Slowly but surely, we are approaching the end of a monumental enterprise by an international team of scholars: to provide the modern reader with a comprehensive critical edition (Arnaldi de Villanova Opera Medica Omnia, Granada-Barcelona, 1975 [= AVOMO]) of the authentic medical works composed by the renowned physician Arnau de Vilanova (c. 1240-1311), whose academic career as a master of medicine unfolded in the last decade of the fourteenth century at the University of Montpellier. To the eleven volumes that have already appeared since 1975 (three in a double-volume format), a twelfth is a newly welcomed addition complementing our understanding of Arnau's contribution to the evolution of learned medicine around 1300 in its theoretical and practical dimensions, and of his intellectual world. But far more, this volume should stimulate those interested in the evolution of scientific commentary strategies in the later middle ages to embark on a comparative longue-durée study of the rich Latin tradition of commentaries on the Hippocratic Aphorisms which were part of the Ars medicine, therefore a fundamental component of European medical education from the early twelfth century.
Arnau is known for his deep preoccupation with Galen's medical writings, some that he annotated himself, and many that mark his own medical monographs. They became part of the new Montpellier curriculum of 1309, one of whose architects he was. But Arnau was also interested in some Hippocratic texts, the Aphorisms in particular, which he occasionally integrated into his wide-ranging medical treatises. Though he never envisaged a full commentary on the seven books of the Hippocratic Aphorisms (as some of his colleagues did, most notably Taddeo Alderotti in Bologna), he commented on several individual aphorisms. Arnau's analysis is more discursive than Bernard de Angarra's and Taddeo Alderotti's commentaries on the same aphorisms. It evinces broader argumentation and generalizations together with organic links to his clinical experience, concentrates much more on Galen's thought, and is not limited to discussing technically a series of problems and solutions. Two surviving commentaries are offered here in a meticulously executed edition of the Latin text, preceded by informative, detailed, and wide-ranging bilingual (Catalan and English) introductions that contextualize each text within Arnau's medical output and his scholastic medical milieu.
In the 1290s Arnau commented on aphorism 2.34 (In morbis minus...) which he believed contained the seed of certain general rules that physicians could use to organize their therapeutic practice. In 1301 he explicated aphorism 1.1 (Vita brevis...) to teach his students at Montpellier how medical knowledge could best be gathered, organized, and communicated. The present volume (no. 14) presents in chronological order editions of Arnau's commentaries on these aphorisms (both carefully prepared by Michael R. McVaugh, the editor of a long list of medical texts by Arnau already published in this series). The commentary on aphorism 2.34 (introduced by Michael McVaugh) is preceded by Galen's commentary on the same aphorism in the translation usually attributed to Constantine the African. This is a clever editorial decision, letting the modern reader understand better the impact of the Galenic commentary on Arnau's commentary. It is regrettable that the volume's editors refrained from doing likewise when they presented Arnau's commentary on aphorism 1.1 without its Galenic precursor. Since the editors themselves convincingly show that in many respects Arnau's commentary may be described more as an exposition of Galen's commentary on the Hippocratic aphorisms than as an exposition of the aphorisms themselves, when renewed attention to Galen was transforming scholastic medicine, the absence of the original Galenic commentary in this particular case is all the more conspicuous. The extremely helpful introduction to aphorism 1.1 was jointly prepared by Michael McVaugh and Fernando Salmón.
Taken together, both commentaries allow us a glimpse at Arnau's deep appreciation of Hippocratic medicine, and at his intellectual development while teaching at Montpellier. In both, Arnau shows how clinical "operative" medicine could be ideally suited to aphoristic instruction. Individual aphorisms could be systematically unpacked to yield specific rules of practice that went beyond the original simple insight. Both commentaries transmit a view of practical medicine as a body of knowledge built up gradually since Hippocrates, and which still can be improved quantitatively and qualitatively, implying belief in a form of medical progress insofar as the medical art is concerned. Both commentaries show that how to discover truth in clinical medicine, and how to pass that truth on to the future, were the subjects dear to Arnau as a trainer of medical practitioners as well as future academic medical teachers. In commenting on individual aphorisms he targeted students seeking the master's degree, which would allow them to teach--not only to practice, and those who intended merely to practice medicine but not to complete a full academic course in medicine. The commentaries attest to a larger project Arnau had in mind, but never completed when he left Montpellier for Rome: to produce a full commentary on his Medicationis parabole of 1300 (AVOMO 6.1-2) and on another set of aphorisms that would deal with diseases in particular members. Such a project, which Arnau left unfinished, would amount to a full synthesis of operative medicine, a practical summa, that would reduce the overwhelming book-knowledge accumulated by 1300 to a set of simple rules applicable to each individual case. This could become as impressive a text as his summa of theoretical medicine, the Speculum medicine of c. 1308.
