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Nyctalopia in antiquity
Nyctalopia in Antiquity A Review of the Ancient Greek, Latin, and Byzantine Literature Dimitrios Brouzas, MD, Antonios Charakidas, MD, Michael Vasilakis, MD, Panagiotis Nikakis, MD, Dimitrios Chatzoulis, MD Objective: To investigate the original definition and use of the term nyctalopia in ancient medical literature in view of the controversy between the English and some continental European literatures. Design: Historical manuscript. Methods: We review the use of the term in ancient Greek, Roman, and early Byzantine medical literature (5th century BC–7th century AD) and include a quick reference to the theories on its etymology. Results: Physicians of antiquity defined as nyctalopia the symptom of defective dark adaptation, most commonly in the clinical setting of vitamin A deficiency. An alternative definition, the improvement of vision at night, is not recorded before the 2nd century AD and seems to result from a broader interpretation of the word, lacking medical acceptance at that time. Conclusions: We propose to the ophthalmic community the use of the term nyctalopia exclusively for the description of defective dark adaptation. Ophthalmology 2001;108:1917–1921 © 2001 by the American Academy of Ophthalmology. Nyctalopia is the rare example of a medical term that, because of controversial definition or inappropriate use, confuses rather than facilitates the communication among physicians of different linguistic backgrounds. For the English-speaking ophthalmologists, nyctalopia is a synonym for defective dark adaptation,1 whereas for most of the authors in continental Europe, notably French,2 Italian,3 and Greek,4 the word describes a relative improvement of vision at night. The purpose of this historical article is to investigate the original meaning of the term nyctalopia by reviewing its use in ancient Greek, Roman, and early Byzantine medical literature (5th century BC–7th century AD).
Materials and Methods We reviewed the relevant texts of ancient Greek, Latin, and Byzantine authors, following the references of Liddell & Scott’s Greek-English Lexicon, 9th edition (1940), Durling’s Dictionary of Medical Terms in Galen, Ed. E. J. Brill (1993), and the Thesaurus Linguae Graecae on CD-ROM (version 5.0, Silver Mountain Software Corp). We used established editions of each author’s work, quoting the English translation where it was available or translating ourselves from the original. In cases of conflicting versions, we assessed the stemma codicum, that is, the interdepen-
Originally received: June 29, 2000. Accepted: June 13, 2001. Manuscript no. 200388. From the “Hippocration” General Hospital of Athens, Athens, Greece. Correspondence to Dimitrios Brouzas, MD, 10 G. Papandreou Str, ByronAthens GR-162 31, Greece. E-mail: [email protected]. © 2001 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
dencies of the manuscripts on which each edition is founded to decide which translation to follow.
Results The first reference to the term is found in the works of Hippocrates (460 –379 BC), who repeatedly mentions nyctalopia or its derivatives nyctalope and nyctalopic in the sixth book of his Epidemics, describing what is known as the “epidemic of Perinthus”: Coughs began around the winter solstice . . . . Others had inflammation of the throat and others quinsy, others paralyses, others, primarily children, nyctalopia . . . . Nyctalopia did not develop subsequently in those with coughs or it quickly replaced the coughs. . . . The nyctalopia became established just as the affections from other causes. Nyctalopic problems developed mostly in children.5 In the book On Vision, Hippocrates proposes a treatment for nyctalopia: Nyctalope’s medicament: drink elaterion (⫽ a potent purgative) . . . and eat one or two livers of calf, as large as possible.6 Finally, in Prorrhetic II, a treatise on the prognostic value of signs and symptoms, Hippocrates offers the sole survived description of the term (Fig 1): Those who do not see at night, whom we call nyctalopes, are taken by the disease young, either as children or also as young men; they escape from it spontaneously, some on the fortieth day, others in seven months, and in others it lasts as much as a whole year. . . .7 Nevertheless, the presence of the negation “ . . . do not see at night . . . ” is not recorded in every survived manuscript of the HippoISSN 0161-6420/01/$–see front matter PII S0161-6420(01)00802-8
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Figure 1. Hippocrates, Prorrhetic II, §147: “Those who do not see at night, whom we call nyctalopes . . .”
