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Chapter 2

Cause, Authority, Sign, and Book

Phisik in late medieval England was many things. It was written in university textbooks and in the margins of household manuscripts. Its practitioners were learned and unlearned, men and women, variably Latin- and English-literate. Medical care was sometimes a craft and sometimes a science. In the midst of this heterogeneity, however, phisik also fostered a set of ideas and practices peculiar to it. The later Middle Ages saw the dissemination of the medical framework, in which bodies were explained and manipulated as natural things, composite and changeable. Inquiry into the forces that sustained life assumed new relevance as more and more readers came into contact with medical expertise. In order to capture both the widespread tendencies of late medieval medicine and the variability of their expressions, the following chapter examines phisik under four different rubrics: cause, authority, sign, and book. These four words cut different, twisting paths through the thickets of medical discourse, from the classrooms of Montpellier to the small towns of Nottinghamshire, from leprosy’s diagnosis to John Lydgate’s most popular poem. The chapter aims to throw light on some of the central concerns of phisik, including its interests in why bodies change, the grounds of medical authority, how to interpret symptoms, and the best ways to transmit medical knowledge. Together, these topics yield a portrait of the plural and contentious nature of late medieval medicine.

Cause

One of the central projects of medieval medical inquiry was the investigation of causes. Chaucer’s Physician on his way to Canterbury is called a “verray, parfit praktisour [true and perfect practitioner]” in part because he “knew the cause of everich [every] maladye.”¹ According to the popular encyclopedia De proprietatibus rerum, compiled by Bartholomaeus Anglicus (d. 1272) and translated into Middle English by John Trevisa (d. 1402), a physician “nedith to knowe causis and occasiouns of eveles [diseases]” because “medicynes may never be sikerliche [securely] itake yif [if] the cause of the evel [disease] is unknowe.”² These vernacular formulations reiterate a notion expressed by earlier medical writers. In the influential medical encyclopedia known as the Canon, an Arabic work written by the Persian philosopher and scientist Avicenna (Ibn Sina, d. 1037) and translated into Latin by the circle of Gerard of Cremona (d. 1187), knowledge of causes is made medicine’s first task: “Since medicine considers the human body [corpus humanum] from the standpoint of how it is made healthy and how it sickens, and since we can have knowledge of neither unless it is known through its causes [causas], we must in medicine know the causes of health and of sickness.”³ The statement sounds commonsensical: it is useful to know why someone falls ill when reasoning out a cure. But it is also a testament to Avicenna’s Aristotelianism. The Canon self-consciously sought to synthesize Galenic medicine and Aristotelian philosophy. It is no surprise then that the work found eager acceptance among European readers increasingly shaped by Aristotle’s logic and theory of knowledge. Aristotle identifies true knowledge with a knowledge of causes: “We suppose ourselves to know something without qualification (as opposed to sophistically, accidentally) when we judge that we understand the cause upon which the thing depends”; and, more simply, “we know when we understand the cause [tunc scimus cum causam cognoscimus].”⁴

When Avicenna declared causation the sine qua non of medical knowledge, his statement appeared at the start of a vast and systematic tome. However, the meaning of the claim shifted as the Canon came to be digested by later medical writers. This happened, for instance, when the Italian surgeon Lanfranc of Milan (d. 1306) adapted Avicenna’s dictum in his Chirurgia magna: “Avicenna said that one cannot understand something that has been caused unless we know it by the causes themselves [ut dicit Avicenna, notitia rei quae causam habet non potest haberi nisi per suas causas sciatur].”⁵ In the hierarchies that organized medieval medicine, surgery was traditionally defined against physica as a lower form of knowledge, more manual and empirical. But Lanfranc’s citation signals his bid to raise surgery’s intellectual profile and to shift it from a craft to an art. In this newly “rational” surgery, which began in northern Italy and spread to France, surgical writers imported scholastic models while at the same time dislodging them from the university curriculum.⁶ During the fourteenth century, Lanfranc’s treatise together with other works of rational surgery found their way to eager readers in England, and Middle English translations of Lanfranc’s surgical writings survive in at least ten manuscripts. In these Englishings, practical instruction often took priority over theoretical schemes. One Middle English surgery, written in London in 1392, adapted Lanfranc’s treatise by excising its theoretical material and emphasizing the redactor’s own empirical findings.⁷ “Avicen seith knoulechinge of a thing that hath cause mai nought be knowen but bi his cause [Avicenna says that knowledge of a thing that has a cause may not be known except by its cause],” reads another translation, completed by 1380.⁸ In the phrase’s new vernacular milieu, the importance of causal understanding is reiterated at an even greater remove from academic contexts. Causation here has less to do syllogisms and more to do with observed relationships and palpable results.

Learned medicine poured huge quantities of intellectual energy into understanding causation. Three major schemes were available to medieval thinkers to explain sickness and health: the Aristotelian, the Galenic, and the Joannitian. All three were deployed within the basic framework of bodily complexion, which was determined by the balance of the four elements and four humors, with their respective qualities of heat, cold, moisture, and dryness. The scheme with the broadest intellectual reach was no doubt Aristotle’s model of the four causes: material, formal, final, and efficient (materialis, formalis, finalis, efficiens). While not strictly medical, it would have been familiar to anyone with a passing training in the liberal arts, and it was integral to the development of scholastic natural philosophy. Yet much in Aristotelian thought mitigated against its usefulness for medicine. Aristotle’s emphasis on causal linearity and teleology, his wish to move swiftly beyond the evidence of the senses, and his expressed desire for certainty based on first principles set his thought at odds with the scenes of practice in which medicine was constantly entangled. Aristotle’s causes, thanks to their emphasis on fixed and stable properties, tended to be best for defining identities rather than accounting for change.

Galen (d. c. 210), the most influential of classical medical writers, modified the Aristotelian framework and fitted it to the doctor’s practical concern for bodily alteration. Galen subdivided Aristotle’s most dynamic category, efficient cause, into three medical causes: a body’s predisposition (in medieval Latin, the causa antecedens); the external factor leading to a harmful change in the body (causa primitiva or procatarctica); and the condition actually preventing the body’s proper function (causa coniuncta or contentiva).⁹ Later medical writers did not always employ this exact vocabulary, but their nosology tended to address all three topics in their discussions of causes. Yet the most popular and widely elaborated framework of specifically medical causation was the triad of categories known as the res naturales, the res non naturales, and the res contra natura, or, in a Middle English translation of Guy de Chauliac’s inventarium—“kyndely thinges and noght kyndely and thinges agenst kynde.”¹⁰ These were popularized in the Isagoge of Joannitius (Hunayn ibn Ishaq, d. 873), which was translated by Constantine the African (d. c. 1098). The res naturales encompassed what was intrinsic to the body; the contra-naturals consisted of diseases and their symptoms, which opposed the body’s health; and the non-naturals stood in between. Neither good nor bad in themselves, the non-naturals were those elements of everyday life—air, diet, exertion, rest, excretion, and mood—that influenced somatic states. As Galen remarked of the six factors, “The body cannot but be altered and changed in relation to all these causes.”¹¹ The highest expression of the medieval physician’s art was thought to be the management of these non-naturals. English readers’ interest in their proper handling is evident in the popularity of texts mixing medical and moral advice, like John Lydgate’s most copied poem, the “Dietary” (discussed below), and recensions of the advice-for-princes manual the Secretum Secretorum, which included instructions on hygiene and regimen.

Even with these three flexible etiological schemata, medical writers in the late thirteenth century seized on a further causal rubric, that of “specific” or “occult” causation. It accounted for effects that could not be predicted in advance on the basis of primary qualities. For instance, no calculation of degrees of heat and cold, dryness and moisture could foretell the behavior of a magnet. Its properties of attraction could only be discovered empirically—although once discovered they were considered natural, not magical or supernatural. “Occult causation” made room for what could be learned from experience, beyond existent medical theory.¹²

These several schemes of etiological thinking—Aristotelian, Galenic, Joannitian, and (as an auxiliary) “specific” or “occult”—were products of learned medicine’s etiological imagination. They show the science’s restive puzzling over how to understand the nature of living bodies and the changes they undergo. Yet despite these many tools—or, in some cases, because of them—etiological explanation in phisik remained difficult. Causation cannot simply be observed. It is a relation that requires abstract thought to formulate. Medical experts needed to posit connections among causes, symptoms, and treatments. The intricacy of the task became an increasingly common topic of discussion in medical writing. For instance, the French surgeon Henri de Mondeville (d. 1316) drew attention to it in his Chirurgia of the early fourteenth century, which subsequently circulated in England.¹³ According to Mondeville, it is only in the case of such thumpingly obvious causes as “a stick, or stone, a knife, or something of that kind” that ordinary people can perceive relationships of causation. When the harm results rather from “an intrinsic, interior, or antecedent cause [a causa intrinseca interiore vel antecedente],” the vulgus is at a loss.¹⁴ Mondeville, like Lanfranc of Milan, was part of a tradition that aimed to intellectualize surgery, and causal explanation was central to that project. His written expertise is laid out on the page like academic commentary: “I have presented the appropriate surgical procedure pure and simple, but next to it I have presented its causes and reasons and explanations in smaller letters than the text itself, as if in a commentary or gloss.”¹⁵ The manuscript layout insists on the connection between surgical practice and causal explanation. As he goes on, Mondeville declares that a practitioner who fails to realize that every illness derives from a general and rational system of causes will, as a result of this ignorance, attribute each sickness to an isolated cause and will therefore be no better than an empiric.¹⁶

Mondeville was an especially innovative medical thinker, and one of the points where he can be seen responding to the intellectual problems of the early fourteenth century is in his unusual enumeration of fifty-two contingentia, or contingent factors, in his surgical practica.¹⁷ The list begins with the familiar Joannitian framework of naturals, non-naturals, and contra-naturals and then broadens to include miscellaneous factors not captured under any formal systemization of medical causes. Mondeville explains that the surgeon usually needs to know everything, omitting nothing, about all the details of a patient’s past that may bear on his choice of treatment.¹⁸ Each of these factors—“every individual condition as revealed in a patient, or in a wounded member, or in an illness, or wherever, whether it be favorable or harmful [omnis particularis conditio existens aut reperta in patiente, membro laeso et morbo curando et aliis aliquibus inferius hic notandis, quae condicio nocet aut confert]”—“creates a problem for the surgeon during treatment [ponit difficultatem in curatione morbi curandi per cyrurgicos].”¹⁹ Mondeville’s list of contingentia insists that in applying general scientific principles to particular cases, the surgeon has to be constantly alert to individuating factors.²⁰

