing decades, Bloodgood and his surgical kindred advanced the fledgling specialty of surgical pathology to such an extent that many surgeon/pathologists had difficulty mastering both disciplines. Since demand for pathologists was growing, physicians could choose to restrict their work to the laboratory if desired. By the end of the 1930s, more hospitals with the urging of the American College of Surgeons were willing ─ if not compelled ─ to support pathologists full time [9, 13].

The creativity and inventiveness of surgical pathologists blossomed as its ranks grew. Although space does not permit description of the many advances in surgical pathology made during this era, by the end of World War II histopathologic interpretation of tissue had become the standard by which most serious human maladies were diagnosed [7‒9, 13].

Ophthalmology was never a tissue-diagnosis-driven surgical specialty, and for this reason the impetus to probe the realm of pathology was not as acute as it was for general surgeons. The early study of ocular pathology was undertaken by physicians who wanted to enhance their understanding into the mechanisms of eye disease. The few eye surgeons and anatomists who had the wherewithal to study the nascent discipline of ocular histopathology in the late 19th century found the subject ripe for discovery.

Investigation into the microscopic anatomy of the eye extended over decades. Notable contributors like Heinrich Müller (1820–1864), Carl Wedl (1815–1891), Theodor Leber (1840–1917), Sir William Bowman (1816–1892), Ramón y Cajal (1852–1934), and Stephen Polyad (1889–1955) found that the study of structure was nearly inseparable from the need and desire to study function [15]. During this era, the first generation of modern ophthalmic pathologists appeared: Ernst Fuchs (1851–1930), Hermann Knapp (1832–1914), Sir John Herbert Parsons (1868–1957), and Edward Treacher Collins (1862–1937) [15].

The Collected Papers of Sir W. Bowman, BART FRS, published in 1888 represents the first English language text that comprehensively surveyed modern ocular histology and descriptive pathology [15, 16]. The first modern single-volume ocular pathology text in 1896 is credited to Treacher Collins and was based on his corpus of Hunterian lectures [17]. By comparison, Parsons’s The Pathology of the Eye was a vast work consisting of four volumes published over 4 years (1904 through 1908). Duke-Elder depicted the treatise as the first of its type to coalesce the subject into a self-contained discipline [18]. What ophthalmologists lacked up to this time, however, was a textbook that related the essential pathology of ocular disease with the needs of most physicians in clinical practice.

Eugene Wolff and Jonas S. Friedenwald were men of wide-ranging talents, whose interests in ophthalmic pathology culminated in the publications of two textbooks with nearly identical titles [19, 20]. Friedenwald’s The Pathology of the Eye was published by McMillan in 1929, followed by Wolff’s A Pathology of the Eye, published in 1934 by H.K. Lewis & Company of London. Both textbooks were the product of lectures and course works given by each man to students, house officers, and surgeons to bridge the gap between clinical ophthalmology and pathology. Unlike ophthalmic pathology texts that preceded them, these were designed to effectively transfer knowledge between two rapidly expanding specialties. Friedenwald and Wolff ostensibly wrote the books for eye specialists, but even casual inspection of the texts revealed that they bestowed an equivalent bounty of knowledge toward the education of pathologists.

Both authors organized chapters according to anatomic location and shared pathogeneses. Friedenwald emphasized mechanisms over anatomy, assembling just two of 15 chapters by anatomic location (cornea/conjunctiva and the ocular adnexa). The remaining 13 chapters were constructed around concepts of shared pathogenesis (e.g., inflammation, injury, senile changes, tumors, etc.) (Table 1). Wolff, on the other hand, preferred grouping disorders by anatomic site (uveal tract, lens, vitreous, retina, etc.) with six of 18 chapters erected around a commonality in pathogenesis (e.g., injuries, glaucoma, changes in diabetes, etc.) (Table 1).