cratic work.8 The older surviving copies of the archetype are found in the manuscripts coded I (Parisinus Graecus 2140, 13th century), Hb (Parisinus Graecus 2142, 14th century), and R (Vaticanus Graecus 277, 14th century).9 All three were copied from the now partially lost manuscript M (Marcianus Venetus Graecus 269, 11th century), the missing pages being the ones containing “Prorrhetic II” 9. Of the three older surviving manuscripts, I and Hb do not include the negation, whereas manuscript R clearly reads “ . . . do not see at night” (emphasis ours).10 The absence of a sufficiently old and established manuscript allows some speculation on the original intentions of the author. Aristotle11 and Galen,12,13 both of whom adopted the definition of impaired night vision, regarded Hippocrates as an authority, and it would have been almost out of the question to reverse his saying. Palladius, a 5th century AD scholar of Hippocratic work, in his commentary on the sixth book of Epidemics, quotes the great physician’s definition of nyctalopia as impaired night vision.14 In addition, given the proposed treatment of nyctalopia by Hippocrates, there are medical reasons to believe—as will be explained in the following section—that Hippocrates included the negation and regarded nyctalopia as the equivalent of defective night vision.
Aristotle (384 –322 BC), only a few years later, considered nyctalopia as a disease characterized by an impairment of nocturnal vision that affects “dark eyes,” although he obviously erred in the description of its mechanism (On the Creation of Animals, 780a; Fig 2): . . . the blue eyes do not see well during the day and the dark eyes during the night. . . . The glaucoma affects more the blue eyes and nyctalopia the dark eyes. . . . Nyctalopia is an abundance of fluids and affects mostly the young as their brain is more humid.11 Dioscourides Pedanius (1st century AD), a Greek physician who worked for the Roman military, was a famous researcher of the pharmaceutical properties of plants and herbs, and his treatise, De Materia Medica, was established as a reference book on pharmacology throughout antiquity and the Middle Ages. Dioscourides provided no definition, but noted that “against nyctalopia is useful the smearing [on the eyes] of blood from turtledove, woodpigeon, dove, grouse or wild goat. . . . Also smearing of the juices that run while the goat’s liver is grilled and consumption of the liver itself. . . .”15 An authority of the stature of Galen (130 –201 AD) is the first
Figure 2. Aristotle, On the Creation of Animals, §780a: “. . . the dark eyes (do not see) during the night . . . nyctalopia (affects) the dark eyes . . .”
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Figure 3. Galen, Opera Omnia vol XIX, Interpretation of Hippocrates’ terms: “Nyctalopes: these who are blind at night”
to mention a second definition of nyctalopia. An ardent student and admirer of the Hippocratic Corpus, Galen himself wrote extensively, and his definition of the term seems to be clear and precise when he writes, “Nyctalopes: these who are blind at night,”12 (Fig 3) and also that, “They call nyctalope . . . someone who appears not to see at night.”13 It is in his book Commentaries on Hippocrates’ Sixth Book of Epidemics that Galen, with an apparent amazement, provides a second definition of the word: Nyctalopia is the condition when someone can see neither in the moon’s light nor in the light of lanterns . . . but so also call a disease where the opposite is observed, namely to see better at night than the day. Some confirm that the word that describes night-blindness is also used for these patients, so that eventually the word describes two kinds of diseases: the disease where we do not see at night and the one where we do not see during the day.16 Although it seems that Galen accepted as correct the mainstream definition of nyctalopia as impaired night vision, he could not conceal the fact that “some” interpret the term differently. This is the first quotation of an alternative use, probably emerging as a novelty sometime during the Roman period. Galen’s therapeutic approach also consists of the time-honored regimen of grilled goat’s liver, the smearing of the eyes with “ichor,” that is, the juices of the grilled meat, and the exposure of the diseased eyes to the steam of the grill.17 The German scholar Karl-Gottlob Ku¨hn published the first comprehensive edition of Galen’s works in 1825, but subsequent research concluded that some of the texts were written not by Galen himself but by a group of unknown authors collectively dubbed “Pseudo-Galen.” Two references to nyctalopia are found in their works, the one declaring that “those who suffer from it do not see during the day, but are able to see at night”18 and the other defining as nyctalopes “ . . . those who see worse in daytime, but better when the sun sets and even better at night. Or on the
