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 1 2 T H F D I T I D N

OiPiros
Pharmacotherapy
Handbook
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Scfiwpr> ghdirFvi i n r

Vicki L Eltngi
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CrmlyV DiPiro

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Hill
 DiPiro’s
Pharmacotherapy
Handbook
Twelfth Edition

00_Schwinghammer_FM.indd 1 01/06/23 5:54 PM

 DiPiro’s
Pharmacotherapy
Handbook
Twelfth Edition

Terry L. Schwinghammer, PharmD, FCCP, FASHP, FAPhA

Professor Emeritus, Department of Clinical Pharmacy
School of Pharmacy
West Virginia University
Morgantown, West Virginia

Joseph T. DiPiro, PharmD, FCCP, FAAAS

Professor of Pharmacy and Associate Vice President for Health Sciences
Virginia Commonwealth University
Richmond, Virginia

Vicki L. Ellingrod, PharmD, FCCP, FACNP

Dean and John Gideon Searle Professor of Pharmacy, College of Pharmacy
Professor of Psychiatry, Medical School
Adjunct Professor of Psychology, College of Literature, Science, and the Arts
University of Michigan
Ann Arbor, Michigan

Cecily V. DiPiro, PharmD

Consultant Pharmacist
Midlothian, Virginia

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto

00_Schwinghammer_FM.indd 3 01/06/23 5:54 PM

DiPiro’s Pharmacotherapy Handbook, Twelfth Edition

Copyright © 2023 by McGraw Hill, LLC. All rights reserved. Printed in the United
States of America. Except as permitted under the United States Copyright Act of
1976, no part of this publication may be reproduced or distributed in any form or by
any means, or stored in a data base or retrieval system, without the prior written per-
mission of the publisher.

Previous editions copyright © 2021, 2018, 2015, 2012, 2006, 2003, 2000, by McGraw Hill;
copyright © 1998 by Appleton & Lange.

1 2 3 4 5 6 7 8 9 LCR 28 27 26 25 24 23

ISBN 978-1-264-27791-9
MHID 1-264-27791-1

This book was set in Minion Pro by MPS Limited.

The editors were Michael Weitz and Peter J. Boyle.
The production supervisor was Catherine H. Saggese.
Project management was provided by Poonam Bisht, MPS Limited.

Library of Congress Control Number: 2023937871

ALGrawany
 Contents

Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

INTRODUCTION
Edited by Cecily V. DiPiro and Terry L. Schwinghammer
The Patient Care Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SECTION 1: BONE AND JOINT DISORDERS

Edited by Terry L. Schwinghammer
1. Gout and Hyperuricemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2. Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3. Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4. Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

SECTION 2: CARDIOVASCULAR DISORDERS

Edited by Terry L. Schwinghammer
5. Acute Coronary Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
6. Arrhythmias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
7. Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
8. Dyslipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
9. Heart Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
10. Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
11. Ischemic Heart Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
12. Shock Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
13. Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
14. Venous Thromboembolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

SECTION 3: DERMATOLOGIC DISORDERS

Edited by Terry L. Schwinghammer
15. Acne Vulgaris. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
16. Dermatologic Drug Reactions and Common Skin Conditions. . . . . . . . . . . . . . 176
17. Psoriasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

SECTION 4: ENDOCRINOLOGIC DISORDERS

Edited by Terry L. Schwinghammer
18. Adrenal Gland Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
19. Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
20. Thyroid Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

SECTION 5: GASTROINTESTINAL DISORDERS

Edited by Joseph T. DiPiro and Terry L. Schwinghammer
21. Cirrhosis and Portal Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

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Contents

22. Constipation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

23. Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
24. Gastroesophageal Reflux Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
25. Hepatitis, Viral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
26. Inflammatory Bowel Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
27. Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
28. Pancreatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
29. Peptic Ulcer Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

SECTION 6: GYNECOLOGIC AND OBSTETRIC DISORDERS

Edited by Vicki L. Ellingrod
30. Contraception. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
31. Hormone Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
32. Pregnancy and Lactation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