The difficulty of etiology found its paradigmatic expression in what was the most well-known piece of medical writing in the Middle Ages, the first aphorism of Hippocrates: “Life is short, art is truly long; the time is acute, experience treacherous, and judgment difficult” (Vita brevis, ars vero longa; tempus autem acutum, experimentum fallax, iudicium autem difficile).²¹ Or, in the paraphrase most familiar to students of Middle English literature: “The lyf so short, the craft so long to lerne, / Th’assay so hard, so sharp the conquerynge.”²² While the narrator of Chaucer’s Parliament of Fowls deploys the aphorism to comment on the labors of love, and indirectly, the labors of poetry, the phrase’s first context of meaning was medicine. The latter half of the aphorism continues: “The physician must not only be prepared to do what is right himself, but also to ensure that the patient, the attendants, and the externals cooperate.”²³ From its earliest versions, the articella (the collection of texts that served as the basis of academic medical education from the twelfth century to the end of the Middle Ages) included the Aphorisms alongside Galen’s commentary on the same text. Galen directly links the meaning of the first aphorism to the ambiguities of causation: “If someone is treated with different medicines, and improves or worsens as a result, it is not easy to decide which of these helped or harmed him.”²⁴ The first medieval expositors of the aphorism emphasized the difficulty resulting from both the numerousness of physical influences and the vastness of medical learning. Bartholomew of Salerno explains, “Art is long because of the multitude and difficulty of things comprehended in the art” (ars vero longa propter multitudinem et rerum difficultatem huic arti subiacentium), and Maurus of Salerno identified medicine’s “length” with its dispersion into a multiplicity of rules and precepts (Ars est longa, idest variis regulis et preceptis diffusa).²⁵

In 1301 Arnau of Vilanova (d. 1311), then perhaps the most famous physician in Europe, delivered a set of lectures to medical students at Montpellier concerning this single Hippocratic aphorism.²⁶ In the first lectio Arnau describes the factors that make the acquisition of medical art a project that exceeds the human lifetime. In the second lecture, he argues that this asymmetry of art and life can be addressed by studying the archive of medical thought. Accordingly, “it is necessary to communicate medical discoveries [inventa de medicina] to posterity in writing [per scripturam] …, and it is necessary for those wishing to be perfected in medicine to study those writings diligently.”²⁷ Considered together, Arnau’s first two lectiones express both wariness and optimism: what is proper to the art of medicine is overwhelmingly vast, but we can make progress by contributing to and relying upon medicine’s textual tradition.

The third lectio, focused on medical practice, considers the difficulties of comprehending causation. Again and again in the course of the lecture, Arnau draws attention to the surfeit of causal factors that a physician faces. When a practitioner sets about diagnosis, he needs to know as much as possible about the patient—about symptoms (accidentia), lifestyle, and personal history. The properly knowledgeable physician should then be able to link all the symptoms to their causes: knowing the disease and its cause allows him to proceed to proper treatment. And yet, contingencies arise—on account of a patient’s unique complexion, or the changing environment, or the preparation of medicines, or even the origins of a piece of fruit: “Will this patient be better helped by figs from Persia or India or Damascus, or by Alexandrine or insular dates? There is a great diversity found in things of the same kind, for example, plants that grow in the fields versus the same ones that grow in the mountains.”²⁸

As the lectio continues, Arnau praises Hippocrates for enjoining physicians to pay attention to external contingencies, and he warns his students to be on guard against whatever factors might impinge on patients’ health, since “by anticipating future contingencies through their causes, physicians can usefully give commands that will allow [their patients] to avoid harmful effects.”²⁹ To illustrate this ability, Arnau launches into a tour de force of etiological imagination, in which the litany of contingencies threatens to outpace any power of anticipation. The passage moves with metonymic agitation through the scene environing a patient, discovering in each detail the body’s alarming vulnerability to its surround. “For example,” Arnau says,

the physician finds that his patient’s home is situated at the foot of a bell tower; he can anticipate that the bells might cause a noise that would be unpleasant and harmful for someone suffering from headache. Likewise he anticipates that where there are many dogs there can be importunate and annoying barking. Likewise if he finds a north or south window in line with his patient’s head, he knows that when those winds blow the patient’s head will suffer unless his bed is moved or the window is tightly shut. Likewise if he sees that the bottle of syrup or decoction stands uncovered in some corner or window and he finds spider webs over it, he can anticipate that spiders may get into these vessels. If he finds his patient’s house is roofless and open, subject to the gusts of the winds, he can foresee that a patient with dysentery who lives in such a place may incur gripes or other lesions of the stomach when any light air blows. Likewise if he is treating cancers or fistulas or swellings in the private parts and groin, and if these parts are exposed for any period of time, remaining so as long as the physician is at work cleansing or anointing or plastering, he can foresee that the patient may suffer problems with a chill in his hips or pains in the thigh or belly or other passions if he is not protected with hot air or warm cloths. If a patient suffers from hemorrhoids, or has recently had a rupture of the lungs, so that it would do him harm to get upset and he must speak in a low tone, the physician can anticipate that the patient will have reason to shout or perhaps to become angry if he has an attendant who is deaf or careless or sleepy.³⁰

A good physician on Arnau’s account is one who recognizes that his patient’s environment is alive with causal forces and charged with contingencies that might be anticipated and kept back from the patient’s susceptible physiology. Urban soundscapes, the room’s architectural axis, filaments of spider web drifting in the corner: these quotidian details and many others are pulled into potential contact with corporeality. The effect of the list is not to reassure the audience of its exhaustiveness. “If I were to tell you all I have myself seen and heard, the day would not be long enough to describe the cases to you,” Arnau remarks.³¹ Here he echoes the kernel of the Hippocratic aphorism in connection to his own lecture: the day is short, but the art is long. Instead of actual comprehensiveness, his catalogue evokes the endless differentiation of circumstances, each one stirring with narrative potential, moving along its anticipated trajectory and conjuring a near future that is simultaneously treacherous and alterable. This is a causally volatile but also labile world.

This welter of potential influences cannot, finally, be exhausted. Arnau understands contingentia to “make a fully rational course of treatment impossible,” as McVaugh observes.³² Indeed, the analogy that Arnau offers for the physician’s labors is intriguingly distinct from any bookish model of medical expertise:

Now the physician’s role regarding a course of treatment is like a sailor’s, because both govern what is committed to them not by following necessary and permanent rules but by weighing contingent and variable factors. For the sailor has to alter the sails and other things as the winds change; the physician has to modify his tools and practices in accordance with the changes and variations in the illness as well as in the dispositions of the air and the other circumstances by which the body is affected.³³

The simile shows the medical practitioner buffeted by a maelstrom of circumstances. Just as the sailor has no stable ground to stand upon as he steers the ship and no place outside the wind wherein to set the sails, so the physician operates within ongoing “changes and variations.” It is not adherence to certain rules that makes a good physician but rather the habitus of real-time adjustment and judgment, which can be only partially captured by rational discourse. Arnau’s three lectures on the first Hippocratic aphorism argue for both the importance of medicine’s growing archive of written expertise and this archive’s insufficiency in the face of specific cases. The physician responds by altering the course of treatment, “modify[ing] his tools and practices,” as the winds change. Illness can have no single fixed course of treatment for every patient.

The later Middle Ages was an age of etiological imagination. Within the broad context of causational fascination, academic medicine developed an especially elaborate vocabulary of forces, which was adapted and deployed to account for the interplay of environment, behavior, pharmacopeia, and bodily disposition as these factors met in patients’ embodied present and shaped their future. From the fourteenth century, medical writers devoted more and more intellectual resources to rendering contingency, or the unpredictable confluence of heterogeneous causes, itself an object of thought. Mediating between natural philosophy’s general principles and the particularities of an individual patient looked increasingly daunting: Vita brevis, ars vero longa. Scholastic schemes of explanation, lit up by the urgencies of pain, vitality, and life and death, circulated in new contexts and arguably made medicine the premier discourse of everyday etiology.

Authority

In late medieval England, the authority to cure was a decentralized and varied power. Medical practitioners came from many backgrounds and claimed the power to explain and heal on various grounds. The infirm might seek health care from physicians, apothecaries, astrologers, members of barber-surgeon guilds, itinerant “leeches” with or without formal education, midwives, tooth-drawers, oculists, parish priests, monastic communities, saints’ shrines, or members of their own or other local households. These care-givers were varied in the actions they performed, in the basis for their efficacy or expertise, and in their accessibility and cost to patients. Medical texts in circulation likewise asserted their authority according to heterogeneous criteria. Some attached their contents to well-known authors, like Galen or Avicenna, and one popular remedy book claimed its discovery in Hippocrates’ tomb.³⁴ Other works named prominent medieval surgeons like Lanfranc of Milan or Guy de Chauliac. Some incorporated bits of academic apparatus into practical instruction, signaling their legitimacy through scholastic mise-en-page. Still others claimed practical efficacy in the form of local testimonies, or probatur statements attributed to nearby individuals—as in the many verifications attributed to the Rector of Oswaldkirk in the remedy book of Robert Thornton.³⁵ If, as Emily Steiner has argued, “authority is never properly one thing” but instead is “something that one is always in relation to, that one is never absolutely identical to, and that one can only provisionally be said to possess,” the discourse and practice of phisik were the occasions for authority’s especially motley manifestations.³⁶

Jostlings among the sundry models of authority formed the texture of late medieval medical discourse. With the exception of short-lived efforts by elite physicians in the early fifteenth century (discussed below), medical authority was neither newly consolidated nor newly centralized in late medieval England. Centralization came later, for instance, with the founding of the Royal College of Physicians in 1518. While guilds were common for barbers and for apothecaries (often as “grocers”), these trades were only partly medical in concern, and English towns lacked anything like the broadly medical guild that existed, for instance, in late medieval Florence.³⁷ In distinction from the rest of western Europe, English towns also had no tradition of providing physicians with salaries to help care for the poor and sick, nor did the crown fund charitable practitioners.³⁸ Apart from elite clients, then, there was little incentive in England for medical credentials. As a result, providing guidance to the sick remained a much less professionalized endeavor than it did on the continent, where medicine’s secularization was well underway by the later thirteenth century. The numbers of physicians educated in England remained small—fewer than a hundred in total at Oxford before 1500, and about half that number in Cambridge.³⁹ Faye Getz’s study of Oxford medical men in the fourteenth century discovers only four (out of forty) without record of ecclesiastical income, meaning that a minimum of 90 percent held benefices.⁴⁰ In the fifteenth century, Oxford medical graduates “did not change their essentially clerical and academic nature.”⁴¹ In addition to these few clerical graduates, it was often parish priests who were responsible for providing basic medical advice as well as access to written remedies, as manuscript evidence suggests.⁴²

Medicine’s entanglement with many different social roles meant that medical practice, and the authority that grounded it, was often available to local reinvention and negotiation. Though medicine assumed prominence in new contexts and the sheer number of medical manuscripts was soaring, caring for the sick and interpreting exceptional bodies were projects whose proper authorities were not known in advance. This fluidity gave rise to distinctive patterns of health care, including a certain itinerancy in one’s course of treatment, as patients expected to visit multiple practitioners in the pursuit of care.

