This decree was issued amid tensions concerning the role of Aristotelian philosophy in scriptural and moral matters. In no uncertain terms, the rule about physician of the soul takes the moralists’ side in seeking to subordinate naturalistic concerns to spiritual ones. Importantly, however, it leaves room for debate about causation. Bodily sickness is only sometimes (nonnumquam) the result of sin, which means that humoral, astrological, and other natural forces remain explanations circulating uneasily alongside moral and divine ones. This unsettledness necessitates the ongoing work of causal discernment and etiological narration. Given the ceaseless negotiation between medicine and religion throughout the Middle Ages, it is notable that Darrel Amundsen has found a close predecessor for the 1215 decree, in a twelfth-century medical treatise on physicians’ etiquette. It advises the physician to send his patient to confession before commencing any examination, because if the patient “hears mention of this [confession] after you have examined him and have considered the signs of disease, he will begin to despair of recovery, because he will think you despair of it too.”84 The Lateran decree offers an identical version of patient psychology; a recommendation for confession in the course of treatment makes the patient despair, perhaps fatally. In the overlap of these two documents, one sees medici of body and soul worrying, in almost identical terms, over how the sick will navigate the crisscrossing urgencies of physical and sacramental care.
When, in the General Prologue of the Canterbury Tales, Chaucer sketches his archetypical member of the medical profession, he makes explicit reference to etiology. The portrait of the “Doctour of Phisik” marks the close relation between medical skill and the knowledge of causes:
He knew the cause of everich maladye,
Were it of hoot, or coold, or moyste, or drye,
And where they engendred, and of what humour.
He was a verray, parfit praktisour:
The cause yknowe, and of his harm the roote,
Anon he yaf the sike man his boote.85
[He knew the cause of every disease, whether it was hot, cold, moist, or dry, and where they were engendered, and from what humor. He was a true and perfect practitioner: having learned the cause and the root of the harm, he soon gave the sick man his remedy.]
Etiological know-how is tied directly to the physician’s success in healing. According to the verses, identifying the “cause” of every illness means being able to place it within the system of elemental qualities at the foundation of medieval pathology. Although the basis of the Galenic system in the four qualities may seem simple, the portrait emphasizes the elaborate learning that makes such explanation possible. The narrator lists a rather staggering library of medical authorities that the Physician “wel knew” (lines 429–34), and also mentions his expertise in surgery, astrology, and the crafting of measured regimens. It is the fact that his treatments are informed by etiological acumen that makes the Doctour “a verray, parfit praktisour”: because he understands the cause and “roote” of the patient’s “harm,” he is able to give the “sike man” the proper remedy.
Yet the narrator’s famously offhand comment that the Doctour of Phisik’s “studie was but litel on the Bible” also suggests a limit to the physician’s explanatory authority. His current journey to the shrine of the “hooly blisful martir” who “hath holpen [has helped]” pilgrims “whan that they were seeke [sick]” gently qualifies the practical effectiveness of his remedies.86 The shrine was famous for its curative properties, and many of the ampullae that pilgrims used to collect holy water, which was supposedly tinctured with Saint Thomas’s blood, bear the words Optimus egrorum medicus fit Toma Bonorum, or “Thomas is the best doctor of the worthy sick.” The Doctour of Phisik may be a master of some causes but ignorant of others. In the Middle Ages there was no a priori principle to guarantee that a naturalistic explanation for health was more appropriate than a supernatural one, or vice versa.87 The controversy that the Physician has inspired among modern readers—does Chaucer portray him as laudable or blameworthy?88—reflects what was an open question in the later Middle Ages. How legitimate was it to bracket the Bible and concentrate on the intricate technicalities of the medical arts? Chaucer’s portrait implies at once the height of the Physician’s learned authority and its provisionality within the wider frame of the Canterbury pilgrimage and the Christian cosmos. The narrator’s lightness of touch in evoking both medical authority and its limits suggests something of the undecidability of religion’s and medicine’s claims on the body.
The “Specific Rationality” of Medicine
Medieval medicine’s special relation to etiology stemmed not only from the vast number of physical causes it sought to comprehend. It arose as well from the unique position of phisik among medieval discourses of knowledge. More than any other, medicine was aware of itself as an amalgam of theoretical and practical expertise and sensitive to the fact that this produced its “specific rationality,” or its logic and style of thought.89 The standard primer in medieval medical education, the Isagoge, opens by stating that “Medicine is divided into two parts, namely, the theoretical and the practical [Medicina dividitur in duas partes, scil. in theoricam et practicam].”90 Similarly, Avicenna, at the start of his influential Canon, explains medicine’s division into theory and practice: “Theory is that which, when mastered, gives us a certain knowledge, apart from any question of treatment. Thus we say there are three forms of fever and nine complexions. The practice of medicine is not the work which the physician carries out, but is that branch of medical knowledge which, when acquired, enables one to form an opinion upon which to base the proper plan of treatment.”91 Almost all systematic treatments of medicine begin by dividing medical learning into theory and practice. In doing so, writers flagged medicine’s special responsibility to hold together generality and particularity, philosophy and experience, and universal principles and individual cases.
The epistemological status of medicine was of special concern in the Middle Ages thanks to Aristotelian hierarchies of knowledge. Writing in the early eleventh century, Avicenna was already anxious to synthesize Galenic and Aristotelian systems. That task became urgent for medical thinkers in western Christendom following the ascent of the “new” Aristotle in the thirteenth century. At stake was the standing of medicina in the emerging culture of the university. In the hierarchies that structured academic learning, the more that a discipline mixed in the realm of contingent particulars, the lower its status was on the scale of intellectual value. In accord with Aristotle, thinkers tended to doubt that real truths could be based on particular experiences of an ever-changing physical world. Such observations lacked the necessity and universality proper to scientia, which depended on a rigorous demonstration through deductive process beginning with first principles and definitions.92 Medicine sat uneasily astride the definitions of scientia and ars. It was both a theoretical discipline with its own principles and a practical discipline proceeding by empirical observation and inductive judgment and aiming to affect patients’ health.
Uneasiness about medicine’s epistemological status is nowhere more visible than in the scholastic prologues, or accessus, of medical treatises, which became increasingly elaborate as writers sought to describe medicine in Aristotelian terms.93 There, medical writers questioned whether medicine was a scientia or an ars; if a scientia, whether it was speculative, practical, operative, active, or mechanical; if an ars, whether it was mechanical or “real” (realis); whether it was the most perfect art; and so on.94 Most agreed that to the extent that medical thought moved from causes to effects, it, like natural philosophy, possessed demonstrably true knowledge based on axiomatic principles—and was thus a scientia. But to the extent that the physician tried to infer causes from observable effects and to read etiologies from symptoms, medicine was far from a pure science. Among the medieval disciplines of understanding, then, medicine played fretfully between causes and effects.
Such considerations did not remain confined to academic prefaces. The innovative French surgeon Henri de Mondeville (d. 1316) negotiated medicine’s