SECTION 7: HEMATOLOGIC DISORDERS

Edited by Cecily V. DiPiro
33. Anemias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
34. Sickle Cell Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350

SECTION 8: INFECTIOUS DISEASES

Edited by Joseph T. DiPiro
35. Antimicrobial Regimen Selection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
36. Central Nervous System Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
37. Coronavirus Disease 2019 (COVID-19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
38. Endocarditis and Bacteremia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
39. Fungal Infections, Invasive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
40. Fungal Infections, Superficial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
41. Gastrointestinal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
42. Human Immunodeficiency Virus Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
43. Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
44. Respiratory Tract Infections, Lower. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
45. Respiratory Tract Infections, Upper. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
46. Sepsis and Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
47. Sexually Transmitted Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .476
48. Skin and Soft-Tissue Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
49. Surgical Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
50. Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
51. Urinary Tract Infections and Prostatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
52. Vaccines, Toxoids, and Other Immunobiologics. . . . . . . . . . . . . . . . . . . . . . . . . . .547

SECTION 9: NEUROLOGIC DISORDERS

Edited by Vicki L. Ellingrod
53. Alzheimer Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
54. Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564

vi
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 Contents

55. Headache: Migraine and Tension-Type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 598

56. Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
57. Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
58. Parkinson Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647

SECTION 10: NUTRITION SUPPORT

Edited by Cecily V. DiPiro
59. Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
60. Nutrition Assessment and Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667

SECTION 11: ONCOLOGIC DISORDERS

Edited by Cecily V. DiPiro
61. Breast Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
62. Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
63. Lung Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
64. Lymphomas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
65. Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726

SECTION 12: OPHTHALMIC DISORDERS

Edited by Cecily V. DiPiro
66. Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739

SECTION 13: PSYCHIATRIC DISORDERS

Edited by Vicki L. Ellingrod
67. Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747
68. Bipolar Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763
69. Depressive Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .778
70. Insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 795
71. Opioid Use Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800
72. Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
73. Substance Use Disorders: Non-Opioid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 828

SECTION 14: RENAL DISORDERS

Edited by Cecily V. DiPiro
74. Acid–Base Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845
75. Acute Kidney Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
76. Chronic Kidney Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
77. Electrolyte Homeostasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879

SECTION 15: RESPIRATORY DISORDERS

Edited by Terry L. Schwinghammer
78. Allergic Rhinitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895
79. Asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .904
80. Chronic Obstructive Pulmonary Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917

vii

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Contents

SECTION 16: UROLOGIC DISORDERS

Edited by Cecily V. DiPiro
81. Benign Prostatic Hyperplasia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
82. Erectile Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938
83. Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955

APPENDICES
Edited by Terry L. Schwinghammer
Appendix 1. Pediatric Pharmacotherapy, Nutrition, and Neonatal Critical Care. . . . . 963
Appendix 2. Geriatric Assessment and Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . 972
Appendix 3. Critical Care: Patient Assessment and Pharmacotherapy. . . . . . . . . . . 976
Appendix 4. Drug Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 983
Appendix 5. Drug-Induced Hematologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 988
Appendix 6. Drug-Induced Liver Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 994
Appendix 7. Drug-Induced Pulmonary Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 996
Appendix 8. Drug-Induced Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
Appendix 9. Drug-Induced Ophthalmic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . 1005
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007

viii
ALGrawany
 PREFACE

The 12th edition of this companion to DiPiro’s Pharmacotherapy: A Pathophysiologic

