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Intellectual History

of the Islamicate World 6 (2018) 27–54


brill.com/ihiw

Medical Crises and Critical Days in Avicenna and


After: Insights from the Commentary Tradition

Glen M. Cooper
Pitzer College
glenmcooper@gmail.com

Abstract

Conceptualized as a relationship between the patient, his illness, its resolution, the
celestial bodies, and the doctor, and expressed through metaphors, such as divine
judgment, or effects of the stars, crises and critical days were important elements of
Galenic therapy. While the early Arabic physicians maintained Galenic imagery, Ibn
Sīnā (d. 1037ce) and his followers introduced new imagery that omitted supernatural
influences, and emphasized physical agents. The crisis was now described as a sep-
aration instead of a verdict, and the critical days were caused by the lunar phases
alone. The “body politic” metaphor was introduced to describe medical crises. By
closely examining the writings of Ibn al-Nafīs (d. 1288 ce) on the Canon of Ibn Sīnā
and the Aphorisms of Hippocrates, these shifts in imagery are analysed in detail, and
their implications for our understanding of a period that has been dismissed as “post-
decline” and devoid of innovation.

Keywords

Galenic medicine – body politic metaphor – Ibn Sīnā – Ibn al-Nafīs – medical astrol-
ogy – critical days – medical crises – Arabic medical commentaries

© koninklijke brill nv, leiden, 2018 | doi: 10.1163/2212943X-00601006


28 cooper

Introduction1

The doctrine of medical crises and their associated critical days were impor-
tant parts of Galenic medicine at all of its historical phases, and vestiges of
these concepts survived in medical practice into the modern period, long after
Galenism had been superseded. Mentioned in the Hippocratic writings, but
first formulated theoretically by Galen, crisis doctrine presented a nexus of
medical and astrological concepts and practices, and promised to provide the
physician with prognostic insights into the unfolding of a patient’s disease.
Because of their bases in empirical observation, crises and critical days were
discussed whenever empirical arguments were invoked against astrology.
The crisis doctrine entered Arabic medical thought by the first half of the
ninth century ce.2 Al-Kindī (d. 866 ce) offered an explanation of the criti-
cal days based on the geometrical properties of numbers derived from Nico-
machus of Gerasa (d. c. 120 ce).3 The result was an a priori theory that only
poorly approximates the traditional critical day series. His approach was super-
seded by Ḥunayn’s translations of Galen’s Crises and Critical Days.4
The crisis doctrine seems to have remained fairly stable, in the basic form
that Ḥunayn’s translation cast it, until the Canon of Ibn Sīnā (d. 1037ce).
With the Canon, and in at least one commentary tradition on it, there were
significant conceptual and terminological shifts in crisis doctrine. The present
article will discuss these changes, some of which occurred in the Canon, and
others in the writings of its most famous commentator, Ibn al-Nafīs (d. 1288 ce).
His works to be considered are: Commentary on the Hippocratic Aphorisms5 and

1 This article originated as a paper given at the Arabic Commentaries on the Hippocratic Apho-
risms Conference, University of Manchester, April 9–11, 2015. Many thanks to the organizers
of that conference.
2 See for example, the Alexandrian Summary of Galen’s Critical Days, which seems to have
been available in Arabic before Hunayn’s translation: Bos and Langermann, The Alexandrian
Summaries of Galen’s On Critical Days. Also, Cooper, “Review of G. Bos and Y.T. Langermann,
The Alexandrian Summaries.”
3 Nicomachus, Introductio Arithmeticae, Book i, Ch. 19 (ed. Hoche 1886: 49–55) and Book ii,
Ch. 17 (ed. Hoche 1886: 108–112); (= Introduction to Arithmetic, transl. D’Ooge 1926: 215–220,
and 254–257). For a discussion of how al-Kindī employed the geometrical properties of these
numbers, see the Introduction to Cooper, Galen, De diebus decretoriis, from Greek into Arabic,
pp. 30–33.
4 For al-Kindī’s treatise, see: Klein-Franke, “Die Ursachen der Krisen.” And discussion in:
Cooper, “Rational and Empirical Medicine,” pp. 89–92.
5 Sharḥ fuṣūl Abuqrāṭ, Cairo, 1991.

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medical crises and critical days in avicenna and after 29

Commentary on the Canon6 as well as Epitome of Medicine7 Although there is


some doubt about the authorship of the Epitome, as N. Fancy has argued, its
contents appear to be consistent with the Ibn Sīnā/Ibn al-Nafīs tradition, at
least where crisis theory is concerned.8
These changes include conceptual shifts as well as changes in the astronom-
ical parameters employed in the calculation of the critical days. First, with Ibn
Sīnā, buḥrān (the term used by Ḥunayn ibn Isḥāq to render κρίσις in Arabic)
has moved away from the earlier Syriac sense of “trial or test”, which accurately
reflected Galen’s original judicial sense, and toward faṣl (“division or separa-
tion”), a concept that emphasizes different senses of κρίσις. I shall propose
possible reasons why this happened, and discuss implications of this shift for
the understanding of crisis theory in Arabic.
Second, with Ibn Sīnā, and even more so with Ibn al-Nafīs, there is a greater
emphasis on battle imagery when describing crises than in Galen. Moreover,
new metaphors are introduced, such as the “body politic”, namely, comparing
the patient’s body to a city under the rule of nature as a benevolent king, and
the disease to a besieging enemy, with the crisis as combat between these two
adversaries. I suggest where this imagery may have been derived, and outline
its implications.
Lastly, there are significant changes to the underlying astronomical scheme
for critical day theory, beginning in Ibn Sīnā, and expanded in Ibn al-Nafīs.
I discuss reasons why these changes were introduced and their implications
for the ongoing conceptual relationship between medicine and astrology. In
brief, this new approach retained all of the empirical elements of crisis doctrine
that could actually be observed and measured, but discarded astrological or
superstitious parts that could suggest that crises manifest some sort of divine
or supernatural judgment on the patient.
These findings are consistent with those of other scholars studying the
post-Avicenna Islamic world. In recent years the periodization paradigms of
Islamic intellectual history have been reassessed, and what scholars used to
regard as a period of decline—which produced many commentaries, which
they supposed were derivative—upon closer examination yields evidence of
creative activity in all fields, such as in astronomy and philosophy, as well as in
medicine. Latin medievalists have long known that commentaries were often
the best place for a scholar to circulate his insights and discoveries: associating

6 Sharḥ al-qānūn, Ms. London, Wellcome, Or. 51. A.Z. Iskandar, A Catalogue of Arabic Manu-
scripts, pp. 38–40, 180–181.
7 Mūjiz fī al-Ṭibb, Cairo, 1986.
8 Fancy, Science and Religion in Mamluk Egypt, pp. 116–120.

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30 cooper

one’s writings with a classic text, such as the Canon, enhanced the possibility
that one’s own ideas would be studied along with the Master’s.9
The plan of the present article is as follows: First, the Galenic background
of crisis theory will be sketched, by comparison with which Ibn Sīnā’s and
Ibn al-Nafīs’s modifications can be understood. Then, representative passages
from the Commentary on the Canon and the Commentary on the Hippocratic
Aphorisms, as well as the Epitome of Medicine, in order to illustrate these
innovations.