contrary, those who see little during the day, but nothing at all at night.”19 Despite their anonymity, these authors unmistakably convey the message that by the 2nd century AD, nyctalopia possessed two meanings. In the 4th century, however, the Byzantine physician Oribasius (325– 403 AD) records in his Synopsis to Eustathius only one of the definitions: “They call nyctalope, someone who sees well during the day, but when the sun sets sees worse and during the night can see nothing.”20 In his extensive work, Oribasius rescued many of his predecessors’ theories and it is likely that this particular definition directly reflects the views of Galen, whose authority Oribasius highly esteems “since he makes use of the most exact methods and definitions, following the Hippocratic principles and opinions.”21 Following the practice of compiling and editing the works of the great physicians of antiquity, the 5th century AD scholar Palladius studied the Hippocratic Corpus and remarked that the nyctalopes “see during the day but do not see at night.”14 Because the Hippocratic text was the basis of Palladius’ work, this little but important excerpt offers as well a unique insight into Hippocrates’ own beliefs on the subject. The definition of nyctalopia provided by the physician Aetius Amidenus in the 6th century AD is equivocal. In his Medical Books, Aetius writes that “ . . . they call nyctalopia [the condition], when someone sees well during the day, worse at sunset and when the night falls can see nothing,” to which he adds that “ . . . to some it also happens to see better at night and worse during the day and if the moon is shining to see nothing. This is rare, while the first happens in the majority of cases.”22 Therefore, Aetius definitely confirms the rare use of the word with the meaning of relative improvement of vision at night as Galen and Pseudo-Galenic authors did before him. Another physician of the same era, Alexander of Tralles (525– 605 AD), proposes the classic therapy of goat’s liver “for those who do not see late at night, whom we call nyctalopes.”23 A few years later, Paulus Aegineta (625– 690 AD) wrote: “They call
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Ophthalmology Volume 108, Number 10, October 2001 nyctalope, someone who sees well during the day, but when the sun sets sees worse and during the night can see nothing.”24 Finally, an indirect confirmation of the fact that nyctalopia was meant as a condition of night visual impairment comes from Ali Abu ibn Sina (980 –1037 AD), the most famous and influential of the philosopher-scientists of Islam, known in the West as Avicenna. This ethnic Persian was particularly noted for his contributions in the fields of Aristotelian philosophy and medicine, and his book al Qanum fi al-Tibb (Canon of Medicine), an immense codification of the whole of Ancient and Muslim medical knowledge, includes an extensive reference to “blindness of the night.” Apparently influenced by Aristotle’s views, Avicenna wrote: During the day one can see, but in the end of the day vision weakens. The reason for this seems to be the excessive fluid in the eyes and its condensation . . . . [Night-blindness] more often presents in dark-eyed and not blue-eyed persons, and in those with small pupils and not wide ones . . . .25 Not surprisingly, recommended treatment for the “blindness of the night” included the familiar “nyctalopic” regimen of “juice of goat’s liver on which several cuts with a knife are made” and that is “smeared on the eyes together with Indian salt and long pepper. Sometimes they add these spices while it is being grilled and the sick person should lean over the vapor and then eat the grilled liver.”25
Discussion The survived texts of the ancient medical literature provide enough evidence to conclude that, throughout antiquity, the term nyctalopia described the symptom of defective dark adaptation. Nonetheless, by the 2nd century AD, an alternative definition of nyctalopia, the ability to see better at night than during the day, must also have been available, as Galen, Pseudo-Galenic authors, and Aetius reported. A reference to the etymology of nyctalopia and the study of the therapeutic regimen proposed by the ancient physicians may cast some light on this controversy. Scholars have not yet reached agreement on the exact origin of the word nyctalops (nyctalope), from which the derivatives nyctalopia and nyctalopic are also formed. Two different etymologies have been proposed, the first one assigning to the term a broader meaning and the other providing a more limited and specific definition. The first theory, supported among others by Liddell and Scott in their Greek-English Lexicon,26 suggested that the term derives from the words Nyct- 共 ⫽ night兲 ⫹ ops 共 ⫽ eye, vision兲, (“Nyct-” is the root of the word “nyx” [⫽night, nominative case]) meaning “a condition of night vision” but not specifically positive or negative. According to the second proposed etymology, the word derives from Nyct- 共 ⫽ night兲 ⫹ alaos 共 ⫽ blind兲 ⫹ ops 共 ⫽ eye, vision兲, literally meaning “a condition of night-blindness.” This view is supported not only by Webster’s English Dictionary,27 but also by lexicographers since as early as the 12th