Approach is designed to provide practitioners and students with critical information
to guide medication decision-making in collaborative, interprofessional healthcare
settings. To ensure brevity, clarity, and portability, a bulleted format provides essential
textual information along with key tables, figures, and treatment algorithms.
Corresponding to the major sections in DiPiro’s Pharmacotherapy textbook, medical
conditions are alphabetized within the following sections: Bone and Joint Disorders;
Cardiovascular Disorders; Dermatologic Disorders; Endocrinologic Disorders;
Gastrointestinal Disorders; Gynecologic and Obstetric Disorders; Hematologic
Disorders; Infectious Diseases; Neurologic Disorders; Nutrition Support; Oncologic
Disorders; Ophthalmic Disorders; Psychiatric Disorders; Renal Disorders; Respiratory
Disorders; and Urologic Disorders. The Handbook includes nine tabular appendices
involving: (1) pediatric pharmacotherapy, nutrition, and neonatal critical care; (2)
geriatric assessment and pharmacotherapy; (3) critical care patient assessment and
pharmacotherapy; (4) drug allergy; (5) drug-induced hematologic disorders; (6) drug-
induced liver disease; (7) drug-induced pulmonary disease; (8) drug-induced kidney
disease; and (9) drug-induced ophthalmic disorders. This edition also includes new
chapters on coronavirus disease and multiple sclerosis.
Each chapter is organized in a consistent format:
• Disease state definition
• Pathophysiology
• Clinical presentation
• Diagnosis
• Treatment
• Evaluation of therapeutic outcomes
The Treatment section may include goals of treatment, general approach to treat-
ment, nonpharmacologic therapy, drug selection guidelines, dosing recommenda-
tions, adverse effects, pharmacokinetic considerations, and important drug–drug
interactions. For more in-depth information, the reader is encouraged to refer to
the corresponding chapter in the primary textbook, DiPiro’s Pharmacotherapy: A
Pathophysiologic Approach, 12th edition. These chapters also provide guidance on
application of the Pharmacists’ Patient Care Process for specific conditions.
It is our hope that students and practitioners find this book to be helpful on their
daily journey to provide the highest quality individualized, patient-centered care. We
invite your comments on how we may improve subsequent editions of this work; you
may write to [email protected]. Please indicate the author and title
of this handbook in the subject line of your e-mail.
Terry L. Schwinghammer
Joseph T. DiPiro
Vicki L. Ellingrod
Cecily V. DiPiro

ix

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 INTRODUCTION
Edited by Cecily V. DiPiro and Terry L. Schwinghammer

The Patient Care Process

Health professionals who provide direct patient care are often called practitioners.
Health professionals practice when they use their unique knowledge and skills to serve
patients. A healthcare practice is not a physical location or simply a list of activities;
rather, a professional practice requires three essential elements: (1) a philosophy of
practice, (2) a process of care, and (3) a practice management system.
A practice philosophy is the moral purpose and commonly held set of values that
guides the profession. It is the critical foundation on which the practices of pharmacy,
medicine, nursing, and dentistry are built. Although the concept of pharmaceutical
care is not formally included in the code of ethics for the pharmacy profession or the
oath of a pharmacist, pharmacists understand that they have a unique responsibility
for addressing the drug-related needs of patients and should be held accountable for
preventing, identifying, and resolving drug therapy problems.
The patient care process is a fundamental series of actions that guide the activities
of health professionals. In 2014, the Joint Commission for Pharmacy Practitioners
(JCPP)—representing 11 national pharmacy organizations—endorsed a framework
for providing clinically oriented patient care services called the Pharmacists’ Patient
Care Process. This process includes five essential steps: (1) collecting subjective and
objective information about the patient; (2) assessing the collected data to identify
problems, determine the adequacy of current treatments, and set priorities; (3) creating
an individualized care plan that is evidence-based and cost-effective; (4) implementing
the care plan; and (5) monitoring the patient over time during follow-up encounters to
evaluate the effectiveness of the plan and modify it as needed (Fig. 1). In addition to
the five fundamental steps, a patient-centered approach to decision making is essential.
A practice management system is necessary to support the efficient and effective
delivery of services, including physical, financial, and human resources with policies
and procedures to carry out the work of patient care.
This chapter provides a brief summary of the patient care process applied to drug
therapy management and the practice management issues influencing adoption and
application of this process by pharmacists.

