Symptomatic Subjects. Julie Orlemanski
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