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century. The prominent Byzantine author Eustathius (1115– 1195) vividly noted in his Commentaries on Homer’s Odyssey, referring to the composite words deriving from alaos, “nyctalope: the one with blind eyes at night.”28 Another word used by some European medical literature for the description of impaired night vision, albeit incorrectly, is the term hemeralopia, which derives from the same roots as nyctalopia with substitution of the component ‘nyct’ (night) with ‘hemer’ (day). This word first appeared in a list of ophthalmic diseases in Pseudo-Galen’s Introduction29 without any explanation concerning its meaning and use. The fact that this passage is of disputed originality and that the word does not reappear in ancient literature casts doubt on the consistent use of this term in antiquity. The therapeutic approach, nevertheless, may provide a clearer insight to the nature of nyctalopia because ancient physicians unanimously accept liver and liver derivatives as treatment for the disease. Hippocrates proposed “ . . . one or two livers of calf, as large as possible,”6 and Dioscourides noted that “against nyctalopia . . . smearing [on the eyes] of the juices that run while the goat’s liver is grilled and consumption of the liver itself . . . .”15 Galen advised consumption “ . . . of grilled goat’s liver,” the smearing of the eyes with “ichor,” that is, the juices of the grilled meat, and the exposure of the diseased eyes to the steam of the grill,17 and Alexander of Tralles proposed a similar regimen. This therapy also was adopted in medieval Arabic and Muslim ophthalmic literature. Apart from Avicenna’s Canon, references on a similar treatment for “al ama al laily” or “al ashaoua” (nyctalopia) appear in texts of Hunain Ibn Is-Haq (809 – 877 AD),30 in Tadhirat al-Kahhalin,31 (A Manual) written by Ali ibn Isa, a famous Arab oculist who flourished in Baghdad in the first half of the 11th century. Kitab al-muntakhab fi ilaz al-ain32 (Book of Selective Eye Diseases), written by Ammar ibn Ali al-Mawsili, who was a contemporary of Ali ibn Isa working in Egypt, also offered reference to nyctalopia and its therapeutic regimen. In the historical and social setting of that era, chronic malnutrition was common for large parts of the population, especially children. Because liver is a known source of vitamin A, it is tempting to speculate that the nyctalopia mentioned by the ancient physicians was mainly the defective dark adaptation of vitamin A deficiency.
Conclusions The ancient authors used the term nyctalopia mainly to define the symptom of impaired dark adaptation. The present use of the word in some of the continental European literature, the one that denotes a relative improvement of vision at night, has a long history of its own because, however rare or inappropriate, it has existed at least since the 2nd century AD. Nevertheless, a medical term with two contradictory definitions is obviously a paradox. To overcome the present confusion, we propose to the ophthalmic community the sole use of the term nyctalopia for the description of defective dark adaptation, this definition likely being closer to its original meaning.
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References 1. Kanski JJ. Clinical Ophthalmology: A Systematic Approach, 4th ed. Boston: Butterworth-Heinemann, 1999;439. 2. Cassell’s French-English Dictionary. Avon: The Bath Press, 1988;517. 3. Macchi V, ed. Italian-English Dictionary, 2nd ed. Firenze: Sansoni, 1981;1482. 4. Babiniotis G. Dictionary of Modern Greek Language. Athens: Center of Lexicology 1997;1214. 5. Smith WD. trans-ed. Hippocrates, Vol. VII. Cambridge: Harvard University Press, 1994;269 –71. 6. Joly R, Hippocrate, De la vision. Paris: Belles Lettres C.U.F. 1978;171. 7. De Mercy M. Prognostics et Prorrhe´tiques D’ Hippocrate. Paris: Crochard 1815;353. 8. Potter P. Hippocrates, Vol. VIII. Cambridge, MA: Harvard University Press, 1994;281–3. 9. Potter P. Hippocrates, Vol. VIII. Cambridge: Harvard University Press, 1994;1– 4. 10. Grmek MD, ed. Hippocratica, Actes du Colloque Hippocratique de Paris. Paris: E´ditions du Centre National de la Recherche Scientifique, 1980;175. 11. Lulofs Drossaart HJ, ed. Aristotelis De Generatione Animalium. Oxford: Oxford Classical Texts, 1965;178 –9. 12. Ku¨hn KG. Claudii Galeni Opera Omnia, Vol. XIX. Leipzig: Officı´na Libraria Car. Cnoblochii, 1830;124. 13. Ku¨hn KG. Claudii Galeni Opera Omnia, Vol X. Leipzig: Officı´na Libraria Car. Cnoblochii, 1825;84. 14. Dietz FR. Scholia in Hippocratis de popularibus morbis librum VI. Ko¨nigsberg: Borntraeger 1834;181–2. 15. Goodyer J. Dioscorides De Materia Medica. Oxford: Oxford University Press, 1934;II:79.1, II.45.1. 16. Wenkebach E. In Hippocratis epidemiarum librum VI commentaria. Corpus Medicorum Graecorum V, 10, 2, 2. Berlin: Academia litterarum 1956;387–90. 17. Ku¨hn, KG. Claudii Galeni Opera Omnia, Vol XII. Leipzig: Officı´na Libraria Car. Cnoblochii, 1827;802–3.