One writer and practitioner who exemplifies the protean character of English medical expertise is the surgeon John Arderne (b. 1307/8–d. 1377 or after), recently deemed “the most important English person in his field before the seventeenth century.”⁴³ Arderne opens his best-known piece of writing, a treatise on the treatment of anal fistula, with biographical flourish. A Middle English translation of the original Latin reads, “I, John Arderne, fro the first pestilence that was in the yere of oure lord 1349 duellid [resided] in Newerk in Notyngham-shire unto the yere of oure lord 1370, and ther I helid many men of fistula in ano.”⁴⁴ From there, Arderne lists the satisfied noblemen and clerics whom he cured, starting with “Sire Adam Everyngham of Laxton-in-the-Clay byside Tukkesford” and going on through nineteen further individuals, each named and specified in terms of geography and social rank. “All thise forseid cured I afore the makyng of this boke,” he declares, thereby linking his composition to an impressive and locally detailed career of surgical success.⁴⁵ Arderne’s Practica is unabashed in claiming the originality and value of his surgical technique, but it also stakes a claim to erudition. Arderne quotes extensively from the corpus of recent Latin practicae, including those by Lanfranc of Milan and Bernard of Gordon. His references indicate the availability of up-to-date continental medical texts for lay readers. Arderne is also the author of De curo oculorum (On the cure of eyes) and a less unified set of materials sometimes titled in manuscripts Liber medicinalium.

Being trained in surgery, a craft, it is unlikely that Arderne attended university. Yet he wrote in Latin, of a sort. Peter Murray Jones describes the surgeon’s language as a “polyglot rather than a consistent Latin,” with passages in Middle English and French, and its grammar “like that of a man thinking in English but writing in Latin.”⁴⁶ The halting modulations of Arderne’s prose testify to this English practitioner’s belabored but also bravura entry into the learned tradition of European surgery. The Practica’s amalgam of manual expertise and learned synthesis was appealing in late medieval England—at least according to Arderne’s account of the high fees he commanded and according to the large number of extant copies of his writings. A total of forty manuscripts survive. Of these, thirty-two preserve Arderne’s Latin texts in whole or in part; the remaining eight are in Middle English and give evidence of four separate translation efforts.⁴⁷ Arderne’s name appears more frequently in Middle English scientific and medical texts than does that of any other English practitioner.⁴⁸ His considerable authority, then, took shape between manual dexterity and erudition, vernacularity and Latinity, medical practice and medical writing.

Several manuscripts of Arderne’s Liber medicinalium preserve a collection of experimenta, or case histories.⁴⁹ Some of these histories record the details of Arderne’s own patients; others describe illnesses and treatments from a third-person perspective. One of the latter type illustrates the itineraries of care that are characteristic of late medieval phisik. The narrative is not so much the story of a cure as it is a tour of expertise. In it, a chaplain from “Colston faste by Byngham” is suffering from a painful, egg-shaped nodule on his chest. He receives medical advice from three sources in turn. First (in the words of a Middle English translation), “he was tawght of a lady [a quadam domina edoctus] to leye an emplastre ther to,” and on her advice he takes to drinking a honey-based wound medicine, “the drynke of Antioche,” for a “longe tyme.”⁵⁰ But at a certain point the ineffectiveness of the lady’s remedies becomes evident to the chaplain: “whan he perceyved that the forseyde medicines prevayled hym nowght he wente un to the Town of Notyngham to be leten blood.” With this decision, his pursuit of a cure assumes a new direction: from local environs to nearby town, from nonprofessional woman to craft-trained man, and from noninvasive herbal concoctions to bloodletting.

The chaplain visits a barber (barbitonsor). In the hierarchy of medieval English medical expertise barbers played an emphatically manual role, being distinguished from surgeons in the relative simplicity of the procedures allowed to them. If figures like Lanfranc of Milan, Henri de Mondeville, and John Arderne were forging an intellectual identity for surgery, barbers by contrast tended to be relegated to the position of unreconstructed empirics. But in this story, the barber shows his medical ambition: when he sees the nodule on the chaplain’s chest, he tells his customer that he recommends a more drastic course of procedure, “kuttynge or corrosyve [incision or corrosives].” The chaplain hesitates and decides to speak to an experienced surgeon (sirurgicus expertus) in the same town. This authority figure, who is also called medicus (leche in the Middle English translation), warns against any such violentas medicinas and explains that if the chaplain were to undergo them, “it wolde brynge hym to the deeth with owten ony rekevere [recovery] [usque ad mortem ipsius langorem irrecuperabilem].”⁵¹ This is where the experimentum ends: the reader never finds out if the chaplain is cured. Instead the story rests with having sketched a provisional hierarchy of medical advice, a hierarchy emerging dynamically from the chaplain’s itinerary—from a local lady to an overreaching barber-surgeon and finally to (in the Middle English) “awyse Sirurgyan.”

The figure of the domina in Arderne’s story is an interesting one. The title domina—or, in the Middle English translation, “lady”—indicates that this was a woman of means, probably propertied and respected, distinct from the figure of the vetula, or old woman, sometimes ridiculed by male medical writers. Upper-class women seem to have dispensed medicines quite regularly as part of their responsibilities in the household. The fifteenth-century commonplace book produced by the medical practitioner Thomas Fayreford, for instance, records the source of one recipe as Lady Poynings—who is elsewhere listed as one of Fayreford’s patients. Fayreford also cites a successful treatment by “quidam domina,” which succeeded even when “omnes scientes in Londyn” failed.⁵² A brief letter from Sir John Paston II to his wife attests to her role as both a medical authority and, in this case, a medical writer. Sometime between 1487 and 1495, Paston wrote to “Mastress Margery”:

I prey yow in all hast possybyll to send me by the next swer messenger that ye can gete a large playster of your flose ungwentorum for the Kynges Attorney Jamys Hobart; for all hys dysease is but an ache in hys knee.… But when ye send me the playster ye must send me wryghtyng hough it shold be leyd to and takyn from hys knee, and hough longe it shold abyd on hys kne unremevyd, and hough longe the playster wyll laste good, and whethyr he must lape eny more clothys a-bowte the playster to kepe it warme or nought.⁵³

[I ask you to send me, in all possible haste, by the next reliable messenger that you can get, a large preparation of your poultice “flose ungwentorum,” for the king’s attorney James Hobart. For all his discomfort is but an ache in his knees.… But when you send me the plaster you must send me some writing about how it should be laid on and taken from his knee, and how long it should stay on his knee unremoved, and how long the plaster will remain good, and whether he should wind any more cloth about the plaster to keep it warm or not.]

Paston asks not only that Margery send him the medical preparation but also that she include written instructions, which marks her participation in the wide ranks of English medical literacy.⁵⁴ It is striking that Paston writes from his location among more elite court circles to seek out the medical expertise of his Norfolk home. In this, he perhaps echoes the perspective of his mother, who wrote to John Paston I in 1464, “fore Goddys sake be ware what medesynys ye take of any fysissyanys [physicians] of London. I schal never trust to hem.”⁵⁵ One medical book that may have been made for the Paston family—the “litel boke of fisik” written by the professional scribe William Ebesham—contains Middle English texts about uroscopy, the plague, and astrology juxtaposed with roughly equivalent Latin versions.⁵⁶ This book, with its doubling of Latin and Middle English expertise, raises questions about how it might have been read and used in the Paston household.

Many further examples could be adduced to show how medieval patients moved among care-givers, testing whether this one or that one could help. Records of cures at saints’ shrines tell a similar story: those healed often reported prior visits to medical experts, whose failures drove them to seek miraculous aid.⁵⁷ While such details of past treatment function to bolster saintly reputations and cannot be taken at face value, they do attest to the prevalence of conceiving healing as a winding, multistop route. Just as it was difficult to determine the exact chain of causes behind a symptom, it was hard to know just whose efficacy, or what kinds of expertise and influence, would lead to a cure. Whether the Nottingham surgeon trumps the local domina, or Margery Paston’s cure outpaces those of court physicians, these and other examples suggest that medical discourse in late medieval England was composed of variegated and overlapping therapeutic competencies and that hierarchies of expertise often emerged locally through particular itineraries of care.

There were, however, two notable and closely related attempts at systematic change. In the first quarter of the fifteenth century, university-trained physicians twice tried to centralize the regulation of who could practice medicine. The first of these attempts was national in scope. In 1421 a group of physicians from Oxford and Cambridge petitioned Parliament and Henry V to establish them as a licensing body. Medical practice, they claimed, should be restricted to those who “have long tyme y used the Scoles of Fisyk withynne som Universitee, and be graduated in the same.”⁵⁸ They demanded “that no Woman use the practyse of Fisyk.” To enforce the new rule that all medical authority be academically ratified, the physicians asked that warrants be sent to “all the Sherrefs of Engelond” summoning anyone lacking academic credentials to “trewe and streyte examinacion” in “one of the Universitees of this lond.” In other words, they called on the state’s system of judicial power, its traveling courts endowed with an authority leading back to the crown, to make medicine a university-controlled pursuit.