Galenic Conceptual Background

In the Greek medical tradition, medical crisis theory consisted of two parts: the
crises and the critical days. Crises first. According to Galen, a medical crisis is
the often traumatic and violent cluster of symptoms through which harmful
material, which was thought to be causing the illness, is expelled from the
body.10 This is sometimes manifested as rigour, vomiting, excessive sweating,
nosebleed, etc. A crisis also represents the turning point of an illness, after
which the patient is thought either to recover or to relapse.11 In order to know
whether a complete or trustworthy crisis has occurred, one must be able to
determine that the harmful substance has actually been neutralized by the
body (through a process of concoction or “cooking”).12 Since one cannot peer
directly into the body, the signs of concoction are sought in the substances
evacuated from the three major organ regions: the head (via nasal secretions),
the respiratory organs (via the sputums), and the abdominal organs (via urines
and excrements).13 The physician sought evidence of a coalescence in these
fluids: e.g. a runny nose does not represent concoction—hence a complete

9 For an example of this new approach in Arabic studies, see A. Ahmed, “Post-Classical
Philosophical Commentaries.”
10 Galen, De crisibus. See also Galenos Περὶ κρίσεων, ed. B. Alexanderson, k 9,550,1–552,10
(Alexanderson ed., pp. 69,1–70,14), where “crisis” is defined. Also, Galen, Critical Days,
k 9,771,5–9 (Cooper ed., pp. 98–99).
11 Galen, Critical Days, k 9,769,1–770,5 (Cooper ed., pp. 96–97).
12 The Hippocratic writings refer to this process often, e.g. Epidemics i, ii (Loeb, ed. W.H.S.
Jones, pp. 150–151). For a discussion of this concept (pepsis) in Aristotle, see G.E.R. Lloyd,
“The Master Cook,” pp. 83–86.
13 Most of Galen’s Crises is devoted to showing the reader how to infer the states of each
organ system from these substances. See Galen, Crises, k 705,15–706,14 (Alexanderson ed.,
p. 169, 5–19).

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medical crises and critical days in avicenna and after 31

crisis—until it produces a more solid green matter. Not clear urine, but urine
with a heavy sediment, indicates a concoction. Nor watery stools, but stools,
even if diarrhea, with visibly coalesced matter.
Crises were thought to occur more frequently on specific days after the
illness began, known as the critical days, the most important of which were
days 4, 7, 11, 14, 17 and 20, which feature prominently in the patients’ case
histories of the Hippocratic Epidemics. These days offered a handy way to
predict the course of certain illnesses. The Hippocratics derived this series of
days initially from observation, after which they attempted to “explain” them
via an idiosyncratic way of counting four and seven day periods, whereby some
of the adjacent intervals overlap and others are separate.14 Galen, however,
generates them as multiples of a numerical parameter, which he derives in the
Critical Days from the lunar periods.15 Ibn Sīnā and Ibn al-Nafīs offer their own
parameters, as I shall explain.
A medical astrological approach, merely suggested by Galen, but developed
later by others, employed the moon in aspect with the signs of the zodiac
to predict the character of the upcoming crises. The beginning point of the
illness was first determined, and then the critical days scheme was placed
over it. One could leave it at that, merely applying the critical days template
over the beginning time to predict when the critical days would occur, or
one could, in addition, cast a full horoscope of the illness, from the time
of its “birth,” complete with all the elements of horoscopic astrology.16 The
distinction between these two approaches was that the former considered only
the physical effects of the planets, via natural astrology, and the latter employed
the entire prognostic and divinatory apparatus of traditional horoscopic, or
via judicial, astrology.17 Galen’s approach was overwhelmingly along natural
astrological lines, and the Galenic tradition mainly followed him in this. The
judicial astrological aspect of the theory is conspicuously absent from both Ibn
Sīnā and Ibn al-Nafīs.

14 See Critical Days, k 9,901,1–7 (Cooper ed., 320–321), and k 9,850,16–851,6 (Cooper ed.,
pp. 244–245). Also, Commentary, p. 451, but note that συνημμένη is from συνάπτω (“to join
together”).
15 Galen, Critical Days, k 9,929,3–933,12 (Cooper ed., pp. 366–375). See the chart in Cooper,
“Rational and Empirical Medicine,” p. 88.
16 See Galen, Critical Days, k 9,911,18–912,9 (Cooper ed., pp. 338–340).
17 ʿilm aḥkām al-nujūm (“the science of the judgments of the stars”). For the medieval
distinction between judicial and natural astrology, see Isidore of Seville, The Etymologies,
p. 99. See also Cooper, “Galen and Astrology,” pp. 123–124, 139–140.

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In order to appreciate the conceptual shifts in crisis theory that occur in the
Avicennian tradition, we should consider Galen’s definitions more closely. At
the beginning of the Critical Days, when describing the dangerous symptoms of
crises, Galen defines the crisis as a kind of judgment on the patient, whether he
will live or die, and invokes a courtroom image. In Galen’s view, the common
people believed this to be a supernatural judgment. His own views, however,
outline the natural causes of the crises. Both Greek and Arabic are provided
here, as they differ slightly, including an important addition in Arabic.18

Passage 1: Galen Defines a Crisis as a Judicial Verdict19

‫و بعضهم يتقّدم دور حماّ ه و يطول و يصعب و يعرض لهم سبات وغير ذلك من الأعراض‬
‫الصعبة فيرى عند ذلك من حضر المر يض مم ّن يعنى به يخاف عليه خوفا شديدا وتسمعهم‬
‫ن حال ذلك المر يض كحال رجل قد قّدم إلى حاكم يحكم عليه بحكومة في دمه وعلى‬
ّ ‫يقولون إ‬
‫هذا المعنى وضع اسم البحران وهو القضاء أو الحكم‬

But for others, the paroxysm of their fevers comes prematurely, and it
lengthens and increases in severity, and a deep sleep afflicts them, and
other serious symptoms as well, so at that time those who are attending
the patient, who worry about him, are seen to fear greatly for him. And
you hear them saying that the condition of this patient is like that of a
man who has been brought before a judge who condemns him to death.20
On this meaning the name “crisis” is placed, that is to say, the verdict or the
judgment.

The explanatory addition by Ḥunayn (in italics)21 may have been necessary
because the term used to render “crisis”, buḥrān, was not native to Arabic,
but was adopted from Syriac, in which it already had an established tradition,
at least from the time of the early 6th-century Syriac translator Sergius of
Reshʿaynā (d. 536).22 Or, perhaps it was to prevent it from being confused with

18 No textual apparatus is provided, since my argument does not pivot on variant readings.
Greek words from Galen are provided as needed.
19 Galen, Critical Days, k 9,772,3–9 (Cooper ed., pp. 100–101).
20 οὐδὲν ὁ κάμνων ἀποδεῖ τῶν ἐν δικαστηρίῳ περὶ θανάτου κρινομένων (“the patient differs very
little from those condemned to death in the hall of justice”).
21 wa-ʿalā hādhā al-maʿnā wuḍiʿa ism al-buḥrān wa-huwa al-qaḍāʾ aw al-ḥukm.
22 R. Payne-Smith 1879–1901: pp. 506–507; J. Payne-Smith 1903: 41. The medical meaning

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medical crises and critical days in avicenna and after 33

other Arabic words with the same root letters (b-ḥ-r). As will be seen shortly,
the sense of crisis as judgment was not emphasized by Ibn Sīnā or Ibn al-Nafīs.
Later on in the Arabic medical tradition, some scribes reminded readers of
the Syriac, Greek, or Persian origins of certain medical terms. For example, in
the two principal extant manuscripts of Ḥunayn’s translation of Galen’s Crises,
Mss. E and L on which my edition of that work (in preparation) is based,23
there is a gloss—marginal in L but in the line of text in E—wa-l-buḥrānu
ismun suriyānīyun wa-maʿnāhu l-ḥukmu (“buḥrān is a Syriac word, meaning
‘judgment’”).24 So, as of the date of the copying of these manuscripts (613 /1217
for E and 580 /1184 for L), this Syriac information was available to at least
some Arabic physicians.25 In manuscripts E and L, there are several other such
glosses that give the Syriac origin or equivalent of particular terms, as well as
flagging other terms as transliterated Greek or Persian words.