IMPORTANCE OF A STANDARD CARE PROCESS

The stimulus for developing the patient care process for pharmacy was the wide varia-
tion in pharmacists’ practices as they provided direct patient care often using the same
terminology to describe diverse services or, conversely, using different terminology to
describe the same service. Without a consistent patient care process, it has been chal-
lenging for the pharmacy profession to communicate the pharmacist’s role to external
groups and establish the distinct value pharmacists bring to an interprofessional
care team. Moreover, the patient must know and understand what is to be delivered
to determine how best to receive the care provided. Likewise, other members of the
healthcare team must determine how best to integrate the pharmacist’s work into their
efforts caring for the patient. A process of care must be built on a set of fundamental
steps that can address the wide range of complexity that exists among patients. The
process needs to be adaptable to varied settings, diverse populations, and different
acuity levels.

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  |  INTRODUCTION

FIGURE 1. The pharmacists’ patient care process. Joint Commission of Pharmacy

Practitioners. Pharmacists’ Patient Care Process. May 29, 2014. Available at: https://
jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supporting-orga-
nizations.pdf. Reprinted with permission.

THE PATIENT CARE PROCESS TO OPTIMIZE PHARMACOTHERAPY

The application or focus of a profession-specific process of care depends upon the
profession’s knowledge and expertise. For pharmacy, the patient care process is focused
on patient’s medication-related needs and experience with medication therapy. Each
health profession then addresses patient’s needs by assessing patient-specific infor-
mation in a unique manner. For pharmacists providing comprehensive medication
management (CMM), the assessment step involves a systematic examination of the
indication, effectiveness, safety, and adherence for each of the patient’s medications. This
is a unique way of approaching a patient’s health needs; no other discipline applies a
systematic assessment process to medications and the medication experience in this
manner.
The pharmacists’ patient care process is standardized and is not specific to a care
setting—it can be applied wherever CMM is performed. However, the type of informa-
tion collected, its sources, and the duration of time to complete the process may vary
depending on the practice setting and acuity of care. The subsequent sections in this
chapter briefly describe the steps in the patient care process for pharmacists.
COLLECT PATIENT-SPECIFIC INFORMATION
Collect relevant subjective and objective information about the patient and analyze the
data to understand the medical/medication history and clinical status of the patient.
Information from the health record may include patient demographics, active medi-
cal problem list, admission and discharge notes, office visit notes, laboratory values,

2
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 The Patient Care Process   |  

diagnostic tests, and medication lists. Conduct a comprehensive medication review

with the patient that also includes alcohol, tobacco and caffeine use; immunization
status; allergies; and adverse drug effects. Review social determinants of health relevant
to medication use (eg, can the patient afford his/her medications, education level,
housing arrangements, and means of transportation). Obtain and reconcile a complete
medication list that includes all prescription and nonprescription medications as well
as complementary and alternative medicine the patient is taking (ie, name, indication,
strength and formulation, dose, frequency, duration, and response to medication).
Review the indication, effectiveness, and safety of each medication with the patient.
Gather past medication history, if pertinent. Collect information about the patient’s
medication experience (eg, beliefs, expectations, and cultural considerations related to
medications). Ask about the patient’s ability to access medications, manage medications
at home, adhere to the therapy, and use medications appropriately. Gather additional
important information (eg, physical assessment findings, review of systems, home-
monitored blood glucose, blood pressure readings).
ASSESS INFORMATION AND FORMULATE
A MEDICATION THERAPY PROBLEM LIST
Analyze the information collected to formulate a problem list consisting of the patient’s
active medical problems and medication therapy problems in order to prioritize
medication therapy recommendations that achieve the patient’s health goals. Assess
the indication of each medication the patient is taking, including the presence of an
appropriate indication; consider also whether the patient has an untreated medical
condition that requires therapy. Assess the effectiveness of each medication, including
progress toward achieving therapeutic goals; optimal selection of drug product, dose,
and duration of therapy; and need for additional laboratory data to monitor medication
response. Assess the safety of each medication by identifying adverse events; excessive
doses; availability of safer alternatives; pertinent drug-disease, drug-drug, or drug-food
interactions; and need for additional laboratory data to monitor medication safety.
Assess adherence and the patient’s ability to take each medication (eg, administration,
access, affordability). Ensure that medication administration times are appropriate
and convenient for the patient. From all of this information, formulate and prioritize a
medication therapy problem list, classifying the patient’s medication therapy problems
based on indication, effectiveness, safety, and adherence (Table 1).