The basic light microscopic descriptions found in both books are as relevant today as they were 90 years ago. Friedenwald’s Pathology was illustrated with 253 photographs taken by Helenor Campbell (1895–1998) of the Army Medical Museum (later the Armed Forces Institute of Pathology [AFIP]) (Fig. 1, left) [21]. Ms. Campbell was a histology technician who under the leadership of Major George Callender (1884–1973), the Curator of the museum, functioned as the ophthalmic pathologist until the arrival of Lorenz Zimmerman (1920–2013) in 1953 [22]. Wolff’s textbook by comparison had 124 illustrations with a substantial proportion detailed drawings (Fig. 1, right). Wolff was a connoisseur of medical illustrations, overseeing every aspect of their preparation. His first published book in 1926 was Anatomy for Artists, which went through three editions by 1947. Given the quality of black-and-white photomicroscopy at the time, the medical illustrations in Wolff’s book display visual information that could not yet be captured photographically. Wolff enhanced the transfer of information in his illustrations through the use of labels and arrows. He also did his own histological sectioning (Fig. 2, right).

Each author approached the certitude with which ocular diseases are understood with deference. They acknowledged the limitations and vagaries of disease classification. Each approached taxonomy cautiously, favoring systems that had withstood some degree of scrutiny. In discussing the classification of choroidal sarcomas (e.g., melanosarcoma), for instance, neither man supported any of the proposed methods of classification, preferring tumor staging based on tumor size, secondary complications, and extension beyond the eye. Wolff and Friedenwald prized brevity, limited speculation, and valued critical thinking.

Wolff was born in South Africa 3 years before the start of the Second Boer War (Anglo-Boer War [1899–1901]). He immigrated to England along with his family as a young child, where he received his education, including medical at London University College Hospital in 1918 [23, 24]. After a brief return to South Africa, he continued his postgraduate training in ophthalmology in England. After becoming house surgeon at two hospitals, he studied under Percy Flemming and Sir John Parsons at University College Hospital. He was able to successfully combine his interests in anatomy, pathology, ophthalmology, and art through medical illustrations. His participation and oversight in creating realistic and detailed medical illustrations complemented his skills as a writer and lecturer. Perhaps his best known work ─ Anatomy of the Eye and Orbit, was published in 1933 [25]. It went through four editions before revisions were supervised by R.J. Last, Professor of Anatomy at the Royal College of Surgeons. Wolff’s Diseases of the Eye, published in 1937, was equally well received, also going through multiple editions before handing off editorial responsibilities to others [26]. Wolff was a member of the Editorial Board of the British Journal of Ophthalmology (BJO), but his pursuits in original research were limited. He contributed seven papers to the BJO, preferring to dedicate most his time to clinical practice, surgery, and teaching. His proficiencies as an educator were widely recognized. He was much sought after as a lecturer and instructor. Wolff accumulated numerous awards and honors, including William Mackenzie Memorial Medal in 1947. He died unexpectedly a month short of his 58th birthday (Fig. 3, left).

Friedenwald was born into a medical family; his grandfather, Aaron, and father, Harry, were both eye surgeons [27‒29]. He had two uncles in academic medicine. His grandfather and father were native Baltimoreans who received their medical training in America before going to Europe to observe and study under several prominent eye specialists. Aaron and Harry had distinguishing professional careers with successful clinical practices and positions of leadership. Jonas was a serious and exceptional student showing an aptitude in mathematics and physics. He graduated from Johns Hopkins Medical School in 1920 and did postgraduate training in ophthalmic pathology under Frederick Verhoeff (1874–1968) in Boston, and in general ophthalmology with William Zentmayer (1864–1958) and George de Schweinitz (1858–1938) in Philadelphia [27]. When he returned to Baltimore, he was hired by William MacCallum (1874–1944), the chair of pathology at Johns Hopkins, as director of the ophthalmic pathology laboratory (Fig. 3, right).

Friedenwald divided his time between laboratory, clinic, and the operating room. He was a meticulous researcher and experimentalist, contributing to a better understanding of retinal vascular disease, glaucoma, and diabetic eye disease. Using his background in math and physics, he developed and formalized the concept of ocular rigidity [15, 28]. He enjoyed surgery and surgical innovation, and was credited with 140 scientific publications. Friedenwald continued as director of ophthalmic pathology at Johns Hopkins until his death at age 58.