The Avicennian Transformation of Crisis Theory

A preliminary survey of several major pre-Avicennian medical works shows


no significant differences in crisis theory, either theoretical or metaphorical,
from its Galenic-Ḥunaynian expression.26 In addition to sorting out the pre-
Avicennian discussion of crisis theory, the present author is also in the process
of examining the Arabic Aphorisms commentaries, which span the centuries
before and after Ibn Sīnā, for evidence of other conceptual developments.
With Ibn Sīnā, however, Galenic crisis theory exhibits new dimensions.
While the traditional view holds that Ibn Sīnā was a compiler and system-
atizer of earlier medical ideas, recent research has revealed important practical
innovations in his medical work. That research, as with the present discussion,

of the term būḥrān in Syriac: “trial, test, or crisis of an illness”. Payne-Smith 1879–1901:
p. 347.
23 Ms. L: Ms. London, British Museum Or. 6670/1 (580/1184), fols 2v–82r; Ms. E: Ms. Madrid,
Escorial 797/3 (613/1217), fols 69–120. Descriptions of these manuscripts: Cooper, De diebus
decretoriis, Introduction, pp. 77–79.
24 Ms. L, fol. 59r, and Ms. E, fol. 106r.
25 This Arabic passage corresponds to a Greek passage in On Crises, k 9,704 (Alexanderson
ed., p. 168).
26 Works I have examined include the Firdaws al-ḥikma of ʿAli ibn Rabban al-Ṭabarī (d.c.
870 ce), the Kitāb Kāmil al-Ṣināʿa al-Ṭibbīya of ʿAlī ibn al-ʿAbbās al-Mājūsī (d. 994 ce),
and the Miftāḥ al-ṭibb wa-minhāj al-ṭullāb of Abū al-Faraj ʿAlī ibn al-Ḥusayn Ibn Hindū
(d. 1032 ce).

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shows that Ibn Sīnā’s medical ideas were significantly influenced by his philo-
sophical investigations, and so whatever compilations he made, the choice and
manner of the compilation and his strategies for division and classification, as
well as their contents were shaped by his own thought.27
Ibn Sīnā discusses all the particulars of crises in 100 chapters of Book 4 of the
Canon, how to recognize and classify them, and how to manage the patient’s
recovery after he suffers a beneficial crisis.28 Most of this material was treated
in Galen’s Crises, but Ibn Sīnā codifies the doctrine by its parts, quick access for
physicians to specific critical signs and how to interpret them and to adjust the
patient’s regimen.
Critical days are treated more concisely, with ten sections that correspond
to only a part of Galen’s Critical Days.29 This reduction may have been due to
the fact that Galen’s treatise contained both lengthy polemics, as well as an
extended empirical argument that established the canonical critical days.30 A
physician would find Ibn Sīnā’s concise treatment more useful. Accordingly, Ibn
Sīnā addresses the question of when the illness begins, as Galen had done, since
that is when the critical days must be counted from, as well as the character of
each critical day, and how to use the patient’s symptoms on a particular critical
day to anticipate the course of the illness.31

Crisis Theory in the Works of Ibn al-Nafīs

Ibn al-Nafīs (d. 1288 ce) is best known today for his theory of the pulmonary
transit. In his own day, however, he was known as the most important commen-
tator on the Canon, and he was called a “second Ibn Sīnā.”32 In his Commentary
on the Canon, where his pulmonary transit doctrine is found, he engages with
Ibn Sīnā critically, and develops crisis theory further. I begin with the Commen-
tary on the Canon, to show the depth of Ibn al-Nafīs’s analysis of crisis theory,
and then I discuss passages from his Commentary on the Hippocratic Aphorisms
to illustrate some of these ideas.

27 Pormann, “Avicenna on Medical Practice,” p. 107.


28 Ibn Sīnā, Kitāb al-qānūn fi al-ṭibb, Book 4, Fen 2, Treatise 1 (1593 ed., pp. 41–58).
29 Ibid., Book 4, Fen 2, Treatise 2 (1593 ed., pp. 59–62).
30 For a detailed analysis, see: Cooper, “Numbers, Prognosis, and Healing,” pp. 50–56.
31 This crucial issue was discussed by Galen: Critical Days, k 9,795,9–798,7 (Cooper ed.,
pp. 142–149).
32 Fancy, Science and Religion in Mamluk Egypt, p. 25 n. 64.

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medical crises and critical days in avicenna and after 35

Ibn al-Nafīs goes much deeper in his analysis of the critical days in his
Commentary on the Canon than Ibn Sīnā had done in the Canon—or Galen,
for that matter—invoking concepts from astronomy, astrology, meteorology
and other parallel scientific disciplines. Passages from the Commentary on the
Canon that discuss crisis theory vividly demonstrate how certain established
scientific and medical doctrines underwent a critique and amplification in the
13th century. Following N. Fancy’s recent analysis of Ibn al-Nafīs’s doctrines
of pulmonary transit and his Islamic writings, it may be possible to show
(in a future project) how Ibn al-Nafīs’s critique of this Greek-derived medical
astrology was shaped and conditioned by his traditionalist Islamic perspective
and agenda.
The section headings of the Commentary on the Canon below suggest that
Ibn al-Nafīs was most interested in the physical causes of the critical days,
and he begins by discussing planetary phenomena as causes or partial causes,
as well as the apparent power of the numbers of the critical days to modify
the effect of crises. Only Discussions 1, 2 and 4 will be considered in the
present discussion. These passages of the Commentary on the Canon provide
much more theoretical treatment of the relationship between the humours
and the planetary bodies vis-à-vis crisis theory than any previous author I know
of, including Galen himself. They also reflect an effort to make the natural
astrological cosmos compatible with Islamic theology.

Discussion (baḥth) 1: Lunar Influence on the Sublunar Elements


Discussion 2: The Days in which [Luni-solar] Oppositions and their Like
Occur, and How they are Connected with the Critical Days
Discussion 3: The Periods of Crises in Acute Illnesses
Discussion 4: Crises of Illnesses
Discussion 5: The Connections of the Odd- and Even-numbered Days in
the Critical Days, via Number and Weakness

In Discussion 1 (fols. 524a–525b), the general principles behind medical astrol-


ogy (in relation to crisis theory) are outlined and critiqued, including a discus-
sion of the place of free will—an essential element of Islamic theology—in a
cosmos where astral influences on sublunar elements operate. The humoural
theory of disease, whereby health and sickness, as well as crises, are the result
of healthy or unhealthy states and the flowing of the bodily humours (i.e.
blood, phlegm, yellow and black biles), was central to this cosmos. Ibn al-Nafīs
describes how the moon is the primary agent of changes to these humours, by
analogy with its effects on the seas, causing tides. The concept that the moon
causes crises in patients via its phases is scrutinized, and the possible warm-

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36 cooper

ing effects of the varying intensity of its light on the humours are considered.
In the end, however, Ibn al-Nafīs reaches a conclusion similar to those Muslim
thinkers who admitted some aspects of astrology into their Islamic cosmology:
the stars, or in this case the moon and the elements, are not ultimate causes
of the changes we see in the humours (or any other earthly elements). They
function, rather, as intermediary factors (asbāb “causes”) through which God
(al-fāʾil “agent, maker, doer”) is the ultimate Agent of events in our world. The
role of the planets in God’s providential rule had been discussed by Muslim
theologians since the early period of Islam, when faced with the threat to free
will that astrology presented. A slightly later thinker than Ibn al-Nafīs, Niẓām
al-Dīn al-Nīsābūrī (b.c. 1270), suggested that not only the planets, but nature
itself are intermediaries of God’s rule. The planets, while not full determiners
of earthly events, still have a God-given intermediary role in both causing and
indicating events.33
Discussion 2 (fols. 525b–525a) presents the basis of a shift in how medicine
and astrology overlap, which will be discussed in detail in the last section of
the present article. Ibn al-Nafīs justifies Ibn Sīnā’s use of the synodic month
alone as the basis for his medical week, in contrast to Galen, who tried to rec-
oncile the synodic and sidereal months, resulting in a messy parameter without
clear physical justification.34 Ibn al-Nafīs considers aspects of crisis theory in
greater detail, examining the various types of lunar periods, or months, includ-
ing the Islamic and Jewish months. The luni-solar oppositions are the most
significant factors in producing crises, since they involve actual interactions
between physical bodies. Therefore, the synodic month, or the period between
conjunctions of sun and moon (about 29.5 days), is described and found to be
the basis of the primary cycles of critical days. Ibn al-Nafīs carefully explains
how the medical month is three days less than the synodic, a move made by
Galen in the Critical Days but not justified well there.35 He explains that this is
because the moon is ineffective in transmitting the sun’s light around the time
of the new moon when its light is too dim. All of the medically significant lunar
periods are derived by successively halving this reduced month of 26.5 days: 13
1/4 days, 6 5/8 days, etc.
In Discussion 4 (fol. 526b), Ibn al-Nafīs discusses the body as city metaphor,
an ancient metaphor that first appears in the Canon in connection with crisis