One of the most insistent aspects of the petition’s rhetoric is its effort to yoke science and practyse. The word practyse is used with hectic frequency, ten times in the petition’s brief span. The physicians are eager to make the concrete business of healing depend on academic training. Phisik, they claim, is like theology and law; it “should be used and practised” only by those trained in it—but “in this Roialme is every man, be he never so lewed [ignorant], takyng upon hym practyse,” leading to the “grete harme and slaughtre of many men.” However, the petition continues, “if no man practised theryn” except “connynge [knowledgeable] men and approved sufficeantly y learned in art [the liberal arts], filosofye, and fisyk,” then “shulde many men that dyeth, for defaute of help, lyve, and no man perysh by unconnyng [should many men who die for lack of help instead live, and no man perish on account of ignorance].” A university education here is cast as a matter of life and death, in a bid for the intellectualization of healing authority. The physicians’ labor to link academic learning to the efficacy of care suggests that the connection was far from universally recognized. As we have seen, in the Metaphysics Aristotle admits that the empiric’s know-how may top theoretical knowledge in the business of curing: “If, then, someone has the explanation without the experience, … he will often fail to cure.” The ongoing significance of the Aristotelian comment is evident in Antonius of Florence (d. 1459), whose chapter on physicians in his Summa Theologica (a handbook for preachers) refers to what “the Philosopher says in book I of the Metaphysics” in order to remind readers that “we should choose experienced doctors to treat us, rather than those who have knowledge without experience.” Antonius continues, “I consider it safer and better to commit oneself for treatment to practical physicians rather than theoretical ones.”⁵⁹ The petitioning physicians were trying to counter just this idea and the social practices that went with it.

By all evidence, the physicians’ petition came to nothing. For the tiny medical faculties at Oxford and Cambridge, the responsibilities described in the document were unfeasible, and there is no evidence that the act ever came before Parliament after the draft was prepared. Yet two years later, in 1423, university-trained physicians again attempted to secure the rights to medical practice, this time not in all the shires of England but in its most powerful city, London. In alliance with London surgeons, they asked the mayor and aldermen to establish “all Phisicians and Cirurgeans, withinne the libertees of London” as “oon Comminalte [one fellowship].”⁶⁰ In rhetoric similar to the draft act of Parliament, the petition cast practitioners’ ignorance as a menace to public health: many people are “spillide be [ruined by] wreeched and presumptuous practisours in phisyk, nought knowyng the treuthe or ground of that Faculte of Phisyk, and be [by] unkonnyng wirkers in Cirurgy, nought knowyng the trewe crafte of Cirurgy.”⁶¹ Phisik is called a “glorious konnyng [knowledge]” and surgery a “crafte,” but both kinds of expertise require proper training; otherwise, the professions are “disclaundered [slandered]” and people hurt. Insistence on the dangers of medical ignorance in both the 1421 draft act and the London petition implies that the popularization of healing expertise was the occasion for anxiety and that elite physicians thought they could play on such anxiety to launch their ambitious reforms.

The ordinances of the London comminalte extend the vision of two complementary branches of expertise, medicine and surgery, to the physical architecture of the group’s meeting space. The document asks that “oon place” be established in the City of London “contenyng atte lest thre howses [chambers] severall.”⁶² One of these chambers would be for physicians exclusively (“oonly pertenynge to the Faculte of Physick”) and one for surgeons exclusively (“oonly pertenynge to the Crafte of Cirurgye”). The third, however, would be a nonexclusive space of learning, “ichaired and desked for redyng and disputacions in Philosophye and in medicyns.” “Medicine” seems to be the petition’s preferred term for the unified field that physicians and surgeons shared. The common chamber for “redyng and disputacions” corresponds institutionally to the highest office of the comminalte, the “Rectour of the Faculte of Medicyn,” beneath whom are two “Surveiours of the Faculte of Phisyk” and two “Maistres of the Crafte of Cirurgye.”⁶³ While the draft act of Parliament ignores surgery’s independent footing, the comminalte carefully acknowledges it, even incorporating it into the built environment and structures of governance—though the group reserved its highest post, that of rector, for someone with a university degree in medicine.

The only documented action of the comminalte after its establishment in 1423 is the ruling in a case brought by one William Forest, complainant, against three surgeons accused of an “alleged error of treatment of the wound in the muscles of the thumb of the right hand.”⁶⁴ Eight physicians and surgeons made up the advisory jury, among whom were some of the most prominent medical men of late medieval England. The ruling recounts that “on 31 January last past, the moon being consumed in a bloody sign, to wit, Aquarius, under a very malevolent constellation,” William Forest was seriously wounded in the muscles of his hand. On February 9, “the moon being in the sign of Gemini, a great effusion of blood took place.” John Harwe, a “free surgeon,” and two barber-surgeons, John Dalton and Simon Rolf, were involved in stopping the flow of blood, “which broke out six several time in a dangerous fashion, and on the seventh occasion, … the wounded man preferring a mutilated hand rather than death, the said John Harwe, with the consent of the patient, and for lack of other remedy, finally staunched the blood by cautery, as was proper, and thus saved his life.” The advisory jury, “having diligently considered and fully understood the matter, on the evidence of the parties and the sworn testimony,” determined that the surgeon and barber-surgeons “had acted in a surgically correct manner and had made no error, and that therefore they were absolved of all charges made against them by the said William.” In addition, “They further imposed upon the complainant perpetual silence in the matter and, so far as possible, they restored to the defendants who were guiltless and had been maliciously and undeservedly defamed, the full measure of their good reputation, as their merits in the case required. Further they declared that any defect, mutilation or disfigurement of the hand was due either to the constellation aforesaid or some defect of the patient or the original nature of the wound.” The ruling illustrates how the power to narrate mattered in late medieval medicine. William Forest is enjoined to silence, and his own version of events is left out of the ruling. As someone bearing the mark of both injury and treatment, he is forbidden from offering his own account. The jury’s gag order as well as the wish to restore the defendants’ reputations imply the fragility of the surgeons’ standings. A patient’s words mattered in London’s medical marketplace. Although the ruling seems one-sided, with professional self-interest and allegiance stacked against the claimant, it is likely that William Forest soon had the chance to tell his story after all. The comminalte lasted just eighteen months before dissolving under pressure from the powerful guild of barber-surgeons.

The ruling also exemplifies how in late medieval England specialized knowledge of medical causation could trump other explanations. The jury’s linking of astrological details with the “great effusion of blood” depends on the members’ command of a learned system of correspondences between the positions of the stars and bodily flux. This esoteric system underwrites the judgment that the “malevolent constellation” is responsible for Forest’s dangerous bleeding and so for the mutilating treatment, rather than any incompetence on the surgeon’s part. When the expert jury deems that Harwe acted in a “surgically correct manner,” they and he are announced to share this specialist proficiency, which exceeds the patient’s understanding of the situation and so undercuts his account of causation and blame. As in the Isagoge, so in this case: “to the patient [infirmo] these are accidents, while to the doctor [medico], they are signs.”⁶⁵ Faye Getz remarks of the case, “The fact that physic could offer an astrological explanation of this sort in the legal sphere is remarkable. Before this the layman was considered a sufficient arbiter in medical matters that came before the law, and the common law sufficient precedent.”⁶⁶ If lay judgment usually sufficed, elite practitioners in London briefly created an alternative scenario, where they effectively wielded medical astrology in the elite regulation of London’s medical practice. Yet the institution of the comminalte did not last, and Forest likely regained the right to tell his version of events, perhaps even armed with some of the expertise then circulating so plentifully in medical manuscripts. Medicine’s explanatory systems were gaining ground, even if who was able to call on those systems, with what authority, remained a matter for contestation.

Sign

The perceptible qualities of bodies vary among individuals and among groups, and they also shift across an individual’s lifetime. In the Middle Ages, some bodily characteristics were perceived to be fixed, like those codified through species, race, gender, or innate complexion.⁶⁷ Other traits were understood to shift with the body’s ever-fluctuating internal state. Humors tinted the complexion; fever warmed the flesh; indigestion roiled the stomach; lethargy weighed the limbs. Changes like these were clinical signs. Diagnosis was the branch of pathology concerned with bodily signs, and Latin medical manuals included it alongside the other learned operations of medicine: nosological definition, etiology, prognosis, and therapeutics.⁶⁸ Handbooks generally advised that diagnosis should proceed by examining the patient’s appearance, querying her personal history and experience of the illness, scrutinizing her excreta (especially urine), and feeling her pulse.⁶⁹ One symptom could point to many pathologies, and it was only via constellations of symptoms that disease could be reliably identified.

Symptoms are signa naturalia. While natural signs depend on direct or indirect causal relations, causation alone does not make a sign. Signification also requires a “mind apprehending [animam apprehendentem],” as Roger Bacon observes.⁷⁰ Learned traditions of bodily interpretation thus needed to train apprehending minds to recognize what features were meaningful as well as what they meant. This section focuses on two very different frameworks for late medieval corporeal hermeneutics: the diagnosis of leprosy and the practice of physiognomy. Examinations for leprosy regarded the body in terms of pathological change, while physiognomy interpreted it for fixed characterological disposition. Yet both practices faced similar uncertainties as they set about trying to parse living bodies into signifiers and to fix those signifiers with stable meaning. Uncertainties included how to recognize signs as signs, how to weigh conflicting signs against one another, who had the authority to interpret particular bodies, and what models of causation and selfhood undergirded these interpretive systems. Both leprous symptoms and physiognomic indices catalyzed the production of intricate textual aids to address such questions.