18. Ku¨hn KG. Definitiones medicae, Vol XIX. Leipzig: Officı´na Libraria Car. Cnoblochii, 1830;343, 435. 19. Ku¨hn KG. Introductio seu medicus, Vol XIV. Leipzig: Officı´na Libraria Car. Cnoblochii, 1827;16, 776. 20. Raeder J. Oribasii Synopsis ad Eustathium. Leipzig: B. G. Teubner, 1926; 266. 21. Grant M. Dieting for an Emperor: A Translation of Books 1 and 4 of Oribasius’ Medical Compilations. New York: Brill, 1997;5. 22. Olivier A. Aetii Amideni Libri Medicinales V–VIII. Berlin: Academia litterarum 1950;301. 23. Puschmann T. Alexander von Tralles Therapeutica. Vienne: W. Braumu¨ller, 1879; vol II, 47. 24. Heiberg IL. Epitomae medicae libri septem. Corpus Medicorum Graecorum IX, Book 3. Leipzig–Berlin: B. G. Teubner 1921; 22–29. 25. Abu Ali ibn Sina. Canon of Medicine. Book III, Part 3, Art.4 §3. Tashkent, Uzbekistan: Fanlar Nasrioti Academy 1958;280. 26. Liddell H, Scott R. Greek-English Lexicon, 9th ed. Oxford: Clarendon Press, 1940;1183. 27. Grove PB, editor-in-chief. Webster’s Third New International Dictionary of the English Language unabridged. Springfield, MA: Merriam-Webster, 1986;1553. 28. Devar M. Index in Eustathii commentarios in Homeri Iliadem et Odysseam. Hildesheim New York: Georg Olms Verlag 1970;328. 29. Ku¨hn KG. Introductio seu medicus, Vol XIV. Leipzig: Officı´na Libraria Car. Cnoblochii 1827; 15, 768. 30. Meyerhof M, trans. The Book of the Ten Treatises on the Eye Ascribed to Hunain Ibn Is-Haq. Cairo: Government Press, 1928;121. 31. Wood CA. Memorandum Book of a Tenth-century Oculist for the Use of Modern Ophthalmologists. A Translation of the Tadhkirat of Ali ibn Isa of Baghdad (cir. 940 –1010 A.D.), the Most Complete Practical and Original of All the Early Textbooks on the Eye and Its Diseases. Chicago: Northwestern University, 1936; 125. 32. Hirschberg J, Lippert J, Mittwoch E. Ammar b. Ali al-Mausili. Das Buch der Auswahl von den Augenkrankheiten. Leipzig: Veit, 1905; 57.
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Materials and Methods We reviewed the relevant texts of ancient Greek, Latin, and Byzantine authors, following the references of Liddell & Scott’s Greek-English Lexicon, 9th edition (1940), Durling’s Dictionary of Medical Terms in Galen, Ed. E. J. Brill (1993), and the Thesaurus Linguae Graecae on CD-ROM (version 5.0, Silver Mountain Software Corp). We used established editions of each author’s work, quoting the English translation where it was available or translating ourselves from the original. In cases of conflicting versions, we assessed the stemma codicum, that is, the interdepen-
Originally received: June 29, 2000. Accepted: June 13, 2001. Manuscript no. 200388. From the “Hippocration” General Hospital of Athens, Athens, Greece. Correspondence to Dimitrios Brouzas, MD, 10 G. Papandreou Str, ByronAthens GR-162 31, Greece. E-mail: [email protected]. © 2001 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
dencies of the manuscripts on which each edition is founded to decide which translation to follow.
