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The Bowman Lecture Papilloedema THE BOWMAN LECTURE PAPILLOEDEMA: 'THE PENDULUM OF PROGRESS' M. D. SANDERS London I. HISTORICAL BACKGROUND appreCiatIOn a gift in the form of a compound One year after the Battle of Waterloo, William microscope. This may have been one of the crucial Bowman was born into a world entering a period of events in his life, for though the compound micro­ dramatic change. The new age of science would see scope was developed in the previous century, the transport and communication revolutionised and the chromatic aberration was only overcome in 1830 by purpose of human existence shaken by Darwin's Lord Lister's father, just before the gift was made to thoughts on natural selection. Surgery would benefit Bowman. from the techniques of antisepsis and the first Thus in 1837 Queen Victoria ascended the throne, anaesthetic would be administered. In ophthalmol­ and William Bowman aged 21 entered the portals of King's College in London's Strand fully equipped to ogy the description of glaucoma and the invention of contribute to the explosion in knowledge that was the ophthalmoscope would enable the specialty to about to erupt. Todd, the new Professor of Physiol­ survive in its own right, with the inception of its own ogy at King's, was using his phenomenal enthusiasm society. to compile two massive books on the anatomy and Bowman's introduction to medicine probably physiology of the whole body. resulted from an initial injury inflicted to his ha.nd Bowman described the voluntary and involuntary whilst experimenting with gunpowder as a boy.1 He muscles4 and their actions without formal methods of consulted the Birmingham Surgeon Joseph Hodgson fixing or staining specimens, and no microtome. He and was so impressed by his care that he vowed to was left deciding whether to slice or tease the fresh follow suit and become a doctor. Hodgson was 2 material. after moistening with water or syrup or Surgeon to the General Hospital in Birmingham, salts. He added phosphoric, tartaric and citric acids but having trained in London under Travers and to his specimens. He was the first person to use the Lawrence, he went on to found the Birmingham Eye term sarcolemma and his descriptions have survived Hospital in 1824, which he staffed single-handedly the test of time. for four years. Bowman joined Hodgson as an He is most famous for his work on the kidneyS and apprentice at the age of 16, and would probably the description of Bowman's capsule, the epithelial have received his early introduction to ophthalmol­ covering of the glomerulus, which he studied in man, ogy at this time. Hodgson, who ultimately became horse and the boa constrictor after injection of the President of the Royal College of Surgeons, saw his arteries. So in addition to the variety of the tissues protege dedicate his days to meticulous study, with and the complexity of the microscopy, I am amazed papers on paraplegia, and influenza and diseases of at the variety of species studied, the examination, the the trachea and larynx? An illustration by Bowman measurement and the superb illustrations, all drawn at the age of 21, of erisypelas of the trachea, shows by the investigator. Here is an incomplete list of the the maturity of his work and the artistry inherited extent of the comparative anatomy Bowman studied: from his talented parents. He also measured the Muscle: eel, newt, haddock, shave, frog, boa, teal, cardiac orifices for a physician and received in pig, rabbit, crab, hare, lizard, horse, kitten, tipula. Kidney: horse, rabbit, parrot, guinea pig, boa, Correspondence to: Mr M. D. Sanders, FRCP, FRCS. badger, dog, lion, cat, squirrel, tortoise, frog, eel. FRCOphth, Consultant Ophthalmologist, National Hospital for It is not surprising that, after qualifying at the age Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK. of 24, Bowman was elected a Fellow of the Royal Eye (1997) 11, 267-294 © 1997 Royal College of Ophthalmologists 268 M. D. SANDERS Fig. 1. Letter by Sir William Bowman in 1843 to 1. Bowerbank, FRS, discussing the basement membrane of mucous membranes. Society at 25 for his work on muscles and given the Bowman was appointed to the staff of the newly Royal Medal of the Royal Society for his work on the opened King's College Hospital in 1840 and was kidney at the age of 26. Whilst a Resident at High appointed to Moorfields in 1846. His interests now Holborn I was fortunate to purchase a Bowman began to concentrate on the eye, where he left his letter, one of the few remaining, for the princely sum eponymous imprint on the membrane in the cornea, of £4 (Fig. 1). It refers to the basement membrane, a and described the ciliary muscle, previously consid­ term initiated by Bowman in relation here to the ered a ring.9 In 1880 he became the first President of