Leprosy was one of the most overdetermined bodily states of the later Middle Ages. It was regarded alternately as a medical, legal, moral, exegetical, thaumaturgical, and institutional matter, and according to surviving evidence, those diagnosed with leprosy played a variety of roles in medieval communities.⁷¹ As Luke Demaitre has convincingly shown, medical writers in the later Middle Ages adopted a strongly naturalistic approach toward the disease.⁷² Physicians and surgeons left out scriptural and moralistic glosses almost entirely and instead focused on material causes, diagnosis, and therapeutics. Nonetheless, leprosy’s fraught status still mattered profoundly. Because serious social and legal consequences could follow from diagnosis, learned medicine developed an especially elaborate apparatus for identifying the disease. Scenes of examination could become flashpoints for conflict, and diagnosing leprosy emerged as a particularly high-stakes exercise in medical semiotics.

The official examination of someone suspected of having leprosy was called a iudicium, or “judgment,” and those who were responsible for carrying it out were aware of the quasi-judicial character of their determinations. From the second half of the thirteenth century in France and Germany and on the Iberian Peninsula, university-trained physicians hired by city governments tended to be in charge of iudicia. However, because England had many fewer physicians and no tradition of retaining them for purposes of public health, priests and common-law juries remained the leading examiners of those suspected of the disease. This meant that a broader and more heterogeneous fraction of the population was responsible for diagnosis, and their authority was far from unimpeachable. For instance, William Mustardere, rector of Sparham in the late 1460s, diagnosed his parishioner John Folkard with leprosy, urging the man to “withdrawe hym from the compayne of other men.”⁷³ Following this, Folkard “‘manassed [menaced]’” the priest, warning him “that he shuld repent that ever he made any such noyse,” and Mustardere soon found himself thrown in jail.⁷⁴ Carole Rawcliffe observes that “the false or malicious imputation of leprosy might also result in a suit for defamation.… Mistakes could thus inflict lasting damage on the person making as well as receiving the diagnosis.”⁷⁵

It is likely that such nonprofessional examiners were among the readership for the diagnostic guides that circulated both as parts of longer medical compendia and as independent texts in the later Middle Ages. Just prior to giving step-by-step instructions for a diagnostic exam, the surgeon Guy de Chauliac (d. 1368) warns his readers about the serious consequences of such an evaluation. The Middle English translation of Guy’s Chirurgia magna reads:

it is mykel to be taken hede aboute the examynynge and the dome of leprouse men, that is the moste iniurie (i. wrong) to sequestre or withdrawe tho men that schulde not be sequestred or withdrawen and leve leprouse men with the peple, for-whye it is a contagiouse sekenesse and infectynge. And therfore a leche that shal deme ham, he schall ofte byholde ham and turne and unturne the tokenes.⁷⁶

[It is much to be heeded in the examination and judgment of leprous men, that it is the greatest injury, or wrong, to sequester or withdraw those men that should not be sequestered or withdrawn, and to leave leprous men among the people since it is a contagious and infecting sickness. And therefore a medical practitioner who shall judge them, he shall often behold them and consider and reconsider the signs.]

A failure to diagnose would endanger those who do not have leprosy, while a “false positive” would unjustly force the patient to withdraw from social life. In response to these risks, Guy urges greater observational and interpretive effort, “turning and unturning” the symptoms. Indeed, the medieval medical accounts of leprosy consistently emphasize the painstaking labor of diagnosis.

One diagnostic treatise, often attributed in manuscripts to the fourteenth-century Montpellier physician Jordan of Turre, suggests that the examiner organize his observations according to a carefully rational scheme: “Proceed as follows: take a tablet and write the good signs on one side and the bad signs on the other, and you will not become confused.”⁷⁷ Many treatises divided symptoms into “equivocal” and “unequivocal” categories, so that an examiner would not be misled by a signum fallax.⁷⁸ But even those distinctions were uncertain. In his Lilium medicinae, the Montpellier physician Bernard of Gordon (d. c. 1318) includes an extensive discussion of dubia, or doubtful matters, in his chapter on leprosy. At one point he recalls a patient who had fingers and toes “so deformed, disfigured, and falling apart that they had only one joint left.” Yet over the course of twenty years, no facial symptoms appeared. While Bernard treated the man for leprosy, the physician changed his diagnosis in retrospect, since facial disfigurement is such an “unequivocal” sign: “Therefore, I guess, with conjecture in approximation of the truth, that it was not leprosy and that it could not have lasted for so long without disfigurement of the face. Even though I had once believed differently, now, after having labored diligently in this work, I am of another opinion and now I would not declare someone [like him] leprous. However, God knows the truth, I do not know.”⁷⁹ Bernard’s account is striking for its fretful uncertainty. Despite the spectacular disfigurements for which leprosy was known in hagiography and other literary representations, within learned medicine its discernment was treated as a difficult and anxious task.⁸⁰

The volatility of leprosy’s diagnosis is evident in a Chancery warrant from 1468. Written by three physicians of Edward IV, “William Hatteclyff, Roger Marshall and Dominic de Serego, doctors of Arts and Medicine,” the warrant responds to an earlier petition demanding the removal of “Joanna Nightingale of Brentwood in the county of Essex from general intercourse with mankind, because it was presumed by some of her neighbors [ex vicinis suis] that she was infected by foul contact with leprosy [foeda leprae contagione infectam] and was in fact herself a leper.”⁸¹ Joanna apparently refused to accept this initial diagnosis and call for sequestration, and so a writ was prepared on account of the “grievous injury [grave dampnum]” and “manifest perils [periculum manifestum]” of her ongoing presence. The writ instructed the sheriff of Essex to assemble a common-law jury to make Joanna’s diagnosis legally binding:

having taken with you certain discreet and loyal men [discretis et legalibus hominibus] of the county of the aforesaid Joanna, in order to obtain a better knowledge of her disease, you go to the aforesaid Joanna and cause her to be diligently viewed and examined [facias diligenter videri et examinari] in the presence of the foresaid men. And if you find her to be leprous, as was recorded of her, then that you cause her to be removed in as decent a manner as possible, from all intercourse with other persons, and have her betake herself immediately to a secluded place [locum solitarium] as is the custom, lest by common intercourse of this kind injury or danger should in any wise happen to the aforesaid inhabitants.⁸²

As the writ indicates, the diagnosis that was initially “presumed” (praesumeretur) by her neighbors could be formalized and made binding by a local jury. Joanna was to be “diligently viewed and examined” in the jury’s presence, though no mention is made of who should lead the examination. This initial writ is unconcerned with medical learning, and laymen and common law are treated as sufficient arbiters. Instead of medical expertise, the writ focuses on the perceived dangers to the community and to the customary status of sequestration.

However, Joanna was apparently supplied with friends in high places as well as suspicious neighbors. After the issue of the first writ, the Bishop of Bath and Wells and Lord Chancellor Robert Stillington (d. 1491) requested that the king’s own physicians examine Joanna. They agreed and described their diagnostic exam in a second Chancery writ, which stressed the exam’s methodical and learned character. As the writ recounts, “We examined her person, and, as the older and most learned medical authors have directed in these cases, we touched and handled her and made mature, diligent, and proper investigation whether the symptoms indicative of this disease were in her or not [de persona sua consideravimus, et juxta quod antiquiores et sapientissimi medicinae auctores in hujusmodi casibus faciendum docuerant, ipsam tractavimus et palpavimus, per signa, hujusmodi morbi declarativa, discursum fecimus, si in ea reperirentur mature diligenter et prout oportuit inquisivimus].”⁸³ The physicians provide their reader, nominally Edward IV, some background information to appreciate their method: “We are taught by medical science that the disease of leprosy is known by many signs [Docemur equidem ex scientia medicinali morbum leprae in communi per plurima signa].” And so, they continue

in the case of the woman brought before us, upon going through upwards of twenty-five of the more marked signs of general leprosy we do not find that she can be proved to be leprous, by them or a sufficient number of them. And this would suffice, generally, to free her from the suspicion of leprosy, since it is not possible for any to labor under the disease in whom the greater part of these signs are not found [in hoc casu, mulieris nobis oblatae per viginti quinque & ultra signa leprae in communi famosiora discurrentes, non invenimus ipsam ex illis aut eorumdem sufficienti numero posse convinci leprosam, tt hoc quidem generaliter pro liberando ipsam a dicta praesumptione sufficeret, cum non sit possibile leprae morbo quempiam laborare in quo non multa pars hujusmodi signorum reperiatur].⁸⁴

We can discern in this passage the influence of treatises like Jordanus of Turre’s, with its instructions to notate symptoms on a chart of “good signs” and “bad,” as well as Bernard of Gordon’s careful parsing of equivocal and unequivocal signs. The physicians even recount an otiose further step in their exam, when they search for the symptoms of leprosy’s four subvarieties: “going through upwards of forty distinctive signs of the different varieties of leprosy, we do not find that this woman is to be marked as suffering under any of the four kinds, but is utterly free and untainted [liberam prorsus et immunem].” They conclude their diagnosis, “We are prepared to declare the same more fully to your highness by scientific process [per processum scientificum], if and wherever it shall be necessary.”⁸⁵ With this last statement they promise an even greater display of learned rigor, should the occasion demand it.

In this document, then, the practice of bodily interpretation appears in its deeply social aspect. Joanna’s neighbors are the first to diagnose her, drawing on the traditions of sequestration in canon law (and ultimately Mosaic Law) as well as novel rhetorics of contagion.⁸⁶ It is impossible now to determine the reasons behind this initial diagnosis. Were there visible symptoms that called for it, or was it motivated by the desire to lay hold of a woman’s property, or to bridle her willful behavior? Joanna’s neighbors, finding their diagnosis ignored, petitioned the court of Chancery to lend it legal force. But against the normal course of common law, in which a jury’s judgment was adequate to determine leprosy, the king’s own physicians were solicited. Thanks to the exceptional intervention of Joanna’s apparent ally Robert Stillington, scientific discourse gained a foothold in the situation, and the physicians answered the earlier writ with their own exam, rendering “the truth [veritas] on this subject most plain and clear [clarissima].”⁸⁷ None of the documents includes Joanna’s own account, but her refusal to accede to her neighbors’ diagnosis is a statement in itself. Though the patient’s speech is given no particular authority in the document, it is her diagnostic dissent that gathers a conflicting set of interpretive practices around her. The situation illustrates how the parsing of bodily signs was the occasion not only for interpretation but also for the extrasemiotic negotiation among different authorities and systems of bodily discernment.