TABLE 1 Medication Therapy Problem Categories Framework

Medication-Related Needs Medication Therapy Problem Category
Indication Unnecessary medication therapy
Needs additional medication therapy
Effectiveness Ineffective medication
Dosage too low
Needs additional monitoring
Safety Adverse medication event
Dosage too high
Needs additional monitoring
Adherence Adherence
Cost
Pharmacy Quality Alliance. PQA Medication Therapy Problem Categories Framework. August 2017.
Available at: https://www.pqaalliance.org/assets/Measures/PQA%20MTP%20Categories%20
Framework.pdf.

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  |  INTRODUCTION

DEVELOP THE CARE PLAN

Working in collaboration with other healthcare professionals and the patient or care-
giver, develop an individualized, patient-centered care plan that is evidence based and
affordable for the patient. Design the plan to manage the patient’s active medical con-
ditions and resolve the identified medication therapy problems. Coordinate care with
the primary care provider and other healthcare team members to reach consensus on
the proposed care plan, when needed. Identify the monitoring parameters necessary to
assess effectiveness, safety, and adherence, including frequency of follow-up monitor-
ing. Design personalized education and interventions for the patient, and reconcile all
medication lists (eg, from the medical record, patient, pharmacy) to arrive at an accu-
rate and updated medication list. Determine who will implement components of the
care plan (ie, patient, clinical pharmacist, other providers). Determine the appropriate
time frame and mode for patient follow-up (eg, in person, by phone, electronically).
IMPLEMENT THE CARE PLAN
Implement the care plan in collaboration with other healthcare professionals and the
patient or caregiver. Discuss the care plan with the patient, educate the patient about
the medications and goals of therapy, make sure the patient understands and agrees
with the plan, and implement recommendations that are within your scope of practice.
For recommendations that cannot be independently implemented, communicate the
care plan to the rest of the team, indicating where input is required by other team mem-
bers. Document the encounter in the health record (eg, assessment, medication therapy
care plan, rationale, monitoring, and follow-up). Arrange patient follow-up based on
the determined time frame and communicate follow-up instructions with the patient.
FOLLOW-UP WITH THE PATIENT
Provide targeted follow-up and monitoring (whether in person, electronically, or via
phone) to optimize the care plan and identify and resolve medication therapy prob-
lems. Modify the plan when needed in collaboration with other team members and the
patient or caregiver to achieve patient and clinical goals of therapy. Plan for a CMM
follow-up visit at least annually, and repeat all steps of the patient care process at that
time to ensure continuity of care and ongoing medication optimization. Refer the
patient back to the provider (and document accordingly) if it is determined that the
patient no longer needs CMM services.

PRACTICE MANAGEMENT ISSUES

A practice management system is essential to the care process and includes the metrics
to ensure patient health outcomes are being achieved; efficient workflow; communica-
tion and documentation using the power of information technology (IT); and data
that accurately reflect the attribution and value the practitioner brings to patient care.
QUALITY METRICS
The patient care process sets a standard of achievable performance by defining the
parameters of the process that can be measured. With the movement toward outcome-
based healthcare models and value-based payment systems, it is critical to objectively
measure the impact a patient care service has on a patient’s health and well-being. For
the process to be measurable, each element must be clearly defined and performed in
a similar manner during each patient encounter. The lack of clarity and consistency
has hindered collection of robust evidence to support the value of pharmacists’ patient
care services. The standard patient care process gives pharmacists an opportunity to
show value on a large scale because the services are comparable and clearly understood
across practice settings.
WORKFLOW, DOCUMENTATION, AND INFORMATION SYSTEMS
Healthcare systems are rapidly embracing the power of technology to analyze infor-
mation and gain important insights about the health outcomes being achieved. The
uniform patient care process sets a standard for the practice workflow that allows IT
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 The Patient Care Process   |  