In the absence of any surviving manuscript copies, the edition of Arnau's 8000-word commentary on aphorism 2.34 is based on the first printed edition of his complete works (Lyons, 1504). "Of those who suffer illness, those patients are less in danger whose illness is in accord with their nature and age and bearing and season, than are those whose illness is not so in accord" is the wording of the aphorism which leads Arnau to a four-part discussion of this short text:
1. Exposition of the text--a brief restatement of the aphorism, remaining close to Hippocrates's language explaining the meaning of the text and its author's purpose.
2. Establishing its truth by demonstration based on Galen's commentary and views in other Galenic texts which seem to contradict the rule of the aphorism.
3. Uncovering its relevance by asking whether it applies to some diseases, or rather is a universal rule.
4. Showing its utility for the medical practitioner seems to be Arnau's main purpose in commenting on this aphorism at length. Arnau demonstrates how Hippocrates's original generalization could be developed into rules about the course of a disease, which in turn lead to further rules about the disease's proper treatment. His didactic purpose in commenting on the aphorism was to make prognosis more efficient and accurate and to construct the prognostic gaze of his students in a manner consonant with the spirit of the aphoristic text. The therapeutic implications which he raised (when should one prefer complexion-changing [alterative] medicines over those which merely expel the disease-generating matter [evacuative]) were directly linked to the prognostic rules that he formulated.
Possibly a decade later, Arnau composed the much longer commentary (over 20,000 words long and conventionally known in the printed editions of his complete works as the Repetitio super "Vita brevis") on the opening Hippocratic aphorism known as Vita brevis. The text, never fully completed, seems nevertheless to have been endorsed by Arnau himself, who directed the readers of his Speculum medicine to this commentary on aphorism 1.1. Only one manuscript preserves the full text of the commentary which is divided into three distinct lectiones. And it is possibly a reportatio--a student's transcript of an oral commentary, often commissioned by the master who delivered it and who would later go over the text, refine it, and oversee the publication of a finished version.
The text of Aphorism 1.1 reads:
Life is short (vita brevis), the art long (ars vero longa), opportunity fleeting (tempus autem acutum), experiment treacherous (experimentum fallax), judgment difficult (iudicium autem difficile). The physician must not only be prepared to do what is right himself, but also to ensure that the patient (egrotantem), the attendants (presentes), and the externals (ea que extrinsecus sunt) cooperate."
It was sufficiently broad and general to allow medieval commentators to develop any theme that interested them. Many devoted all their commentary to the first half only. Arnau's commentary which was significantly longer and more detailed than the commentaries of all his colleagues (Cardinalis and Bernard de Angarra in Montpellier; Taddeo Alderotti in Bologna), paid particular attention to the second part of the aphorism. It conveys Arnau's understanding of behavior appropriate to the medical practitioner and clearly expresses his own peculiar interests around 1300: devising new methods of medical exposition and communication; stressing the nature and implementation of the new Galenic diagnosis (the "judgment" in the Hippocratic aphorism); and fleshing out the ways this diagnosis determined the encounter of the physician with his patient.
The first lectio deals with the meaning and truth of the first part of the aphorism, which is more theoretical hence important mainly for those who wish to become teachers, and not only practitioners. Arnau devotes most of the discussion to showing the common denominator that lets the Hippocratic categories of "short" and "long" be applied to life and art in a direct and comparative relationship. The acquisition of the art exceeds the human lifespan because of: the rapidity of illness in the patients he learns from (tempus acutum); the inconsistency of the phenomena (experimentum fallax); the difficulty of determining or distinguishing the cause of a particular effect, hence of obtaining an exact and certain diagnosis. According to Arnau, the implicit meaning of the first section of the aphorism must be that every medical investigator should write down his findings in a brief and intelligible (i.e. aphoristic or tabular) mode so that they can be passed on to future investigators who will start their investigation where the previous investigator stopped. Arnau's agreement with Galen, that in Aphorism 1.1 Hippocrates must have meant to convince the reader of the general need for the aphoristic approach, must be read in the context of the growing awareness of those engaged in medical learning around 1300 that the amount of available information was overwhelming and that new devices had to be invented (or old methods adopted) to bring it under control.