33 Morrison, Islam and Science, pp. 102–106, 116–118.


34 See Critical Days, k 9,929,3–933,12 (Cooper ed., pp. 366–375) and discussion at pp. 75–
76.
35 Galen, Critical Days, k 9,931,8–14, (Cooper ed., pp. 368–371).

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medical crises and critical days in avicenna and after 37

theory (to my knowledge).36 He explains how the crisis is the means for the
body to expel the disease, to prevent the evil illness from overcoming the city.
Nature is the defending power (sulṭān) in the city, and the physician must be
his ally against the onslaught of the enemy disease.

Crisis Conceived as as “Separation” Rather Than “Judgment”

The most significant conceptual shift introduced in the Canon and continued
in the tradition is a paring down of the concept of the crisis to a purely
natural process, devoid of any sense of supernatural judgment. He does this
by taking buḥrān to be synonymous with Arabic faṣala (“to divide”) and its
forms, ignoring the senses of “trial” and “judgment” that featured prominently
in the Greek and Syriac traditions. The notion also appears in Ibn al-Nafīs’s
Commentary on the Hippocratic Aphorisms.

Passage 2: Crisis as Separation37

‫ ونقله الأطباء إلى الانفصال الواقع بين الطبيعة‬.‫ هو الفصل في الخطاب‬،‫البحران في لغة اليونان‬
.‫ إما إلى الصحة أو إلى العطب‬،‫ ورسموه بأنه تغير عظيم يحدث في المرض‬،‫والمرض‬
.‫ وهو البحران الكامل‬،‫ تارة يكون بأن تقهر الطبيعة المرض وتدفعه بالتمام‬،‫وهذا الانفصال‬
‫ وتارة بأن تدفعه‬.‫ وهو البحران النقص‬،‫ يتمكم به من قهره بالتمام ببحران آخر‬،‫وتارة بأن تقهر قهرا‬
‫ وتارة بأن يستولي‬.‫ وهو بحران الانتقال‬،‫ إلى بعض الأطراف‬،‫عن القلب والأعضاء الشر يفة‬
‫ وهو البحران الرديء‬،‫ أو ببحران آخر يكون هذا مهيأ له‬،‫ فيفسد البدن بذلك البحران‬،‫المرض‬
.‫ سواء كان باستفراغ أو بانتقال‬،‫ ما ينقضي به المرض‬،‫ والبحران التام‬.

Commentary: The word crisis (i.e. buḥrān) in the Greek language means
“division; separation.” Moreover, the doctors translate it as “a separation
that occurs between nature and the illness.” They describe it thus: “a big
change that happens to the illness, either towards recovery or toward
death.”38

36 See Cooper, “Byzantium between East and West,” pp. 281–283, for how Anna Comnena
used the medical aspects of the “body politic” metaphor to organize her Alexiad.
37 Ibn al-Nafīs, Commentary on the Hippocratic Aphorisms, pp. 144–145.
38 See Galen, Critical Days, k 9,769,1–770,6 (Cooper ed., pp. 96–96).

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38 cooper

And sometimes this separation results in nature conquering the illness,


which is to say, expelling it completely. That is a complete crisis. Some-
times it results in nature’s victory over the illness, which makes possible
its complete victory via another kind of crisis, namely, a defective crisis.
At other times, it results in nature expelling the illness from the region
of the heart and the vital organs, towards the extremities. This is a trans-
ferring crisis. Sometimes it results in the illness attaining mastery, so that
the body is corrupted by this crisis, or by another crisis whose occurrence
this one prepares. This is a bad crisis. The complete crisis brings the ill-
ness to a conclusion, no matter whether it be via an evacuation, or via a
transferring.39

As described in the Critical Days, crises carry vestiges of their ancient associa-
tion with supernatural judgment. This would seem compatible with an Islamic
notion of God’s involvement in natural affairs, in the extreme version of which
physicians’ efforts would be ultimately pointless. The Avicennian tradition,
however, characterized the crisis purely naturalistically as a contest between
nature and the disease, with the doctor assisting nature. Ibn al-Nafīs seems to
be inconsistent on this issue: In one passage of the Commentary on the Canon,
he suggests that God is somehow responsible for all the events on earth,40 but
in another passage, he states that nature has the capacity to exercise ijtihād
on behalf of the patient, and to have intentions and concerns for the patient’s
welfare.41
Given the Syriac meaning of buḥrān (“trial, test”), which Ḥunayn empha-
sized in his translations, and which some later scribes sought to preserve, it
seems odd that the Avicennian medical tradition would settle on “division”
( faṣl).42 However, the Greek word κρίσις has “division” as one of its senses.43 I
think it more likely, though, that Ibn Sīnā either assumed that the word was Ara-

39 “Evacuation” means that the harmful substance is conveyed from the body via the sweat,
urine, or excrement. “Transferring” means the relocation of the putrid matter that causes
the illness to an inflammation that can be drained.
40 Sharḥ al-qānūn, Ms. London, Wellcome, Or. 51, fols. 524a–525b.
41 Ibid., fol. 526b. This is similar to Galen’s notion that nature is always trying to work out the
best outcome for patients. Ijtihād here means a kind of exertion, but not necessarily its
legal sense of “exercising independent judgment” in adjudicating a case.
42 Ibn Sīnā, Kitāb al-qānūn fi al-ṭibb, Book 4, Fen 2, Treatise 1, Chapter 1 (1593 ed., p. 41). There
is no mention of Greek or Syriac.
43 From κρίνω “to divide, distinguish, separate”. Liddell and Scott, Greek-English Lexicon,
p. 996.

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medical crises and critical days in avicenna and after 39

bic with the roots b-ḥ-r, for which the verb baḥara means “to cut; to divide,”44
or he interpreted the word contextually, as “separation.” The author of the Epit-
ome, however, distinguishes what he takes to be the Greek sense of buḥrān,
namely, faṣl, from how the word has come to be used in Arabic, which he says is
derived from its sense of “intensity” (shidda). He states: “the (menstrual) blood
is said to be critical (baḥrāni) when it is an intense red (shadīdat al-ḥumra).”45
He refers to the Prophet Muḥammad’s discussion of the menstrual blood (dam
baḥrāni), whose deep red colour is said to be baḥrāni.46 Lane was unaware of
the Syriac origin of buḥrān, calling it “post-classical” Arabic. This suggests that
none of the Arabic dictionaries on which his compendium is based mentioned
it, which may indicate that the word was already assimilated into Arabic. Even
though this is technically a mistake, the sense of “intensity” is consistent with
the idea that the crisis is the point of the greatest intensity of symptoms, when
the paroxysms are most violent.47
The sense of “separation” of buḥrān, which by Ibn Sīnā’s time had become its
primary sense, can be seen from the medical context. A crisis occurs in order
for nature to separate the disease-producing substances from the body, which
are expelled. The patient’s full recovery depends on this complete separation
and expulsion taking place. Ibn al-Nafīs, moreover, suggests that the sense of
crisis as “division” applies to the illness scenario as a division between two
adversaries. The combatants are nature and the illness, which Ibn Sīnā also
characterizes in terms of the “body as city” metaphor, with nature as the power
(sulṭān) that protects the city, and the illness as an enemy attacking the city
from outside.
Not all Arabic physicians omit the courtroom metaphor in their discussion
of crisis. Al-Sinjārī (fl. 12th c. ce), who lived after Ibn Sīnā, in his Commentary
on the Hippocratic Aphorisms, compares the disease and nature to two oppo-
nents (khaṣmān and ʿudūl al-muzkāt wal-lāmuzkāt), and the doctor is a judge
(qāḍī).48 Al-Sinjārī retains the idea of “judgment”, but now the physician is the
judge.