Results The first reference to the term is found in the works of Hippocrates (460 –379 BC), who repeatedly mentions nyctalopia or its derivatives nyctalope and nyctalopic in the sixth book of his Epidemics, describing what is known as the “epidemic of Perinthus”: Coughs began around the winter solstice . . . . Others had inflammation of the throat and others quinsy, others paralyses, others, primarily children, nyctalopia . . . . Nyctalopia did not develop subsequently in those with coughs or it quickly replaced the coughs. . . . The nyctalopia became established just as the affections from other causes. Nyctalopic problems developed mostly in children.5 In the book On Vision, Hippocrates proposes a treatment for nyctalopia: Nyctalope’s medicament: drink elaterion (⫽ a potent purgative) . . . and eat one or two livers of calf, as large as possible.6 Finally, in Prorrhetic II, a treatise on the prognostic value of signs and symptoms, Hippocrates offers the sole survived description of the term (Fig 1): Those who do not see at night, whom we call nyctalopes, are taken by the disease young, either as children or also as young men; they escape from it spontaneously, some on the fortieth day, others in seven months, and in others it lasts as much as a whole year. . . .7 Nevertheless, the presence of the negation “ . . . do not see at night . . . ” is not recorded in every survived manuscript of the HippoISSN 0161-6420/01/$–see front matter PII S0161-6420(01)00802-8
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Figure 1. Hippocrates, Prorrhetic II, §147: “Those who do not see at night, whom we call nyctalopes . . .”
cratic work.8 The older surviving copies of the archetype are found in the manuscripts coded I (Parisinus Graecus 2140, 13th century), Hb (Parisinus Graecus 2142, 14th century), and R (Vaticanus Graecus 277, 14th century).9 All three were copied from the now partially lost manuscript M (Marcianus Venetus Graecus 269, 11th century), the missing pages being the ones containing “Prorrhetic II” 9. Of the three older surviving manuscripts, I and Hb do not include the negation, whereas manuscript R clearly reads “ . . . do not see at night” (emphasis ours).10 The absence of a sufficiently old and established manuscript allows some speculation on the original intentions of the author. Aristotle11 and Galen,12,13 both of whom adopted the definition of impaired night vision, regarded Hippocrates as an authority, and it would have been almost out of the question to reverse his saying. Palladius, a 5th century AD scholar of Hippocratic work, in his commentary on the sixth book of Epidemics, quotes the great physician’s definition of nyctalopia as impaired night vision.14 In addition, given the proposed treatment of nyctalopia by Hippocrates, there are medical reasons to believe—as will be explained in the following section—that Hippocrates included the negation and regarded nyctalopia as the equivalent of defective night vision.
Aristotle (384 –322 BC), only a few years later, considered nyctalopia as a disease characterized by an impairment of nocturnal vision that affects “dark eyes,” although he obviously erred in the description of its mechanism (On the Creation of Animals, 780a; Fig 2): . . . the blue eyes do not see well during the day and the dark eyes during the night. . . . The glaucoma affects more the blue eyes and nyctalopia the dark eyes. . . . Nyctalopia is an abundance of fluids and affects mostly the young as their brain is more humid.11 Dioscourides Pedanius (1st century AD), a Greek physician who worked for the Roman military, was a famous researcher of the pharmaceutical properties of plants and herbs, and his treatise, De Materia Medica, was established as a reference book on pharmacology throughout antiquity and the Middle Ages. Dioscourides provided no definition, but noted that “against nyctalopia is useful the smearing [on the eyes] of blood from turtledove, woodpigeon, dove, grouse or wild goat. . . . Also smearing of the juices that run while the goat’s liver is grilled and consumption of the liver itself. . . .”15 An authority of the stature of Galen (130 –201 AD) is the first
Figure 2. Aristotle, On the Creation of Animals, §780a: “. . . the dark eyes (do not see) during the night . . . nyctalopia (affects) the dark eyes . . .”
