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Show Journal of Neuro- Ophthalmology 20( 1): 22- 24, 2000. © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia The Blind Beautiful Eye Moshe Feinsod, MD Master Jehan Yperman, a medieval surgeon, observed that when the optic nerve is injured, the eye becomes blind and beautiful. This is an attempt to trace the footsteps of this forgotten surgeon and to track the history of the cosmetic use of the belladonna herb, as well as the concept of amaurotic mydriasis. Key Words: Amaurotic mydriasis- Atropa belladonna- History of medicine- Medieval ages- Monocular visual loss. A casual browse through the library resulted in a small book that previously evaded my quests. It was a French translation of surgical treaties on the head and the eye by a medieval surgeon, Master Jehan Yperman ( 1). The name was new to me, and my curiosity increased when, in the opening sentences of the section on the eye, I read " The eye is connected to the brain by a nerve that if injured the eye becomes blind and beautiful." This stimulated me to find out who Jehan Yperman was, and whether his phrase, the " blind beautiful eye," meant that he had the same associations that we may have with the plant Atropa belladonna and with the amaurotic pupil. JEHAN YPERMAN From the twelfth through the fourteenth centuries, Flanders ( modern southwestern Belgium) was a prosperous industrial and commercial center. The prominence and the wealth of Flanders are reflected in the standing of the local dialect, Thiois ( now called Flemish), in which many books, poetry, and plays were written. The region was devastated in the fourteenth century by successive battles and the plagues of the Black Death, and a large part of its rich cultural tradition sank into oblivion. The independence that Belgium achieved in 1830 initiated intensive research into its history and culture. Among the precious documents that this search turned up were four copies ( found in various libraries and collections) of a book on surgery by Master Jehan Yperman, handwritten and illuminated on parchment or paper. The manuscripts were edited first by Broeckx and Carolus ( 2,3) and later studied by other scholars ( 4,5), and then by De Mets ( 1), who translated the book from Thiois into modern French. From the recovered city archives, they could also reconstruct many milestones of Yperman's life. The dates of Jehan Yperman '$ birth and death are a source of dispute among scholars ( 6). We do know, however, that in 1295, he was the recipient of a scholarship from his hometown of Ypres to study surgery in Paris under Lanfranc, who was later recognized as the father of French surgery. From 1302 until 1331, Yperman served as chief surgeon of Ypres, which was then a large and prosperous medieval city. In this capacity, he followed Ypres's militia and mercenaries onto the battlefield and took care of the city's sick at their homes if they were rich, or in the charity hospitals if they were poor. Traditionally, it is Ambroise Pare ( 1510- 1590) who receives credit for being the first to write surgical treaties not in Latin, a language he did not know, but in French, considered then a " vulgar" language. Yperman's treaties were written 2 centuries earlier, by this university-educated surgeon who was very familiar with ancient and medieval heritage. Yperman wrote the treaties in their language, for the benefit of the practicing surgeons of his country. His books were considered important enough to be copied by hand, several times, decades after he died. The treaties of Cyrurgie are comprised of seven books dealing with the head, eyes, nose, mouth, ears, throat, and the remainder of the body. The first two books on the head and the eyes are the most detailed. They were not just a copy of teachings of old masters but were the writings of an experienced surgeon. Yperman's manuscripts were rediscovered after centuries of oblivion, but are mentioned only en passant textbooks on medical history ( 7,8,9). His books still awaits recognition as an important source on medieval medicine. Manuscript received April 21, 1999; accepted November 4, 1999. From the Head Injury Applied Research Center, Department of Neurosurgery, Rambam ( Maimonides) Medical Center, B. Rappaport Faculty of Medicine, The Technion, Israel Institute of Technology, Haifa, Israel. Address correspondence and reprint requests to Moshe Feinsod, MD, Head, Department of