mucous membranes, and alludes to the Cyclopedia the Ophthalmological Society of the United King­ and the Anatomy and Physiological Anatomy of dom (OSUK), and in recognition of his services Sir Man, the two massive tomes compiled by Todd. The William Gowers suggested the founding of the letter is written to Bowerbank, also a Fellow of the Bowman Lectureship, to provide the best extant Royal Society, an amateur palaeontologist and, like information upon some subject, the endeavour being Bowman, graced with a banking father. Bowman's to contribute each year something real towards the father was also interested in botany and geology and advancement of knowledge for the good of man's a Fellow of the Linnean Society, and his mother a estate, which had been Bowman's life-long ambi­ gifted painter of flowers. The hand-writing of this tion.lO Gowers gave this Lecture 100 years ago and letter is identical to that published by James,6 with an wrote the first textbook on medical ophthalmology,ll identical signature; but is in contrast to the hand­ with early illustrations of papilloedema and ischae­ writing ascribed to Bowman by others?,8 mic optic neuropathy. The ophthalmoscope was THE BOWMAN LECTURE 269 Fig. 2. Staff at the National Hospital, Queen Square in 1915, showing Marcus Cunn (1), Sir Hughlings Jackson (2), Brudenel Carter (3) and Sir William Cowers (4). greeted most enthusiastically by physicians and past months have veered from Sir Isaac Newton's neurologists for the detection of hypertension and comment: brain tumours, and the early staff of the National If I have seen a little further, Hospital were part of this vanguard (Fig. 2). The It is because I have stood on the shoulders of great Sir Hughlings Jackson, who was both President giants. of the OSUK and Bowman Lecturer, counted it the luckiest thing in his medical life that he began the to Tennyson's poem: scientific study of his profession at an ophthalmic The other follies reach us not; hospital, for 'there', he said, 'one has the opportunity Nor much their wisdom teaches, D of being well disciplined in exact observation,.l And most of sterling worth is what, Hughlings Jackson and Gowers persuaded the Our own experience preaches. National Hospital to appoint two ophthalmologists to the staff to use the new instrument. Marcus Gunn Tennyson was painted by G. F. Watts, who was a was appointed, being both President and Bowman friend and patient of Bowman and Bowman owned Lecturer of the Society, and Brudenel Carter, who the painting, which subsequently became known as the Bowman Tennyson.14 15 One of the significant elegantly graced the stage of London ophthalmology . paintings of Bowman was also painted by G. F. and will be mentioned later. Watts. The great father of ophthalmic genetics, Edward Nettleship, was both a President of the OSUK and Bowman Lecturer, and contributed to the subject of II. PAPILLOEDEMA this present Bowman Lecture by describing early 12 Guarding the entry and exit of neuronal and vascular reports of papilloedema and giving the first elements to and from the eye, the lamina cribrosa 13 description of choroidal folds in papilloedema. comprises two to three hundred pores of varying Sir William Bowman would be proud that his sizes in a collagen matrix.16�18 A vascular system Society (the OSUK) has become a Royal College, consists of an arterial circle of Zinn, producing but probably less enthusiastic about being dislodged arterioles of variable pattern that perfuse the lamina from his lofty perch on the representative armorial cribrosa19.2o (Fig. 3) with a venous exit in the central bearings. retinal vein. One million nerve fibres traverse this I accept the distinction of being asked to give the area and as the neurones emerge they acquire a 57th Bowman Lecture as a great personal gesture, myelin sheath. This area is probably the site for the but also as a tribute to the role of a clinician with an neuronal damage in glaucoma,21.22 the site of central academic interest, and to the role of neuro-ophthal­ retinal artery and vein occlusions and of all cases of mology in the future of modern ophthalmology. disc oedema.23 The optic disc is therefore an area of Having read with respect, fascination and humility extreme importance to a wide body of ophthalmol­ many of the previous lectures, my thoughts over the ogists and merits our meticulous attention. 270 M. D. SANDERS Fig. 3. The lamina crib rosa and pores (courtesy of Prof B. Tengroth) and a methacrylate cast of the microcirculation (courtesy of Miss Jane Olver). This lecture will consider papilloedema, which I convenient in medicine to have a single diagnosis, would like to consider in the general context of optic but when these conditions overlap diagnosis is more disc swelling, because all ophthalmologists are exacting.
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