The approachability of Friedenwald’s The Pathology made it both popular and essential reading for those in training. About 20 years after its publication, Friedenwald collaborated with the AFIP and the American Academy of Ophthalmology and Otolaryngology to expand and update the textbook. He spearheaded the project, recruiting seven leading ophthalmic academicians as co-authors including A. Edward Maumenee (1913–1998), Micheal Hogan (1907–1975), and Helenor Campbell Wilder. In 1952, the vastly reorganized Atlas and Textbook of Ophthalmic Pathology was published with Friedenwald as primary author and editor [30]. A decade later, Lorenz Zimmerman and Michael Hogan would oversee another major revision [31]. This 797-page encyclopedic reference would 23 years later evolve into the three-volume, 2,900-page third edition, authored by six current and past members of the AFIP [32].

Wolff’s A Pathology enjoyed similar popularity in the United Kingdom and in other English-speaking countries. The pace at which new knowledge was being generated resulted in a larger and expanded second edition 10 years later. It received considerable praise for its succinct descriptions, superb illustrations, and up-to-date references [33]. It had 211 illustrations, fully 70% more than the first edition, many of which were drawings. How histopathology contributes to understanding disease mechanisms was a central theme. A hallmark of Wolff’s writing was his clarity of language and thought. The third edition came out in 1951 with 318 illustrations, some of which were now in color [34]. Still the sole author, Wolff continued to emphasize that eye disease is largely understood through the study of pathology. Much of the new material in the third edition dealt with recent insights into diabetic retinopathy, retrolental fibroplasia (retinopathy of prematurity), and the pathobiology of uveal melanoma and retinoblastoma. Many of the book’s illustrations remained as drawings, an editorial decision which continued to draw praise as late as mid-20th century [34].

The publication histories of The Pathology and A Pathology may have differed due to variances in the professional environments in which the authors worked. Friedenwald was affiliated with Johns Hopkins Hospital and found support for his academic interests through the American Academy of Ophthalmology and Otolaryngology. He also had geographic proximity to the AFIP and access to experienced professionals in pathology and ophthalmology, most notably Helenor Campbell Wilder. Wolff, on the other hand, worked mostly alone with the aid of medical illustrators. It is unclear if this isolation was one of choice, or if it was inevitably due to the structure of academic medicine in England.

The long-term influence that these two pioneering textbooks have had on ophthalmic education is profound [35]. They were the first comprehensive English language books on ophthalmic pathology aimed at the educational needs of trainees as well as a resource for those in practice. These publications helped ensure that ophthalmic pathology would never be left out of any progressive educational syllabus for ophthalmology.

One is left to speculate as to what motivated Friedenwald and Wolff to write their pathology textbooks. From an historical perspective, their textbooks came at a time when the specialties of ophthalmology and anatomic pathology were expanding in different directions. The clinical practice of ophthalmology infrequently interacted with pathology compared to other surgical specialties, a phenomenon that Friedenwald and Wolff were aware of. Both men, however, had a deep interest in medicine as a biologic science, having devoted a considerable amount of their professional lives to the study of anatomy, physiology, and the pathogenesis of disease. Their regard for ophthalmology as a biological science was demonstrable in formal lectures to trainees and postgraduates surgeons, and through their textbooks on ophthalmic pathology. The publications of The Pathology of the Eye and A Pathology of the Eye, in 1929 and 1934, respectively, made the subject of anatomic pathology accessible and relevant to residents in training and practicing ophthalmic surgeons. Not only did these landmark textbooks help secure ophthalmology to mainstream medicine, they were resources for pathologists to learn about diseases of the eye.

Lynn E. Harman and Hans Grossniklaus reviewed and critiqued the manuscript during preparation.

This study was an historical perspective and not considered human research.

The author has no conflicts to declare.

No funding was received. No sponsor support was obtained.

Subject of the Synder Lecture, to be presented at the 36th annual meeting of the Cogan Ophthalmic History Society, Miami, FL, April 19, 2024.