Neurosurgery, Rambam ( Maimonides) Medical Center, Haifa 31096, Israel. THE BEAUTIFUL EYE The eye has been recognized as an organ of beauty since antiquity. In early Biblical time, the young David is described as " ruddy with beautiful eyes" ( Samuel A 16: 12). In the Song of Solomon, the eyes of the beloved are described as " like doves beside springs of water, 22 THE BLIND BEAUTIFUL EYE 23 bathed in milk fitly set" ( 5: 12). Similar descriptions can be found in every culture around the world; what is not said is what feature of the eye makes it beautiful. The ancient Egyptians, and later the Greeks, used colored ointments on the eyelids as a cure for various ophthalmic disorders. According to the Bible, and as can be seen in archaeologic findings from many ancient cultures, as well as can be seen in modern days, women tried to enhance the features and hence the beauty or the charm of their eyes by adding color or mascara to the lids and eyelashes. There is no Greek or Egyptian written account of an attempt to change the appearance of the eye itself for cosmetic reasons by changing the size of the pupil. The first record of such a practice is by Matthiolus in 1565 ( 10,11), who recounted that Venetian women used to enhance their beauty by using juices or extracts from leaves of the herb Solatrum maius, which dilated the pupils and gave their eyes greater brilliance. The Venetians called the plant " herba belladonna." This name also was used during the same period in Tuscany( 12). This use of the herbal extract is not mentioned in the writings of the Greco- Roman naturalists Theophrastus ( 370- 287 BC), Dioscorides ( first century AD), or Pliny the Elder ( 23- 79 AD), or in other ancient sources ( 13,14). It is probable, however, that the use of belladonna herbal extracts as a cosmetic agent became popular in other regions, too, ( 12) some time during the Middle Ages, before being recorded in botanical literature of the sixteenth century. The habitat of the herb extends over central and southern Europe and England, where it is now cultivated ( 15). Its use must also have spread up north to Sweden, for the great Swedish botanist Carl Von Linne ( Linneus) ( 1707- 1778), in his Systema Naturae ( 1735) and the binomial nomenclature in science, gave the plant the name Atropa belladonna. The origins of the atropa part of the plant's name can be traced with less effort than can belladonna. Theophrastus ( 370- 287 BC; the Greek physician- botanist) described in his De historia plantarum the hallucinogenic effects of the Solatrum ( believed to be the belladonna, or a related plant) and quoted, " If one takes one dram of the preparation he will be afflicted with levity and laughter as in a kind of madness but only to a point where he sees something attractive and beautiful. After two drams a greater madness is induced and the eyes and the mind will see apparitions and stunning fantasies. After three drams the subject will strain under a madness from which he cannot free himself and ceaseless rages will ensue. Four drams will destroy the man." ( 10). This description brought I. Bodaeus ( 16) to suggest, in his commentary on Theophrastus, that some of the hallucinations, which were mentioned also by Pliny the Elder ( 10), were of sexual fantasies of beautiful women- hence the name belladonna. The toxic effects of the belladonna herb and its relatives were used in antiquity and in the Middle Ages ( the vernacular medieval English name of the plant was dwale, and later, deadly night shade), either as anesthetics, as an old medieval document narrates (" A drynke bat men callen dwale to make a man to slepe whyle men kerven him"; 17), or in a less benevolent application, as an accidental or premeditated poison, which the other name implies. In the sixteenth and seventeenth centuries, poisoning was widely used in Italy and other parts of Europe, and belladonna was one of the agents employed ( 15). It may be that belladonna or related extracts were used by many surgeons, Yperman among them, because of their hallucinogenic properties. The lethal properties brought Linne to give the name of Atropos, one of the three fates in Greek mythology, who cut the thread of life when man's course was run, as the first name of the plant. Pultney ( 18) ( 1757) drew attention to the mydriatic properties of the belladonna. He reported on accidental mydriasis when belladonna extract was used as an analgesic. Later, Daries ( 19) ( 1776) reported the same observation. Neither referred to its cosmetic use. Since Himly ( 20) used it intentionally in 1801 to facilitate the removal of the lens, belladonna extracts and, later, purified atropine became an integral part of the ophthalmologic pharmacopeia. THE AMAUROTIC PUPIL The pupil's size attracted medical attention since the Greco- Roman period. Hirschberg ( 21), in his monumental work, tells that Celsus coined the term mydriasis. Hippocrates and Galen knew that mydriasis interferes with vision. Galen attributed importance to pupillary size and instructed that the examination of pupil size should be performed by covering the eyes alternatingly. He noted that the pupil of the good eye would always look smaller. The Arab ophthalmologic literature that followed does not seem to be concerned with the clinical implications of pupillary size. They conveyed, however the Galenian knowledge that the pupils may dilate after head injury. Yperman is not mentioned in Hirschberg's ( 22) review of medieval ophthalmology, which depends mainly on Guy de Chauliac's ( 1300- 1370) Chirurgia Magna. This encyclopedic book served as a textbook and guide for many generations. Hirschberg admired the comprehensive way in which Chauliac reviewed his predecessors' contributions to ophthalmology. The book was mainly about cataract surgery. Chauliac himself did not write on the pupil's size as a sign of blindness nor of drugs causing pupillary changes. Yperman's observation on the " blind beautiful eye" is original; it was not copied or borrowed from his teacher Lanfranc nor from earlier physicians and surgeons. Amaurotic mydriasis was recently studied by Lepore ( 23), who presented no evidence for its monocular occurrence. According to him, one of the first descriptions of amaurotic mydriasis occurrence was by Whytt ( 24), who, in the mid- eighteenth century, observed that " whatever intercepts the rays of light so as to prevent their affecting the retina, or whatever renders this membrane insensible to their action, occasions a preternatural dila- ] Neuro- Ophlhalmol, Vol. 20, No. 1, 2000 24 M. FEINSOD I:" IL,, a:: ; iu. ' ? - I. 4. tation of the pupil." According to Mettler ( 25), Magendie believed that optic nerve section caused pupillary dilatation and fixation, but he also supposed this occurred when the trigeminus was sectioned. It was Herbert Mayo ( 1796- 1852) of Middlesex Hospital, London, who correctly correlated mydriasis with section of the oculomotor nerve. In her comprehensive book The Pupil ( 26), Dr. Lo-wenfeld strongly negates the concept of amaurotic mydriasis, because as long as the third nerve is not affected and both eyes are open, the size of the pupils should be equal. However, when the pupils are tested using Galen's method of covering the two eyes alternatingly, each pupil is seen only when it reacts directly, and it is therefore that the pupil in the good eye always looks smaller. Galen was offering a preoperative pupillary test for cataractous eye, but over centuries to come, his method of examination may have been adopted for other conditions. This may explain why, as Lowenfeld says, " Many authors will swear that the pupil of the blind eye is always larger than its normal fellow pupil." Centuries after Yperman, a long line of famous neurosurgeons ( i. e., Rowbotham ( 27), Gurdjian and Webster ( 28), and others such as Duke- Elder ( 29)) wrote about a " paralytic pupil" after optic nerve injury. Whether Yperman really meant by the words " blind beautiful eye" to describe a blind eye with a large pupil may remain an enigma. Versed in academic medicine of his time, which was mainly Galenic, together with knowledge of popular practices, he may have had the potential to recognize a " neuro- ophthalmologic" phenomenon. If so, one cannot escape a muse relating to the great mathematician and philosopher Whitehead's observation that " Everything of importance has been said before by someone who did not discover it." ( 30). Further study of Yperman's writings may shed light on more overlooked observations of practicing medieval surgeons and help to unfold the full spectrum of medicine of their time. REFERENCES 1. De Mets A. La chirurgie de Maitre Jehan Yperman ( 1260?- 1310?), Livres I et II, Traduits du vieux flamand d'apres les manuscrits de Cambridge et de Bruxelles. Paris: Editions Hippo-crate, 1936. 2. Broeckx MC. 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