44 Lane, p. 156, citing the Tāj al-ʿarūs.


45 Ibn al-Nafis, Mūjiz, p. 290.
46 See also: Sabiq, Fiqh al-sunna, vol. 1, p. 69a, who quotes a ḥadīth: The Prophet in response
to an inquiry about how to tell whether blood is menstrual or venal in origin, specifies that
menstrual blood is dark. Lane, p. 157 also cites baḥrāni as menstrual blood, because of its
intense red color. According to Lane, baḥr designates the bottom of the womb. Baḥrāni
derives from bāḥir, meaning “deep; intense”.
47 See Galen’s discussion in Book i of Critical Days: (Cooper ed., pp. 96 et seq.).
48 al-Sinjārī, Aphorisms Commentary, Book 2, Sect. 24. My gratitude to P.E. Pormann and his

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40 cooper

Passage 3: Al-Sinjārī’s Courtroom Image

ّ ‫ وكما أ‬.‫وشبّهوا الطبيب بالقاضي والبحار ين بالعدول المزكاة واللامزكاة‬


‫ن القاضي لا يمكنه الحكم‬
‫ كذلك الطبيب لا يمكنه الحكم بالإنذاري‬،‫إلا بعدول مزكاة‬

And they likened the physician to a qāḍī and the crises to either court-
room advocates or accusers. Just as the qāḍī is unable to give a judgment
without the advocate, so the physician is unable form a judgment without
the indicator signs

Battle Imagery in Crisis Theory

In the latter half of Passage 2 above, Ibn al-Nafīs outlines the “illness as battle”
metaphor. Galen’s original metaphor for the crisis was a battle between the
crisis and nature, with the patient’s health at stake, but Ibn Sīnā and Ibn al-Nafīs
expanded the battle imagery, characterizing the illness as a hostile combatant,
with nature on the defensive.

Passage 4: Galen’s Battle Metaphor49

‫ن أحد الأشياء التي تهي ّج الطبيعة وتزعجها وتقلقها نو بة الحم ّى فإّنها لا تدع الطبيعة أن‬
ّ ‫فأقول إ‬
‫تسكن وتستقر ّ لـكنّها تحر ّكها وتهي ّجها وكأّنها في المثل تستدعيها إلى المخارجة والمحار بة ولذلك‬
‫يكون البحران في الأمراض الحادّة في الأفراد‬

So, I maintain that one of the things that excites, disturbs and disquiets
nature, is the paroxysm (ὁ παροξυσμός) of the fever. It does not let nature
rest when it (nature) quiets (ἡσυχάζειν) and settles down, but it moves
and excites it, as though it urges it (nature) to come out to battle (τις εἰς
διαμάχην προκαλούμενος) and to the struggle, and because of this the crisis
occurs in acute illnesses in the odd (days).

team at the Arabic Commentaries on the Hippocratic Aphorisms project at the University
of Manchester, uk, for providing me with these passages, especially to K. Karimullah and
S. Barry.
49 Galen, Critical Days k 9,920,16–921,2 (Cooper ed., pp. 354–355).

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medical crises and critical days in avicenna and after 41

As we have seen from Passage 2, and will see in Passage 7 below, and in
the Commentary on the Canon,50 Ibn al-Nafīs employs the battle metaphor
as an organizing schema for the types of crises, and for the strategies the
physician must follow to assist nature in saving the patient, as well as clarifying
that the crisis is the resolution of the battle. In the next two passages, Ibn al-
Nafīs invokes an explicit battle image between nature and the disease, and he
specifically calls the crisis an enemy that oppresses nature.

Passage 5: The Crisis is a Resolution of Battle51

«‫ وحينئذ يكون الضمير في قوله »فيه مضرة‬،‫وذلك عندما تكون الطبيعة في مجاهدة البحران‬
‫ كأنه يقول »فإن الز يادة في الممرض حينئذ مضرة« والغذاء حينئذ يز يد في‬.‫عائدا إلى المرض‬
‫ حينئذ‬-- ‫ بز يادة المرض‬-- ‫ إلا أن المضرة‬،‫ وهذا إن كان في سا ئر الأوقات كذلك‬،‫المرض‬
‫ للمرض الذي هو كالعدو الباغي على الطبيعة‬،‫ لأن تلك الز يادة تكون حينئذ كالنجدة‬،‫أشد‬

Commentary: … And this (is) when nature is in the battle (mujāhada) of


the crisis. In the phrase “there is harm in it”, the pronoun (“it”) refers to the
illness, meaning that “the increase in the illness at that time is harmful.”
And the (giving of) food at that time increases (i.e. intensifies) the illness.
This also happens at other times, although the harm, i.e. an increase of the
illness, is stronger at that time, because this increase at that time is like
an assistant for the illness, which is like the enemy that oppresses nature
(al-ʿudw al-bāghī) …

Passage 6: Crisis as Combat52

‫ قد يصعب مرضه في الليلة التي قبل نو بة الحمى التي يأتي فيها‬،‫ إن من يأتيه البحران‬:‫قال أبقراط‬
.‫ف على الأمر الأكثر‬
ّ ‫ ثم في الليلة التي يعدها يكون أخ‬،‫البحران‬
،‫ فمن شأنه صعو بة المرض قبله‬،‫ تاما أو ناقصا‬،‫ سواء كان مذموما أو محمودا‬،‫كل بحران‬
‫ والتي‬،‫ فلأجل المقاتلة التي تجري بين الطبيعة والمرض‬،‫ أما الصعو بة‬. ‫وحصول خفة بعده‬
.‫ فلأجل إعراض الطبيعة عن المقاتلة بعد البحران‬،‫ وأما الخفة‬. ‫يعقبها البحران‬

50 Ibn al-Nafis, Sharḥ al-qānūn, Ms. London, Wellcome, Or. 51, fol. 526b.
51 Ibn al-Nafīs, Commentary on the Hippocratic Aphorisms, p. 118.
52 Ibn al-Nafīs, Commentary on the Hippocratic Aphorisms, p. 169.

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42 cooper

Hippocrates: “When someone suffers a crisis, his illness becomes difficult


in the night that precedes the paroxysm of the fever in which the crisis
supervenes. Then, in the night afterwards it becomes lighter for the most
part.”
Commentary: In each crisis, whether it is bad or good, complete or
defective, the illness is difficult before it, and easy after it. It is difficult
on account of the combat (al-muqātala) that occurs between nature and
the illness, and which the crisis follows. It is easy on account of nature
withdrawing from the combat after the crisis.

In discussing the combat scenario, Ibn al-Nafīs introduces a new capacity for
nature, the power to exercise ijtihād.