Physiognomy, like leprosy’s diagnosis, occasioned the fraught recoding of medieval bodies into legible signs. The physiognomic art sought to discover a person’s character on the basis of bodily features, and in late medieval England it circulated in the discursive borderlands between medicine, natural philosophy, magic, and literary pleasure. Like phisik, physiognomy derives from the Greek term physis. As one Middle English treatise remarks, “This word phisonomea ys said of phisis, that is nature, and gnomos, that is dyvynynge [divining, discerning].”⁸⁸ In his influential commentary Roger Bacon (d. 1294) gave the word a slightly different gloss: “‘Physiognomy’ is the rule of nature in the complexion of the human body and in its composition—because in Greek ‘nomos’ is ‘law,’ and ‘phisis’ is ‘nature’ [Phisonomia est lex nature in complexione humani corporis et eius composicione, quia Grece ‘nomos’ est ‘lex,’ ‘phisis’ est ‘natura’].”⁸⁹ Whether grounded in gnosis or nomos, medieval physiognomy presumed the ordered lawfulness of nature, which undergirded the correspondence of physical features and character. This mutual entailment of body and behavior was usually explained with a nod to astrology. James Yonge, in his translation and redaction of the Secretum Secretorum in 1422, states that “al bodely thyngis [all bodily things] be governyd and ordaynyd by the Planetes and the Sterris [stars],” and accordingly everyone is “disposid dyversly [diversely] to vertues and to vices.”⁹⁰ Astral determinism does not sit comfortably with Christian theology, and Étienne Tempier’s well-known condemnations of 1277 insisted anew that stars merely incline and do not determine human behavior. But physiognomy leaned heavily on this inclination and elaborated the fantasy that bodies, by virtue of being natural things, made persons legible.

Medieval English readers appear to have been eager for physiognomic writings. The catalogue Scientific and Medical Writings in Old and Middle English lists 113 manuscript witnesses for Middle English texts of physiognomy from the fourteenth and fifteenth centuries (although this number is somewhat inflated by separate entries for prologues and texts). Anglo-Latin physiognomies survive even more plentifully. Physiognomy’s manuscript contexts indicate its flexible generic identity, moving between the medicoscientific and the fantastic. Those in straightforwardly medical contexts include, for instance, three Latin tracts in a medical compilation owned by St. Mary’s Priory, Coventry, which bears annotations and signs of use, like the addition of recipes by the infirmarius.⁹¹ One of the remarkable “Sloane Group” of medical manuscripts—identified by Linda Voigts as the productions of a bookmaker specializing in medical compilations—includes a physiognomy, as do three closely related manuscripts.⁹² Roland l’Ecrivain, a member of the Parisian medical faculty, presented an original physiognomy to the Duke of Bedford in 1430. However, physiognomic instructions also appeared alongside more esoteric and exotic materials, like texts on alchemy and divination.⁹³ In two manuscripts, a physiognomy is incorporated into a romance, the Buik of King Alexander the Conquerour, in a combination implying that the pleasures of fantastic narrative and physiognomy were thought congruent, or even mutually amplifying.⁹⁴ Exoticism is also emphasized in John Metham’s mid-fifteenth-century book, written for Sir Miles Stapleton: a love plot set in Persia is sandwiched between a palmistry and a physiognomy. One late thirteenth-century Latin physiognomy, owned and annotated in the library of Bury St. Edmunds, is preceded by a letter from the legendary figure of Prester John.⁹⁵

Physiognomy’s fungible generic identity reflects medieval readers’ uncertain sense of what to do with physiognomy’s implications for embodied subjectivity. If the heavenly bodies or other natural forces imprinted personality and left its indices all over the face to be read, where did this leave moral deliberation and free will? However, to critique physiognomy too stridently, or to insist too vehemently on the untrammeled freedom of human behavior, destroyed physiognomy’s alluring promise that learned expertise could turn the treacherous world into a domain of natural signs. Friction between the desire for knowledge and anxiety about physical determinism is variously legible in physiognomic texts, but I focus here on one Middle English example—the unexceptional seventh chapter of a treatise on natural philosophy. The treatise was written around 1400 in a compilation of medical and scientific texts, now London, British Library, Sloane MS 213. The chapter claims that its physiognomic lore is drawn from Aristotle’s teachings to his pupil Alexander, marking its source as the Secretum Secretorum, the pseudo-Aristotelian treatise translated (in full) from Arabic to Latin around 1230. More than six hundred manuscript witnesses of the Secretum survive, in Latin and various European vernaculars; it was a remarkably popular text.⁹⁶ The physiognomic portion often circulated separately from the rest of the book, as it does in Sloane MS 213.

“Here sues certeyne rewles of phisnomy” (Here follow certain rules of physiognomy) reads the rubric at the start of the chapter, and its contents mostly take the form of rules, or straightforward principles for translating between body and character:

Nose when it es sotyl and small, he that owes it es wrathfull and angry. Who that has a longe nose straght to the mouthe he es gentill, worthy and hardy. Whose nose es like an ape, he es hasty. Schorte nose toknes a schrewe, and if the noseholes be wyde also, that es a synger and liccherous.⁹⁷

[When a nose is subtle and small, he that owns it is wrathful and angry. He who has a long nose, straight to the mouth, is noble, worthy and strong. He whose nose is like an ape’s, he is hasty. A short nose signifies a rogue, and if the nose-holes are also wide, then he is a singer and lecherous.]

A long list of such physiognomic signs was the quintessential form of the genre. The repetitive sentences that make up the bulk of physiognomic treatises tend to follow one of two formulas: either whoever has x is y—as in, “Who that has right litel eares he es foltisch, thevysch and liccherous [foolish, thieving, and lecherous]”—or, alternatively, x signifies y—as in, “Many heres upon aither [either] schuldre signyfies foly [foolishness, madness].”⁹⁸ Both constructions imply a model of embodiment that is static, deterministic, and interpretable. Physiognomy, as the treatise claims, gives the power “to knowe by onely [only] thoght when men lokes on any man, of what condicions he es.”⁹⁹ Quotidian perceptions of bodily form are transformed into esoteric insight into someone’s true identity, thanks to the insights of the physiognomic text.

In actuality, numerous factors mitigated against the straightforward usefulness of physiognomy. Many observations were difficult to make, like the close scrutiny of the eye’s iris or a view of body parts ordinarily hidden from sight. Even if a slew of physiognomic observations were gathered, how did one harmonize them into a comprehensive sense of the person? What if someone had a long nose, making him noble and worthy, and small ears, meaning he was thieving and lecherous? The treatise instructs its readers, “set noght thi sentence [understanding] ne dome [nor judgment] in one of these signes allone, bot gader the wittenes [gather the evidence] to-gider of ilk [each] one.”¹⁰⁰ But exactly how to synthesize the evidence was far from clear. Still, the idea that physiognomy really was practicable, that its list of rules could make the social field legible, was essential to its appeal. Physiognomic texts were suffused with what might be called an otiose practicality.

If physiognomy then gives literate expression to an ethos of determined character and legible embodiment—and if this ethos must have been part of its attraction—most physiognomic texts also bear within them an antidote to this idea, an antidote in the form of a story. This is the remarkably widespread exemplum of Hippocrates and Philomon (or Polemon), the ancient masters of medicine and of physiognomy, respectively. The tale begins with a group of curious medical students, the “disciples” of Hippocrates, who decide to seek out the philosopher rumored to be the “chefe mayster and hyest doctur” of physiognomy.¹⁰¹ From the start, two disciplines of bodily interpretation, medicine and physiognomy, are set in tense and inquiring relation.

Secretly the students have a portrait made of their teacher, depicting the “fourme and schappe of Ypocras [Hippocrates] in parchemyne [parchment],” and they bring this image to Philomon. They demand, “‘Byholde this figur, and deme [judge] and schewe to us the qualités of the complexion of it.’”¹⁰² Philomon studies the portrait and then declares that the man depicted in it is lecherous, deceitful, and greedy. The students are shocked. Their adventure in cross-disciplinary knowledge testing has gotten away from then, and they nearly kill Philomon on the spot. To appease them, he explains that he was answering them merely according to “‘my sciens’” but that after all, he does recognize that the picture “‘es [is] the figure of the wyse Ypocrase.’” The confused students rush back to their master, seeking his explanation and reassurance. Hippocrates listens to their account and then remarks:

“Trewly Philomon saide sothe, and he lafte noght of the leste letter of the treuthe. Nevertheles, sithen I biheld and knewe me schapli to these thynges filthy and reprovable, I ordeyned my soule kyng above my body, and so I withdrewe my body fro thise thynges and I overcome it in withholdyng of my foule luste.”¹⁰³

[“Truly Philomon spoke the truth, and left out not the least letter. Nevertheless, since I beheld and knew myself inclined to these filthy and blame-worthy things, I ordained my soul king over my body, and so I withdrew my body from these things and I overcame it by withstanding my foul desire.”]

The exemplum then draws to a close with a striking redefinition of Hippocratic medicine: “This es the praysyng and wisdome of the werkes of Ypocras, for phisik es noght elles bot abstynens [abstinence], and conquest of foule covetus lustes [desires].”¹⁰⁴

The exemplum emphasizes the abstract and formal character of physiognomic knowledge and how such abstraction limits what physiognomy can know. Philomon examines “it,” a picture, rather than “him,” Hippocrates. The depicted face is a matter of “fourme,” “schappe,” “figur,” and “qualités,” and it is this image that grounds Philemon’s two contradictory judgments—first, that the man in the portrait is wicked, and second, that the image represents “wyse” Hippocrates. The antithesis between Philomon’s pronouncements testifies to an incoherence in physiognomy’s way of understanding other people, the object of its gaze: it ignores their social identity to insist on their somatic legibility. The Hippocratic triumph over physiognomy consists in setting Philemon’s two aporetic pronouncements into dynamic and transformative relation. If physiognomy never resolves the tension between knowable bodies and volatile agencies, Hippocrates masters that tension within the self. He says of his disposition to vice, “I biheld and knewe me schapli to these thynges.” The word “schapli”—meaning conformed or inclining—echoes the “fourme and schappe” of Hippocrates’ portrait, yet the physician shows not only that “schap” can be comprehended but that its consequences, and therefore its meanings, can be controlled. Hippocrates’ “I” and “me” (“I … knewe me”) are further troped into soul and body: “‘I ordeyned my soule kyng above my body.’” Into the static equations of physiognomic rules, Hippocrates injects temporality, reflexivity, and agency.