systems to capture and extract data for analysis and sharing. The ability to capture
clinical data is currently available through a number of coding systems, such as the
International Classification of Diseases 10th edition (ICD-10) and the Systematized
Nomenclature of Medicine—Clinical Terms (SNOMED-CT). Practitioners need to
understand how coding systems operate behind the scenes when performing and
documenting their clinical activities. This will enable practitioners to assist informa-
tion technologists to effectively design systems to accurately document the elements of
the process that can produce the data on medication-related outcomes.
DOCUMENTATION, ATTRIBUTION, AND PAYMENT
Payment to healthcare providers for patient care services in the United States has
traditionally been based on the documentation and reporting of standard processes of
care. Rules and guidance from Medicare and the Centers for Medicare and Medicaid
Services (CMS) are considered the billing and payment standard for healthcare provid-
ers both for governmental and commercial payers. Reporting the complexity of care
provided is built on top of the documentation requirements; complexity is determined
by the number of required elements in each documentation domain. A billing code is
then assigned to the patient encounter that equates to a payment commensurate with
the level of care provided. This process is the basis for the current fee-for-service
payment structure, and it is likely that this general format will remain in any future
payment model. The traditional SOAP (Subjective, Objective, Assessment, Plan) note
format is often used by pharmacists when documenting patient care and is particularly
appropriate when providing services incident to an eligible Medicare Part B provider.
However, some elements of the SOAP note that are required when using certain bill-
ing codes are not routinely performed by pharmacists (eg, comprehensive physical
examination). The pharmacists’ patient care process establishes a standard framework
that reflects the pharmacist’s work. Using a standard care process accompanied with
a standard documentation framework will result in efficiencies of practice, enable
appropriate and accurate billing, and facilitate the attribution of care to desired patient
outcomes needed in value-based payment models.

See Chapter 1, The Patient Care Process, authored by Stuart T. Haines, Mary Ann
Kliethermes, and Todd D. Sorensen for a more detailed discussion of this topic.

01_Schwinghammer_ch00.indd 5 06/03/23 11:09 AM

ALGrawany
 SECTION 1
BONE AND JOINT DISORDERS
Edited by Terry L. Schwinghammer

1
CHAPTER

Gout and Hyperuricemia

• Gout involves an inflammatory response to precipitation of monosodium urate

(MSU) crystals in both articular and non­articular tissues.

ACUTE GOUTY ARTHRITIS

PATHOPHYSIOLOGY
• The underlying metabolic disorder is elevated serum uric acid (hyperuricemia),
which is defined as a serum that is supersaturated with monosodium urate and
begins to exceed the limit of solubility (>6.8 mg/dL [404 μmol/L]).
• Uric acid is the end product of purine degradation. An increased urate pool in indi-
viduals with gout may result from overproduction or underexcretion.
• Purines originate from dietary purine, conversion of tissue nucleic acid to purine
nucleotides, and de novo synthesis of purine bases.
• Overproduction of uric acid may result from abnormalities in enzyme systems that
regulate purine metabolism (eg, increased activity of phosphoribosyl pyrophosphate
[PRPP] synthetase or deficiency of hypoxanthine-guanine phosphoribosyl transfer-
ase [HGPRT]).
• Uric acid may also be overproduced because of increased breakdown of tissue nucleic
acids, as with myeloproliferative and lymphoproliferative disorders. Cytotoxic drugs can
result in overproduction of uric acid due to lysis and the breakdown of cellular matter.
• Dietary purines are insignificant in generating hyperuricemia without some derange-
ment in purine metabolism or elimination.
• Two-thirds of uric acid produced daily is excreted in urine. The remainder is
eliminated through gastrointestinal (GI) tract after degradation by colonic bacteria.
Decline in urinary excretion to a concentration below the rate of production leads to
hyperuricemia and an increased pool of sodium urate.
• Drugs that decrease renal uric acid clearance include diuretics, nicotinic acid, salicy-
lates (<2 g/day), ethanol, pyrazinamide, levodopa, ethambutol, cyclosporine, and
cytotoxic drugs.
• Deposition of urate crystals in synovial fluid results in inflammation, vasodilation,
increased vascular permeability, complement activation, and chemotactic activity for
polymorphonuclear leukocytes. Phagocytosis of urate crystals by leukocytes results in
rapid lysis of cells and discharge of proteolytic enzymes into cytoplasm. The ensuing
inflammatory reaction causes intense joint pain, erythema, warmth, and swelling.
• Uric acid nephrolithiasis occurs in ∼10% of patients with gout. Predisposing factors
include excessive urinary excretion of uric acid, acidic urine (pH <6), and highly
concentrated urine.
• In acute uric acid nephropathy, acute kidney injury occurs because of blockage of
urine flow from massive precipitation of uric acid crystals in collecting ducts and
ureters. Chronic urate nephropathy is caused by long-term deposition of urate crys-
tals in the renal parenchyma.
• Tophi (urate deposits) are uncommon and are a late complication of hyperuricemia.
The most common sites are the base of the fingers, olecranon bursae, ulnar aspect of
forearm, Achilles tendon, knees, wrists, and hands.