Passage 7: Nature Exercises ijtihād53

‫البحث الرابع في بحار ين الأمراض قوله واعلم أزمن الأمراض آهكما ان البغاة على الملوك حماة‬
‫المدن منهم من مقصده ومعداه إسراع للملـكة أصلا أو لاستيلا التامّ على المدينة وذلك إن ّما‬
‫يسلم بإهلاك الملك الحامي ومنهم من مقصده ليس ذلك فقط بل إما ذلك وإما ثبات بدل‬
‫المدينة بأن يكون له مع الملك الحامي مشاركة في التصر ّف فيها كذلك الأمراض منها ما يرسم‬
‫هلاك الطبيعة وليس الأوهن لا يمكن أن بطول مدتها بل إما تفارقه إذ لا مقصد لها في الدوام‬
‫ومشاركة الطبيعة في التصر ّف في البدن وهذه في الأمراض الحادّة ومنها ما يدوم إما هلاك‬
‫الطبيعة أو دوام المشاركة معها في التصر ّف في البدن وهذه في الأمراض المزمنة ور ب ّما كان‬
‫ك أن تقصد الطبيعة المدافعة‬
ّ ‫القسم الثاني أكثر أعراضها وهي الأمراض السليمة منها ولا ش‬
‫للقتال ينبغي أن يكون لما قصده نفس هلاكها فقط أكثرهما أحدهما يقصد أحد دنيك الأمرين‬
‫فلذلك كان اجتهاد الطبيعة في مقاتلة الأمراض الحادّة أكثر ولذلك تهّم لذلك بالانضاج‬

The Fourth Inquiry: Concerning the Crises of Illnesses. His statement:


“Know the temporal phases of the illnesses.” Just as there is a need for
kings to be defenders of cities, there are those among them whose inten-
tion and goal is primarily to rush to the kingdom, or to take complete
possession of the city. And this only permits the destruction of the pro-
tecting king. And some of them intend not this only, rather, this or to resist
the surrender of the city, through having a share with the protecting king

53 Ibn al-Nafis, Sharḥ al-qānūn, Ms. London, Wellcome, Or. 51, fol. 526b.

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medical crises and critical days in avicenna and after 43

in its acting independently in it. Likewise, some of the illnesses plan to


destroy nature, while it is not the weakest, it is impossible for their interval
to lengthen out. Rather, it either separates itself, since it does not intend
for it to remain and to share with nature in the body’s acting indepen-
dently. These are the acute illnesses. Some others of them continue either
to destroy nature or to continue sharing with it in the body’s acting inde-
pendently, and these are the chronic illnesses. And sometimes the second
portion is most of their symptoms, and these are the safe illnesses among
them. And there is no doubt, if nature intends (taqṣidu) to expel the lethal
(substance), then whatever intends the destruction itself alone must be
the greater of the two. One of the two things intends the one of the two
things that is closer to you, so for this reason nature exerts itself (ijtihād)
more often in the combat (muqātala) with the acute illnesses, and for this
reason it is worried about (tahummu) the concotion.

There are three general outcomes for the deadly struggle (muqātala) between
nature and the illness, which correspond to three types of crisis:

1) The illness defeats nature, resulting in the patient’s death;


2) The illness is partially defeated by nature, and so the crisis transfers to the
patient’s extremities where it must be dealt with through other means;
3) The illness is defeated by nature, which means that the diseased material
is completely expelled.

The multiple uses of qaṣada (“to intend, aim”), and the one instance of hamma
(“to be worried, preoccupied” about), suggests that nature has a kind of basic
intelligence that helps it respond to the onslaught of the disease. Furthermore,
the use of ijtihād suggests that nature exerts itself on behalf of the patient,
working harder when facing an acute illness. This characterization of nature
is consistent with Galen’s, who taught that nature has a basic intelligence
that works for the patient’s welfare, but that it needs the physician’s rational
intervention to be most effective.54

54 For example: De sympt. caus., Bk. ii, k 7, 194–196, and De meth. med., Bk. 8, k 589.

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44 cooper

The Body as a Besieged City

More than merely invoking a combat metaphor for illness and treatment, the
post-Avicennian tradition introduces the besieged city as a metaphor for the
patient’s body, beleaguered by illness. This imagery derives from the ancient
body politic metaphor, which Plato expounded philosophically in Republic.55
Ibn Sīnā likely derived its medical application from al-Fārābī (d. 950 ce), who
had adapted Plato’s Republic to his own philosophical concerns. The author of
the Epitome concisely draws the metaphor, consistent with Ibn Sīnā’s use of it.

Passage 8: The Body is Likened to a City56

ُ ‫…و‬
‫ والطبيعة بالسلطان المحامي عنها‬،‫شب ّه المرض بالعدّو الباغي على المدينة الم ُشَ َبّهة بالبدن‬

… and the illness is likened to an enemy besieging (bil-ʿadūw al-bāghī) a


city, which is (in turn) likened to the body, and nature is likened to the
power (sulṭān) that protects it.

Galen, who does not elaborate on the character of the crisis when invoking his
battle metaphor, reserves the tyrant vs. benevolent ruler metaphor to describe
the relationship between specific critical days and the patient, as follows.

Passage 9: Galen Compares Specific Critical Days to Kings and Tyrants57

‫ن اليوم السابع كالوالي‬


ّ ‫وأنا أشب ّهكثيرا اليوم السابع بالملك وأشب ّه اليوم السادس بالمتغل ّب وذلك أ‬
‫الخـير يشفق على من يحكم عليه بحكم وإن لزمه عقو بة حرص أن ينقص من شّدتها أو يهونها وإن‬
‫ي أمره فيه وأمّا اليوم السادس فيشبه من يسلك بالمستولي عليه خلاف ذلك‬
ّ ‫وجب له حّق قو‬
‫وكأن ّه يسر ّ بعطب المستولي عليه وتشّق عليه سلامته و يحتال في أن يشتفي مم ّن يظفر به و يبلغ‬
‫منه و يحصره في حبسه ليطول عذابه‬

I often compare the seventh day to a king (al-mālik: Greek: βασιλέυς),


and the sixth day to a conqueror (al-mutaghallib: Greek: τύραννος). This
is because the seventh day is like the benevolent ruler (al-wālī al-khayr:

55 The metaphor is far older, however, and appears in ancient Indian literature: Rig Veda,
10.90, “Hymn to Purusha”.
56 Ibn al-Nafis, Mūjiz, p. 290.
57 Galen, Critical Days, 9,786,17–787,7 (Cooper ed., pp. 128–129).

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medical crises and critical days in avicenna and after 45

Greek: ἀγαθός τις ἄρχων) who shows pity for those he judges, and if he
must punish his subjects, he desires to lessen its severity, or to lighten it;
and if a strong penalty is required, then he rules them in accord with it.
But the sixth day resembles one who behaves toward his subjects in an
opposite manner, as if he takes pleasure in the destruction of his subjects,
and the patient’s recovery is irksome to him, and he connives to vent his
anger on him whom he has defeated, and to exhaust him and he holds
him in his clutches in order to prolong his agony.

Thus, for Galen, the evil tyrant is the sixth day rather than the illness, and the
good ruler is the seventh day, rather than nature.
The medical use of the body politic metaphor appears in the Canon, where
Ibn Sīnā employs it to depict the struggle of the body against disease as the
struggle of a city against a besieging invader. He says: “The illness is to the
body, like the external enemy is to the city.”58 More precisely, the struggle is not
between the body and the enemy, but between the benevolent and protecting
power (sulṭān) that rules the city, and the besieging illness. As far as I know,
neither Galen nor any other ancient Greek medical author uses the image of
the body as city in this way.
In all of these accounts of crisis theory, nature is a major factor in healing,
although the details of its capacities differ. For Galen, nature (physis) is the
power that seeks to preserve and restore the health of the body. Nature, how-
ever, is only semi-intelligent, and requires the physician’s assistance—but intel-
ligent nonetheless. Galen explained that this is because we live in the imperfect
sublunar world. If, however, nature had unadulterated access to the influences
of the celestial bodies, which tend to produce pure and perfect harmony in
what they influence, it would operate perfectly in preserving health and healing
patients.59 The physician’s rationality can compensate only partly for nature’s
rational deficiency. Ibn Sīnā and Ibn al-Nafīs, however, conceive of nature as a
benevolent ruling power (sulṭān), with enough intelligence to mount a defense
of the city against a clever and determined enemy. In fact, by applying to nature
the capacity for ijtihād—exertion on behalf of the patient, Ibn al-Nafīs seems
to suggest that nature has the capacity to make basic decisions.
This metaphor should not be applied to more aspects of the entities being
compared than was intended, lest it misleadingly suggest that the disease is lit-
erally external to the body. Rather, the disease that requires a crisis to expel it

58 Ibn Sīnā, Kitāb al-qānūn fi al-ṭibb, Book 4, Part 2, Treatise 1, Chapter 1 (1593 ed., p. 41).
59 Galen, Critical Days, k 9,900,5–902,9 (Cooper ed., pp. 320–325).