The second lectio deals with the utility of the aphorism's first part, which Arnau reads as an exhortation to perfect the medical art in four ways: studying the works of our predecessors; gaining experience carefully and reasonably (even from the laity, when it is possible to show that a medicine's effect is independent of accidental circumstances); judging subtly; recording our discoveries in brief aphorisms. Through a series of individual case studies he teaches the students how an aphorism is to be constructed by overcoming the Hippocratic obstacles to the art of medicine, and (in the third lectio) how careful consideration should be given to the externals which are often the cause for a patient's unexpected reaction to a treatment.
The third lectio targets exclusively the second part of the aphorism, and elaborates its meaning, truth, and utility. For Arnau this part is a Hippocratic summary of the most fundamental considerations for the medical practitioner. It covers how he must go about the care of the patient (determining the disease and its cause, establishing its treatment); what the patient must do; what attendants must do; and how external accidents may affect the treatment. In length it covers almost half of the entire commentary, and unlike the first two lectiones it is oriented to the actual practice of medicine. This more practical bent possibly accounts for the wider diffusion of this lectio, for it circulated under the title De circumspectione medicorum, independently of the other parts of the commentary.
The second part of the aphorism, urging cooperation by the patient, allows Arnau to touch the topic of the patient's trust and confidence leading to obedience as an important constitutive factor in a successful curing process. The patient's obedience is a consequence of trust rather than the effect of an imposed power relationship, and his agency is thus maintained throughout the interaction with the physician. Fernando Salmón thoughtfully places this discussion in the broader context of the thirteenth-century debate on the physiological effect of hope and the themes of trust and obedience in the healing process, and highlights Arnau's original contributions (for example, the prescription of a neutral regimen or palliative drugs comforting the patient physically and emotionally when diagnosis is uncertain, or highlighting the efficacy of visits and comforting verbal expressions on the part of the treating physician as confidence- and hope-enhancing strategies which could effect a more efficient cure). In this context of Arnau's awareness of the impact of emotions on the medical encounter, he is shown to exhibit noticeable empathy with the sick, waiting until the excitement of his arrival has abated before taking a valid reading of a patient's pulse, and encouraging dialogue between the physician and the patient as well as his attendants. The introduction conclusively shows the existence of patient-oriented medicine, which in the thirteenth and fourteenth centuries coexisted with a much more practitioner-centered medicine. Financial considerations never enter Arnau's account of what must concern the physician when he encounters his patient. His fee is never mentioned, nor are techniques for extracting it from reluctant or dissatisfied clients.
The introductions and the editions of both aphorisms unravel the intricate links between the commentary and Arnau's other works--past and future, and expose the astonishing scope of his medical (mainly Galenic) and philosophical (mainly Aristotelian) sources. Among the many surprising nuggets hidden in this edition is (in the commentary on aphorism 1.1) a unique and intriguing dialogue between Arnau and Maimonides' (Raby Moyses) commentary on the Hippocratic aphorisms, a text never translated into Latin in the Middle Ages.
Not only Arnau scholars and those interested in the evolution of late medieval academic and practical medicine will find in this volume valuable insights and thought-provoking conclusions that shed new light on the practice of medicine, the patient-physician relationship, the epistemology of medical knowledge, and medical ethics. Those interested more generally in the evolution of strategies for processing, documenting, preserving, and organizing large and unstable corpora of knowledge will be able to use both the texts and the introductions as useful platforms for larger comparative studies within and outside the frame of late medieval learned medicine. Both editors should be highly commended for having produced yet another high-standard edition, which together with the accompanying introduction has significantly advanced our understanding of the particular case of Arnau de Vilanova and of the larger field of learned medicine around 1300.