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Figure 3. Galen, Opera Omnia vol XIX, Interpretation of Hippocrates’ terms: “Nyctalopes: these who are blind at night”
to mention a second definition of nyctalopia. An ardent student and admirer of the Hippocratic Corpus, Galen himself wrote extensively, and his definition of the term seems to be clear and precise when he writes, “Nyctalopes: these who are blind at night,”12 (Fig 3) and also that, “They call nyctalope . . . someone who appears not to see at night.”13 It is in his book Commentaries on Hippocrates’ Sixth Book of Epidemics that Galen, with an apparent amazement, provides a second definition of the word: Nyctalopia is the condition when someone can see neither in the moon’s light nor in the light of lanterns . . . but so also call a disease where the opposite is observed, namely to see better at night than the day. Some confirm that the word that describes night-blindness is also used for these patients, so that eventually the word describes two kinds of diseases: the disease where we do not see at night and the one where we do not see during the day.16 Although it seems that Galen accepted as correct the mainstream definition of nyctalopia as impaired night vision, he could not conceal the fact that “some” interpret the term differently. This is the first quotation of an alternative use, probably emerging as a novelty sometime during the Roman period. Galen’s therapeutic approach also consists of the time-honored regimen of grilled goat’s liver, the smearing of the eyes with “ichor,” that is, the juices of the grilled meat, and the exposure of the diseased eyes to the steam of the grill.17 The German scholar Karl-Gottlob Ku¨hn published the first comprehensive edition of Galen’s works in 1825, but subsequent research concluded that some of the texts were written not by Galen himself but by a group of unknown authors collectively dubbed “Pseudo-Galen.” Two references to nyctalopia are found in their works, the one declaring that “those who suffer from it do not see during the day, but are able to see at night”18 and the other defining as nyctalopes “ . . . those who see worse in daytime, but better when the sun sets and even better at night. Or on the
contrary, those who see little during the day, but nothing at all at night.”19 Despite their anonymity, these authors unmistakably convey the message that by the 2nd century AD, nyctalopia possessed two meanings. In the 4th century, however, the Byzantine physician Oribasius (325– 403 AD) records in his Synopsis to Eustathius only one of the definitions: “They call nyctalope, someone who sees well during the day, but when the sun sets sees worse and during the night can see nothing.”20 In his extensive work, Oribasius rescued many of his predecessors’ theories and it is likely that this particular definition directly reflects the views of Galen, whose authority Oribasius highly esteems “since he makes use of the most exact methods and definitions, following the Hippocratic principles and opinions.”21 Following the practice of compiling and editing the works of the great physicians of antiquity, the 5th century AD scholar Palladius studied the Hippocratic Corpus and remarked that the nyctalopes “see during the day but do not see at night.”14 Because the Hippocratic text was the basis of Palladius’ work, this little but important excerpt offers as well a unique insight into Hippocrates’ own beliefs on the subject. The definition of nyctalopia provided by the physician Aetius Amidenus in the 6th century AD is equivocal. In his Medical Books, Aetius writes that “ . . . they call nyctalopia [the condition], when someone sees well during the day, worse at sunset and when the night falls can see nothing,” to which he adds that “ . . . to some it also happens to see better at night and worse during the day and if the moon is shining to see nothing. This is rare, while the first happens in the majority of cases.”22 Therefore, Aetius definitely confirms the rare use of the word with the meaning of relative improvement of vision at night as Galen and Pseudo-Galenic authors did before him. Another physician of the same era, Alexander of Tralles (525– 605 AD), proposes the classic therapy of goat’s liver “for those who do not see late at night, whom we call nyctalopes.”23 A few years later, Paulus Aegineta (625– 690 AD) wrote: “They call
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Ophthalmology Volume 108, Number 10, October 2001 nyctalope, someone who sees well during the day, but when the sun sets sees worse and during the night can see nothing.”24 Finally, an indirect confirmation of the fact that nyctalopia was meant as a condition of night visual impairment comes from Ali Abu ibn Sina (980 –1037 AD), the most famous and influential of the philosopher-scientists of Islam, known in the West as Avicenna. This ethnic Persian was particularly noted for his contributions in the fields of Aristotelian philosophy and medicine, and his book al Qanum fi al-Tibb (Canon of Medicine), an immense codification of the whole of Ancient and Muslim medical knowledge, includes an extensive reference to “blindness of the night.” Apparently influenced by Aristotle’s views, Avicenna wrote: During the day one can see, but in the end of the day vision weakens. The reason for this seems to be the excessive fluid in the eyes and its condensation . . . . [Night-blindness] more often presents in dark-eyed and not blue-eyed persons, and in those with small pupils and not wide ones . . . .25 Not surprisingly, recommended treatment for the “blindness of the night” included the familiar “nyctalopic” regimen of “juice of goat’s liver on which several cuts with a knife are made” and that is “smeared on the eyes together with Indian salt and long pepper. Sometimes they add these spices while it is being grilled and the sick person should lean over the vapor and then eat the grilled liver.”25