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46 cooper

is not an outside agency, but an internal corruption of humours or tissues or


both. Galen refers to external factors, it is true, but these are primarily factors
that frustrate nature’s relationship to the body and with the celestial bodies as
well. The placing of nature on the inside of the body suggests that nature is
among the natural endowments or faculties of the patient’s body—generally
consistent with Galen’s views, and with the trend away from astrological influ-
ences.
In al-Fārābī’s magisterial treatise on political philosophy, his adaptation and
development of Plato’s Republic, the The Principles of the Views of the Citizens
of the Excellent City60 he explicitly compares the human body to a city. Al-
Fārābī introduces a number of Greek scientific ideas about the body politic,
not discussed in the Republic, some of which may have been derived from
the Timaeus, and combined into one work, drawing upon the Galenic medical
tradition for the details, thus linking the political body and medicine more
closely. Consistent with his Aristotelian leanings, al-Fārābī makes the heart the
ruling organ (ʿuḍw raʾīs) instead of the head. He is, however, careful to make
the brain the heart’s steward (ṣāḥib dār al-insān) and thus to keep the brain
in the highest circle of power in the state.61 (The strict distinction between
Platonic and Aristotelian philosophical doctrines was obscured in Arabic, since
Aristotle was first introduced into Arabic via a Neoplatonic synthesis of Plato
and Aristotle.)62

Passage 10: al-Fārābī on the “Body Politic”63

‫والمدينة الفاضلة تشبه البدن التامّ الصحيح الذي ٺتعاون أعضاؤهكلها على تتميم حياة الحيوان‬
‫وعلى حفظها عليها وكما أن البدن أعضاؤه مختلفة متفاضلة الفطر والقوى وفيها عضو واحد‬
‫جع ِلت فيه بالطبع‬
ُ ‫ وكل واحد منها‬،‫رئيس وهو القلب وأعضاء تقرب مراتبها من ذلك الرئيس‬
‫قوة يفعل بها فعله اقتفاء لما هو بالطبع غرض ذلك العضو الرئيس‬

60 al-Fārābī, Mabādiʾ ārāʾ ahl al-madīna al-fāḍila (Walzer ed.).


61 “For it is itself subordinate to the heart, whereas all the other organs and limbs are
subordinate to it, in accordance with the natural aim of the heart. It may be compared to
the steward in a household” (… wa-dhālika mathal ṣāḥib dār al-insān): al-Fārābī, Mabādiʾ
ārāʾ ahl al-madīna al-fāḍila, Bk 4, Ch. 11, sect. 1 (Walzer ed., pp. 174–175).
62 Adamson, The Arabic Plotinus, pp. 6–26.
63 al-Fārābī, Mabādiʾ ārāʾ ahl al-madīna al-fāḍila, Bk 4, Ch. 15, sect. 4 (Walzer ed., pp. 231–232).
Walzer’s translation.

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medical crises and critical days in avicenna and after 47

The excellent city resembles the perfect and healthy body, and the parts of
the body cooperate to make the life of the animal perfect and to preserve
it in this state. Now the parts of the body are different and their natural
endowments and faculties are unequal in excellence, there being among
them one ruling part (ʿuḍw raʾīs), namely the heart, and parts that are
close in rank to that ruling part, each having been given by nature a faculty
by which it performs its proper functions in conformity with the natural
aim of that ruling part.

Al-Fārābī then describes the various organs and their functions, from the heart
that rules the whole body on down, with each part having two capacities: on
the one hand, that of ruling over some parts and, on the other, that of being
ruled over by other parts. The same is true for the city. Each rank of person,
from the ruler on down, is analogous to some level of hierarchy in the bodily
organs.

The Lunar Period, the Generating Parameter for the Critical Days,
and Their Implications for Astrology and Medicine

As noted earlier, Ibn Sīnā implicitly criticizes Galen’s parameter on which he


bases his critical day scheme. The section of the Canon called “The Cause of the
Critical Days and their Periods” omits the sidereal month on which Galen had
relied, and presents a theory of lunar influence based on the synodic month
alone. Galen had derived the critical day series from what the tradition would
later term a “medical month”, which is the average of two month types: the
sidereal month of 27 1/3 days, and the (effective) synodic month of 26 and a half
days, which is 29 and a half days minus the roughly 3 days that the moon is
too dark to radiate influence. The average of these two periods is 26 11/16 days,
giving a medical week of 6 35/48 days (= 6.729 days; half week = 3.365 days).
This half week figure was Galen’s generating parameter for the entire series of
critical days and warning days.64
Galen’s justification for averaging the two lunar periods was that the moon’s
absolute position with respect to the stars, as measured by the sidereal month,
has a general influence on everyone, and that its relative position with respect

64 Galen, Critical Days, k 9,929,3–933,12 (Cooper ed., pp. 366–375). For a detailed chart
showing how the critical days are generated from Galen’s parameter, see Cooper, “Rational
and Empirical Medicine,” pp. 88–89.

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48 cooper

to the sun, as measured by the synodic month, has a specific influence, depend-
ing upon when a particular illness begins in a particular patient.65 Ibn Sīnā,
however, simplified Galen’s theory by ignoring the sidereal month completely,
and derived the half week parameter directly from the 26 and a half day (effec-
tive) synodic month, by taking the eighth part of it, which is 3 5/16 or 3.3125
days, which is equivalent to 3 30/96 days for the medical half week (5/96 day
less than Galen’s figure). He then derived all critical days from this figures, with
no stated theoretical explanation nor justification, nor acknowledgement why
he had departed from the ancient scheme. It is possible that he found Galen’s
reasoning unconvincing: Why not use a simpler and sounder basis to get the
same empirical results? In both cases, however, the generating parameters are
very close, with Galen’s being only 5/96 day larger than Ibn Sīnā’s. One could
thus generate the critical day series based on this parameter, and get practi-
cally equivalent results. Practicing physicians knew that medicine was not (as
we might say) “rocket science”, and so this was close enough.

Passage 11: The Generating Parameter of the Critical Days66

‫ فإنها‬،‫ عند أحوال تعرض في القمر‬،‫ل الاستقراء على أن لرطو بات هذا العالم انفعالات‬
ّ ‫قد د‬
‫ ولذلك تزداد الأدمعة ومياه‬،‫ وتزداد عند الاستقبال والتر بيع ونصف‬،‫تنقص عند الاجتماع‬
،‫ ومن اجتماع القمر مع الشمس‬٠‫ وتنقص في أواخرها‬،‫العيون والآبار في أنصاف الشهور‬
‫ تسعة وعشو ين يوما ونصف يوم—بالتقر يب—يحذف منه مدة الاجتماع وما‬،‫إلى اجتماعها‬
‫ تبقى مدة قوة تأثيره ستة وعشرون يوما ونصف يوم؛ فيجمل‬،‫ وهي ثلاثة أيام‬،‫يقرب منها‬
.‫ فيكون البحران في السابع والعشر ين‬،‫ذلك كالدورة التامّة‬
.‫ فيقع البحران في الرابع عشر‬،‫ ثلاثة عشر يوما ور بع‬،‫ وهو حين المقابلة‬،‫ونصف هذه المدة‬
. ‫ فيقع البحران في السابع‬،‫ونصف نصفها—وهو حين التر بيع—ستة أيام ونصف وثمن يوم‬
،‫ فيقع في الرابع تغير—لـكنه لضعفه لم يعد بحرانا‬،‫ ونصف ثمن‬،‫ونصف ذلك ثلاثة أيام ور بع‬
‫ كاليوم الذي يتهيأ فيه العدو الباغي على المدينة للقتال فيكون منذرا‬. ‫بل جعل منذرا بالبحران‬
.‫بيوم القتال‬