Though Philomon’s pronouncement departs from the truth “nought the least letter,” one may suspect that this letter kills (littera enim occidit, 2 Cor. 3:6). The Pauline echo is given support by the fact that the treatise’s physiognomic chapter concludes with a quotation from “seynt Poule”: “‘No man sale [shall] be crouned [crowned], bot als [unless] he has lawfully and stalworthly stryvene [heartily struggled]’” (2 Tim. 2:5).¹⁰⁵ Just prior to this biblical quotation, the treatise switches to a second-person address:

And thus ther thou knowes thi self or any other schaply and bowable to any vice by way of thi compleccion, do thi self and councele other to do as Ypocras did, and make thi soule to reule thi body by gode resoun and discrecion, withstandyng by vertue tho vyces to whilke thou art conable borne of compleccion.¹⁰⁶

[And where you know yourself or any other shaped and inclined to any vice because of your complexion, do for yourself—and counsel others to do—as Hippocrates did, and make your soul rule your body according to good reason and discretion, withstanding by means of virtue those vices to which you are disposed on the basis of complexion.]

Here the treatise veers toward penitential self-discipline and leaves behind the semiotics of small noses, little ears, and hairy shoulders that occupy the bulk of the physiognomic text.

The significance of Hippocrates and Philomon can only be evaluated if the exemplum’s position in the physiognomic text is taken into account. This narrative, arguing for the determinative power of self-governance, constantly circulated alongside physiognomic rules. It is recounted in the works of such medieval thinkers as Albertus Magnus (d. 1280), Roger Bacon (d. 1294), Pietro d’Abano (d. 1316), and Michele Savonarola (d. 1468), all of whom treated physiognomy with intellectual seriousness and respect.¹⁰⁷ Physiognomic rules imply, in their very syntactic form, the mutual determination of physical body and moral disposition. They promote the fantasy that readers can be inducted into an esoteric knowledge that transforms the apprehension of bodies into characterological insight. What this means for readers’ own corporeality the rules leave unexamined. The exemplum, by contrast, shows self-cultivation triumphing over natural disposition to the point that physiognomy’s pronouncements become futile. It refocuses attention away from knowing others to knowing oneself. The point is not that the story makes the science conformable to dogma. The adage astra inclinant, sed non obligant was sufficient to squeeze physiognomy into orthodoxy. Instead, the popularity of this disjunctive conjoining shows that medieval readers found the compound of exemplum and rules good to think with. Story and treatise articulate starkly different versions of embodied subjectivity, and so whatever understandings of the physical self emerge from reading the text as a whole are informed by their dissenting interplay. This is a both/and model of writing about the body, which calls for readers’ active parrying of colliding models of causation, signification, and subjectivity.

Book

What did medieval men and women understand phisik to encompass? Medieval English book-making functions as an important source for recovering contemporary understandings of the discourse. Compared to theology, for instance, medicine generated relatively little commentary about its audience, purpose, and discursive status in late medieval England. While people fiercely debated what counted as religious doctrine and who had a claim to read and write it, medicine catalyzed few polemical articulations. The 1421 and 1423 efforts at elite reform are among the only ones. Instead, epistemological evaluation and metapragmatic reflection were often recorded in the material artifacts of books. Manuscripts embody in their contents and layout medieval ideas about medical genres, intellectual traditions, and the relation between literacy and healing. Take, for instance, the redefinition of phisik that concludes the story of Philomon and Hippocrates: “Phisik es noght elles bot abstynens, and conquest of foule covetus lustes [Medicine is nothing other than abstinence and the conquest of foul, covetous desires].”¹⁰⁸ With this line, the exemplum seems to subordinate the scientific and technical aspects of the Hippocratic art to the project of moral self-governance. Set in contrast to physiognomy’s somatic determinism, phisik is made the standard-bearer for the subject’s freedom from nature.

Yet, just as the story’s constant attachment to the physiognomic rules tempered its critique of them, so phisik’s redefinition here was qualified by the textual and material frameworks in which it was articulated. A quick tour through the contents of the codex in which the words appear, now Sloane MS 213, gives a sense of the discursive environment in which it assumed meaning. The chapter on physiognomy is part of a larger vernacular treatise on natural philosophy, which also treats astrology, meteorological and calendrical prognostics, the four humors, and uroscopy. The treatise helps constitute the Middle English portion of the manuscript, a section of more than thirty folios that also includes texts on medicinal oils and waters, bloodletting, and geometry. Most of the Latin texts in the manuscript appear to be in the same hand, datable roughly to 1400.¹⁰⁹ The Latin works probably by the same scribe include the popular herbal De virtutibus herbarum, a lapidary, a translation of the Sevillian physician Ibn Zuhr’s (d. 1164) regimen of health, Arnau of Vilanova’s translation of a treatise on medicinal simples by the Andalusian polymath Abu al-Salt (d. 1134), a survey of medicinal simples by Jean de Saint Amand (fl. late thirteenth century), and part of the cosmological treatise Imago mundi by Honorius Augustodunensis (d. 1154). A portion of the Isagoge of Joannitius is written in another hand and inserted, and a plague treatise by a later scribe is appended at the end.¹¹⁰ The manuscript is quite finely produced, large in size with initial capitals decorated in blue, green, and red. Around the turn of the fifteenth century someone in England invested considerable expense in this book that unites a wide array of authorities in Latin and vernacular to account for how material substances and physical processes interact with one another and affect the human body.

The contents of the manuscript, then, stand at odds with the moralistic redefinition of medicine offered at the end of the story of Hippocrates and Philomon. The tacit argument from the collection of texts is that phisik is a specialized and technical art, one that entails familiarity with cosmology, herbal and lapidary lore, diagnosis from urine, phlebotomy, and sophisticated accounts of pharmacopeia. When the physiognomic treatise turns from bodily signs to the management of vices, it does so within the horizons of a very learned medical manuscript. In an important essay on scientific and medical books, Linda Voigts picks out Sloane MS 213 as especially representative of this new class of books.¹¹¹ The essay analyzes 178 English scientific and medical manuscripts produced between 1375 and 1500 to show that they share not only a common archive of texts but “physical features that set them off from belletristic, theological, philosophical, chronicle, legal, pedagogical and household manuscripts.”¹¹² These manuscripts testify to an apparently broadly shared sense of what constituted scientific and medical books in late medieval England. Voigts has elsewhere uncovered evidence that this common sensibility supported a medical “publisher,” who in the 1450s and early 1460s produced “a specific kind of manuscript, uniform in appearance and scientific and medical in subject matter.”¹¹³ All of these codices made implicit claims about how medical writing should be used and understood.

Sifting through even a fraction of the medical manuscripts that survive from late medieval England soon reveals that they fail to sort according to ready-made categories. There is no strong or consistent divide between Latinate academic learning and vernacular practicality. The cases where ownership can be traced demonstrate that in plenty of cases elite physicians owned simplistic practical texts and manual practitioners possessed elaborately theoretical ones. For instance, a remarkably learned treatise of nearly two hundred pages in Cambridge, Gonville and Caius MS 176/97—which cites from Joannitius’s Isagoge, Constantine’s Pantegni, Galen’s Tegni, the Canon of Avicenna, Isaac Israeli, Giles of Corbeil, Rhazes, Hippocrates, Galen’s commentary on the Aphorisms, and Walter Agilon and which expounds on a technical difference between Galen and Avicenna on the nature of synochal fever—is, according to its preface, addressed “nought to clerkys, but to myn dere gossip [friend] Thomas Plawdon, citiseyn and barbour of London,” so that he might “betir entre into the worchynge of fisyk in tyme of lakkyng [scarcity] of wise fysicians.”¹¹⁴ Traditionally, barbers held an unexalted position in the hierarchy of medical practitioners, performing at most bloodletting and minor surgeries, but the preface assumes that with the treatise’s help, Plawdon could perform “the worchynge of fisyk.”

Conversely, a medical manuscript known to belong to the elite physician John Argentine (d. 1508) contains “unsophisticated calendrical, uroscopy, bloodletting, and remedy material in the vernacular.”¹¹⁵ Argentine was among the most eminent physicians of fifteenth-century England, having studied medicine in Italy (probably at the medical school in Ferrara), practiced at the English court from 1478 onward, and become provost of King’s College, Cambridge in 1501.¹¹⁶ In his own medical commonplace book, Argentine cites the craft-trained English surgeon John Arderne more than any other medical authority and seems to give equal credence to experimenta, or the empirical cures he comes across in the course of his practice, and the prescriptions of written authorities.¹¹⁷ In England, as these examples suggest, there was no automatic correlation between a reader’s social status and the degree of intellectual sophistication in the medical texts he or she owned. This variability points to the remarkably dynamic and heterogeneous nature of medical literacy in England.