Discussion The survived texts of the ancient medical literature provide enough evidence to conclude that, throughout antiquity, the term nyctalopia described the symptom of defective dark adaptation. Nonetheless, by the 2nd century AD, an alternative definition of nyctalopia, the ability to see better at night than during the day, must also have been available, as Galen, Pseudo-Galenic authors, and Aetius reported. A reference to the etymology of nyctalopia and the study of the therapeutic regimen proposed by the ancient physicians may cast some light on this controversy. Scholars have not yet reached agreement on the exact origin of the word nyctalops (nyctalope), from which the derivatives nyctalopia and nyctalopic are also formed. Two different etymologies have been proposed, the first one assigning to the term a broader meaning and the other providing a more limited and specific definition. The first theory, supported among others by Liddell and Scott in their Greek-English Lexicon,26 suggested that the term derives from the words Nyct- 共 ⫽ night兲 ⫹ ops 共 ⫽ eye, vision兲, (“Nyct-” is the root of the word “nyx” [⫽night, nominative case]) meaning “a condition of night vision” but not specifically positive or negative. According to the second proposed etymology, the word derives from Nyct- 共 ⫽ night兲 ⫹ alaos 共 ⫽ blind兲 ⫹ ops 共 ⫽ eye, vision兲, literally meaning “a condition of night-blindness.” This view is supported not only by Webster’s English Dictionary,27 but also by lexicographers since as early as the 12th
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century. The prominent Byzantine author Eustathius (1115– 1195) vividly noted in his Commentaries on Homer’s Odyssey, referring to the composite words deriving from alaos, “nyctalope: the one with blind eyes at night.”28 Another word used by some European medical literature for the description of impaired night vision, albeit incorrectly, is the term hemeralopia, which derives from the same roots as nyctalopia with substitution of the component ‘nyct’ (night) with ‘hemer’ (day). This word first appeared in a list of ophthalmic diseases in Pseudo-Galen’s Introduction29 without any explanation concerning its meaning and use. The fact that this passage is of disputed originality and that the word does not reappear in ancient literature casts doubt on the consistent use of this term in antiquity. The therapeutic approach, nevertheless, may provide a clearer insight to the nature of nyctalopia because ancient physicians unanimously accept liver and liver derivatives as treatment for the disease. Hippocrates proposed “ . . . one or two livers of calf, as large as possible,”6 and Dioscourides noted that “against nyctalopia . . . smearing [on the eyes] of the juices that run while the goat’s liver is grilled and consumption of the liver itself . . . .”15 Galen advised consumption “ . . . of grilled goat’s liver,” the smearing of the eyes with “ichor,” that is, the juices of the grilled meat, and the exposure of the diseased eyes to the steam of the grill,17 and Alexander of Tralles proposed a similar regimen. This therapy also was adopted in medieval Arabic and Muslim ophthalmic literature. Apart from Avicenna’s Canon, references on a similar treatment for “al ama al laily” or “al ashaoua” (nyctalopia) appear in texts of Hunain Ibn Is-Haq (809 – 877 AD),30 in Tadhirat al-Kahhalin,31 (A Manual) written by Ali ibn Isa, a famous Arab oculist who flourished in Baghdad in the first half of the 11th century. Kitab al-muntakhab fi ilaz al-ain32 (Book of Selective Eye Diseases), written by Ammar ibn Ali al-Mawsili, who was a contemporary of Ali ibn Isa working in Egypt, also offered reference to nyctalopia and its therapeutic regimen. In the historical and social setting of that era, chronic malnutrition was common for large parts of the population, especially children. Because liver is a known source of vitamin A, it is tempting to speculate that the nyctalopia mentioned by the ancient physicians was mainly the defective dark adaptation of vitamin A deficiency.
Conclusions The ancient authors used the term nyctalopia mainly to define the symptom of impaired dark adaptation. The present use of the word in some of the continental European literature, the one that denotes a relative improvement of vision at night, has a long history of its own because, however rare or inappropriate, it has existed at least since the 2nd century AD. Nevertheless, a medical term with two contradictory definitions is obviously a paradox. To overcome the present confusion, we propose to the ophthalmic community the sole use of the term nyctalopia for the description of defective dark adaptation, this definition likely being closer to its original meaning.
Brouzas et al 䡠 Nyctalopia in Antiquity
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