65 Galen, Critical Days, k 9,795,9–799,12 (Cooper ed., pp. 142–151).


66 Ibn al-Nafīs, Commentary on the Hippocratic Aphorisms, pp. 179–181. (Aphorisms text is not
included here).

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medical crises and critical days in avicenna and after 49

Commentary: The investigation indicates that the fluids of this world


are affected when the lunar phases occur, so they decrease during the
conjunction, and they increase during opposition and quartile, and its
half (i.e. octile). For this reason brains increase (in size),67 and the waters
of springs and wells are more abundant at the midpoint of the months,
and they diminish at the ends (of the months). There are 29 and a half
days approximately from the conjunction of the moon with the sun (i.e.
the new moon, or beginning of the month) to their conjunction (again).
However, the period of the conjunction is shortened by approximately
three days.68 The remaining interval of its powerful influence is 26 and a
half days. And this is taken to be as the complete (lunar) period, so the
crisis occurs in the 27th day.
And half of this interval, which is when the opposition occurs, is 13
and a fourth days, so the crisis will occur in the 14th day. And half of its
half, which is when quartile occurs, is 6 and a half days plus an eighth of
a day, so the crisis will occur in the 7th day.69 And half of this is 3 and a
fourth and a half of an eighth of a day, so the crisis will fall in the 4th day.
However, because of its weakness, it is not counted as a crisis, but is taken
to be a warning (sign) for the (upcoming) crisis, such as the day in which
the enemy that oppresses the city is prepared for deadly combat, so it is a
warner of a fatal day.70

Why would Ibn Sīnā and Ibn al-Nafīs depart from Galen’s reckoning? I suggest
that the simplified scheme was more than merely an arithmetic simplification.
Rather, it reflects their attitude toward astrology, and by ignoring the synodic
month they were stripping crisis theory of its overt astrological elements. The
sidereal month, which marks the moon’s position against the zodiac, reflects
the procedures of judicial astrology, which uses positions relative to the fixed

67 For Galen’s discussion of the effects of the lunar phases on the brain, see: Galen, Critical
Days, k 9,903,7–903,11 (Cooper ed., pp. 324–326). For an historical overview and modern
scientific study of the relationship between the full moon and lunatic behavior, see:
Lilienfeld and Arkowitz, “Lunacy and the Full Moon.”
68 Galen explained why this is so: because when the moon has effectively disappeared from
view around the time of the new moon, it has no influence on earth.
69 Note that the day that is counted as a critical day is the one on which the fractional part of
the day falls, i.e. 6 3/4 days means that the seventh day is the critical day. This is consistent
with modern usage, where 3/4 of a day beyond six days would fall on the seventh day.
70 [Check: 3 × (3+1/4+1/16) = 9+.75+.1875 = 9.9375 days, or almost 10 days, but clearly within
the 10th day].

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50 cooper

stars, and relative configurations of planets in the signs and along the ecliptic
to generate predictions about a person’s life and to diagnose his character
or psychic predispositions. Ibn Sīnā had written a treatise against this kind
of astrology, in which he expresses general skepticism about all claims to
precise astrological knowledge.71 Nevertheless, like most pre-modern natural
philosophers, he accepted a natural astrology, which consisted of observable
effects of the sun and moon on the atmosphere, seas, and other terrestrial
phenomena.
The synodic month, however, is not tied to a specific point in the sky, but
depends solely on the relative positions of sun and moon, which produces
the lunar phases. This reflects the concerns of natural astrology, especially
since it admits the influence of the planetary bodies only via their radiated
light on earth—a tangible, physical cause instead of a mystical astrological
one.72 Galen’s compromise between medicine and astrology in his theory of the
critical days makes little physical sense. Al-Kindī may have been motivated by
similar concerns in his Risāla on the critical days (discussed earlier), which also
omits Galen, citing only Hippocrates. There al-Kindī divided up the synodic
month to arrive at his generating parameter. However, because he did not allow
for the period of non-influence around the new moon, and was more interested
in Pythagorean integers, his scheme failed empirically.73
Incidentally, the author of the Epitome introduced an unusual value for the
length of the synodic month. In the Commentary on the Hippocratic Aphorisms
and the Commentary on the Canon, Ibn al-Nafīs gives the length as approxi-
mately 29 and a half days, which is the most commonly used value. This is an
average, since because of the peculiar geometries of the solar and lunar orbits,
no synodic month is exactly the same length. However, in the Epitome, the fig-
ure given is 29+ 1/5+1/6 days, which comes to 29 11/30 days, slightly less than 29
and a half days. I have not yet determined where this figure comes from. Nor is
it clear how this different figure would alter the critical day scheme, which is
derived from the synodic period.
This insistence of Ibn Sīnā and Ibn al-Nafīs that all natural effects be the
result of clear and simple physical causes has a parallel in the history of Islamic
astronomy, which suggests a general trend in the philosophy of science among
Arabic thinkers. In brief, beginning with Ibn al-Haytham’s Shukūk ʿalā Baṭlam-
yūs (“Doubts about Ptolemy”), each component of the planetary motions had

71 Ibn Sīnā, Réfutation de l’astrologie, ed. Y. Michot. Also, McGinnis, Avicenna, p. 220.
72 For a discussion of a similar move in the early Renaissance, to replace celestial with
mundane influences, see Cooper, “Approaches to the Critical Days,” pp. 557–561.
73 Weisser, “Mondphasen und Krisen nach al-Kindi.”

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medical crises and critical days in avicenna and after 51

to be accounted for by a single uniformly rotating physical sphere. Celestial


reference points from the Ptolemaic tradition, such as the equant and the
prosneusis points, that were not tied to a physical body, whether a planet or one
of the moving spheres, had no place in this new kind of science. Generations of
Islamic astronomers vied with each other to find a mathematical description
of the cosmos that was devoid of “imaginary” elements, culminating in the
successful model of Ibn al-Shāṭir (d. 1375ce).74

Conclusion

I have shown how one tradition of medical commentaries, influenced by Ibn


Sīnā and al-Fārābī, reconceived the concepts of crises and critical days. This
tradition is of particular interest because at least the part shaped by Ibn Sīnā
came to the West, and was a part of medical learning and instruction for cen-
turies. The details of the connections with the European tradition have yet to
be determined, and I have yet to examine the medical writings of Ibn Rushd
(d. 1198ce). Of particular note is the incorporation of the body politic metaphor
into medicine, a conceptual scheme that later became very important in West-
ern political theory, through the writings of John of Salisbury (d. 1180 ce), Nicole
Oresme (d. 1382ce), and Christine de Pizan (d. c. 1430 ce). I have yet to dis-
cover how the Arabic and Latin traditions may have been connected on this
point. Given Ibn Sīnā’s modification of critical day theory, with its tacit rejec-
tion of Galen’s scheme, it is not surprising that some Renaissance astrologer-
physicians like Girolamo Cardano (d. 1576ce) preferred Hippocrates to Galen
on astrological matters.75 And the critial days played an important role in the
development of empirical science, as astrology was banished from natural phi-
losophy after the devastating Renaissance critique by Pico della Mirandola
(d. 1494 ce).76 The present excursus has shown how commentaries from a sup-
posed “derivative” period, can yield important insights in the development of
medicine.

74 Saliba, “Arabic Planetary Theories.”


75 Grafton et al., “Between the Election and My Hopes,” pp. 69–71.
76 Pico della Mirandola, Disputationes, ed. Garin (Ch. 16), pp. 322–349.

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52 cooper

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