Medical writings affected not only those who read them but also those who experienced the care that was influenced by them. The medical compendium that is now London, British Library, Harley MS 2390 includes a particularly fascinating document mediating between the practioner-reader and his potential patients. Apparently compiled for an itinerant care-giver, the book originally opened with the words of a public proclamation, or banns, advertising services:

Hoyit, hoyit, yiff there be any man or wymman that is dyshesyd in any dyversse seknesses, that is for to sayne, al maner wonddes, hurttes, wit hegge tooll, swerd or daghard, here is a man that is a conyng man in leche-craftis bothyn in ffysykke & surgere that wylle curyn alle manere off seknesses be the grace off god the qwiche ben curabele.¹¹⁸

[Hear ye, hear ye! If there is any man or woman diseased with any of these diverse sicknesses, that is to say, all kinds of wounds and hurts—with hedge tool, sword, or dagger, here is a man that is a knowledgeable man in leechcrafts, both in phisik and in surgery, who will cure all manner of sicknesses which are curable, by the grace of God.]¹¹⁹

The banns originally occupied the first pages of a compilation of primarily Latin medical texts, including an herbal, two guides to diagnosis from urine, and a collection of medical recipes. After the opening call to attention—hoyit, hoyit—the crier’s script launches into a list of more than thirty ailments that the doctor could cure—from mormals to migraines, from toothache to flux, deafness to gout, scalding to saucefleme, morphew to mouth-worms, epilepsy to hemorrhoids—in other words, “all maner wounddis and dyshesys [diseases] in any partes of mankende qwyche is possybele for to ben curyd [which are curable] be [by] the grace off god and mannys connynge [expertise].”¹²⁰ In the manner of effective advertising, the list both conjures anxieties and offers the possibility of their relief. The disturbing evocation of bodily vulnerability is balanced against the promise of expertise. All these disease names signal simultaneously the teeming plethora of illness and the specialized knowledge of the “connyng man.” In case listeners missed the point, the banns run through a second, similar list: constriction of breath, pains at the heart, aposteme, bladder, stomach, phlegm, costiveness, gas, spleen, swelling, stopping of the kidneys. The paratextual apparatus of the book has a peculiarly immediate relationship with the banns’ vernacular orality. As Voigts has demonstrated, the banns’ catalogue of ailments corresponds almost exactly to the list of rubrics heading the manuscript’s Latin receptarium. The table of contents, it seems, is the source for the startling litany of ailments. Here, a Latinate finding aid is thus turned outward, reaching past the boundaries of the manuscript to address a broader audience, “any man or wymman that is dyshesyd.” Broadcast into the town’s public soundscape, the list of disease names seeks to draw members of the community into contact with the healing knowledge of the book and its user.

What the leech actually offers, according to the banns, are not surgical procedures or prepared medicines. Rather, for a penny a patient can have his or her “water,” or urine, evaluated—“and he xall demyn thoo watteres & tellyn hem of thoo evellys in any man or womanis body & qwatte maledy soo evere it be [and he shall judge those waters and tell them about those harms in any man’s or woman’s body and whatever disease it is].” For another penny, the doctor will “wryttyn hem here medycynes in a bylle [write them their medicines in a document].”¹²¹ The medical practitioner traffics in words—the spoken words of diagnostic consultation and the written words of remedies. The banns show how the language of medical learning might have entered the lives of individuals in the fifteenth century, even those who did not own or read books. If they paid their two pennies, they would have come away with new information about what was going on inside their bodies, information framed in the terms of “leechcraftis.” They would also possess a “bylle” inscribed with a remedy aimed at improving their health by “the grace off god and mannys connynge.” Or, if passersby chose not to consult the visiting doctor, then one imagines they continued onward with a litany of infirmities ringing in their ears.

This section has thus far focused on coherently medical manuscripts from late medieval England. Less commonly, however, medical works might appear in the same manuscripts as works of devotion or entertainment. One well-known example is Lincoln, Lincoln Cathedral MS 91, written by the Yorkshire landowner Robert Thornton, which includes three large thematic sections, dedicated respectively to romances, to moral and devotional materials, and to medical and pharmaceutical knowledge.¹²² Another similar manuscript, which echoes Thornton’s in its deliberate planning and in its codicological divisions by genre, has been reconstructed by Kathleen L. Scott; I refer to it here as the “Rawlinson-Sloane” manuscript.¹²³ It was originally divided into five sections: a didactic and moralistic part; a historical part; a sequence of narrative and literary works; a sequence of “functional and informative” texts, first on hunting and hawking and then on medicine; and finally a religious text, the confessional guide Manuale curatorum.¹²⁴ It was probably assembled for a family of the provincial gentry.¹²⁵

The medical portion of the Rawlinson-Sloane manuscript is exceptional in its searching attitude toward the status of medical knowledge itself. George Keiser has drawn attention to the uniquely moralistic bent of the plague treatise attributed to “Master Thomas Multon,” which alone among Middle English plague texts begins by designating “plague as divine retribution for sin.”¹²⁶ That text’s unusual mingling of religious and medical explanations has a parallel in the manuscript’s dialogue on surgery. The dialogue, unfolding between two “brothers,” is an engaging device added by the translator to frame the contents Roger of Parma’s Practica Chirurgica. However, the dialogue’s opening departs from the surgical source-text to pose unusual questions about the place of medicine in a divinely controlled world. One “brother” queries the other:

Brother, seth thou sayst that God sendeth men syknes and helth hem aftirward when Hym liketh, wherto shuld eny man studien in lechecraft syth God, yf Hym liketh, may hele a man wythout leches, and yf He wil that a man be nat heled, travayle of leches nys but in vayne?¹²⁷

[Brother, since you say that God sends men sickness and heals them afterward when it please him, why should any man study medicine?—since God, if he likes, may heal a man without doctors, and if He wishes that a man not be healed, the work of doctors is but in vain?]

The speaker wants to know—in light of God’s omnipotence, how one to understand the utility of phisik? More broadly, how does one resolve the different versions of causation offered by medicine and religion? The other brother answers quite conventionally by explaining that God imbues his “vertu in word, in ston, and in grasse and bestis, for profite of mankynd” and “men shuld studien in lechecrafft” to help their “bretheren.”¹²⁸ Nonetheless, the question asked explicitly by the first brother continues to be posed tacitly by the very shape of the Rawlinson-Sloane manuscript. Its wide-ranging contents would have required readers to decide when and how to use its differing generic sections. Do romance, religion, and medicine have anything to say to one another? Their material unity in the manuscript suggests that they do, and the nature of that relationship would have been negotiated in the book’s use.

A final example illustrates the textual dynamism of phisik in late medieval England. John Lydgate’s poem the “Dietary” is a close translation of an anonymous Latin Dietarium.¹²⁹ Evidently, the “Dietary” was remarkably appealing to late medieval and early modern readers. It survives in fifty-nine manuscripts and is Lydgate’s most widely attested composition—“topping everything in popularity,” as A. S. G. Edwards comments.¹³⁰ As I have argued elsewhere, the “Dietary” was copied and read as part of at least three distinctive categories of Middle English writing.¹³¹ Two are familiarly Lydgatian: it was treated as a work of literary art, frequently found in poetic anthologies centered on Lydgate’s and Chaucer’s verse, and it also circulated as a piece of moralistic didacticism, for instance accompanying Benedict Burgh’s rendering of the Distichs of Cato. The third tradition of the poem’s circulation is within medical compilations. At least eleven witnesses of the “Dietary” appear within medical and scientific manuscripts, in the company, variously, of Latin, Anglo-Norman, and English medical works, in verse and in prose. Neighboring texts include recipes, charms, phlebotomies, uroscopies, prognostication aids, astrological charts, alchemical instructions, herbals, a treatise on the virtues of rosemary, a lapidary, plague tracts, mnemonics for the four humors, and a Middle English poem on embryology.

In its own contents, Lydgate’s poem itself cannily capitalizes on medicine’s wavering between a specialized, technical discourse and a more general model of moral didacticism and poetic wisdom. The first stanza provides a kind of physiological “hook,” seeming to establish the poem on straightforwardly medical grounds:

For helth of body cover fro cold thi hede.

Ete non raw mete—take gode hede therto—

Drynke holsom drynke, fede thee on lyght brede,

And with apytyte ryse fro thi mete also.¹³²

[For bodily health, cover your head from cold. Eat no raw meat—take heed of that; drink wholesome drink, feed yourself on light bread, and with appetite remaining rise from your food.]

The “Dietary” invites its audience into the poem for the sake of “helth of body,” and the reader embarks amid the typical precepts of medical regimens. Of course, the personalized regimens that physicians would provide to noble clients were tailored to each patient’s particular humoral disposition and way of life. Lydgate’s poem, by contrast, transmits advice so general as to be applicable to everyone. The “Dietary” even eliminates the broad distinctions found in closely related works like the Regimen sanitatis Salernitanum, which differentiates advice for sanguine, choleric, phlegmatic, and melancholic types. This abandonment of physiological nuance facilitates the poem’s blithe weaving between medical and moral advice:

If so be that lechys do thee fayll,

Make this thi governans if that it may be:

Temperat dyet and temperate traveyle,

Not malas for non adversyté,

Meke in trubull, glad in poverté,

Riche with lytell, content with suffyciens,

Mery withouten grugyng to thy degré.

If fysyke lake, make this thy governans.¹³³

[If doctors fail you, make this your rule if you can: temperate diet and work, no resentment for adversity, meek in trouble, glad in poverty, rich with little, content with the necessities, merry in your rank without complaining. If phisik is lacking, make this your rule.]

The remaining eight stanzas continue the pattern, weaving between physiological advice and ethical and spiritual precepts. This generic flexibility, which apparently helped make Lydgate’s “Dietary” so popular, is internal to the poem’s meaning: its theme is the inextricability of phisik and ethics, body and soul, and medicine and broader practices of self-governance.

The books that spoke of English phisik in the later fourteenth and fifteenth centuries were diverse, but as an aggregate they materialized a new sense of what medical codices could encompass and how they could be designed and used. Books of practical science, including phisik, became a prevalent genre that appealed to a broad spectrum of readers and affected an even wider number of medieval men and women. The banns in Harley 2390 show the technical vocabulary of medicine put to use as aural advertising in late medieval towns. The surgical dialogue in the Rawlinson-Sloane manuscript dramatizes medicine’s subordination to theological rubrics. From the redefinition of Hippocratic medicine as “noght elles bot [but] abstynens, and conquest of foule covetus lustes” to the contents of Lydgate’s most popular poem, writers showed themselves interested in integrating the newly prominent discourse of medicine into other models of self-governance. We should also be alert to the corporeal benefits of literary pleasure, or what Glending Olson has called the “hygienic justification” of narrative and poetic delight.¹³⁴ John Arderne, after all, recommends that a “leche” should “talke of gode tales and of honest that may make the pacientes to laugh.”¹³⁵ Attending to the aesthetics of information in medical texts, or what Lisa H. Cooper has memorably called the “poetics of practicality,” highlights the enjoyment of feeling knowledgeable and of imagining oneself ready to act in the face of the body’s intractable materiality.¹³⁶