02_Schwinghammer_ch01.indd 7 5/3/23 4:33 PM

SECTION 1   |   Bone and Joint Disorders

CLINICAL PRESENTATION
• Acute gout attacks are characterized by rapid onset of excruciating pain, swelling,
and inflammation. The attack is typically monoarticular, most often affecting the first
metatarsophalangeal joint (podagra), and then, in order of frequency, the insteps,
ankles, heels, knees, wrists, fingers, and elbows. Attacks commonly begin at night,
with the patient awakening with excruciating pain. Affected joints are erythematous,
warm, and swollen. Fever and leukocytosis are common. Untreated attacks last from
3 to 14 days before spontaneous recovery.
• Acute attacks may occur without provocation or be precipitated by stress, trauma,
alcohol ingestion, infection, surgery, rapid lowering of serum uric acid by uric
acid-lowering agents, and ingestion of drugs known to elevate serum uric acid
concentrations.

DIAGNOSIS
• Definitive diagnosis requires aspiration of synovial fluid from the affected joint
and identification of intracellular crystals of MSU monohydrate in synovial fluid
leukocytes.
• When joint aspiration is not feasible, a presumptive diagnosis is based on presence of
characteristic signs and symptoms as well as the response to treatment.

TREATMENT
• Goals of Treatment: Terminate the acute attack, prevent recurrent attacks, and pre-
vent complications associated with chronic deposition of urate crystals in tissues.
NONPHARMACOLOGIC THERAPY
• Local ice application is the most effective adjunctive treatment.
• Dietary supplements (eg, flaxseed, cherry, celery root) are not recommended.
PHARMACOLOGIC THERAPY (FIG. 1-1)
• Most patients are treated successfully with nonsteroidal anti-inflammatory drugs
(NSAIDs), corticosteroids, or colchicine. Treatment should begin as soon as possible
after the onset of an attack.
NSAIDS
• NSAIDs have excellent efficacy and minimal toxicity with short-term use. Indometh-
acin, naproxen, and sulindac have Food and Drug Administration (FDA) approval
for gout, but others are likely to be effective (Table 1-1).
• Start therapy within 24 hours of attack onset and continue until complete resolu-
tion (usually 5–8 days). Tapering may be considered after resolution, especially if
comorbidities such as impaired hepatic or kidney function make prolonged therapy
undesirable.
• The most common adverse effects involve the GI tract (gastritis, bleeding, and perfo-
ration), kidneys (renal papillary necrosis, reduced glomerular filtration rate), cardio-
vascular system (increased blood pressure, sodium and fluid retention), and central
nervous system (impaired cognitive function, headache, and dizziness).
• Selective cyclooxygenase-2 inhibitors (eg, celecoxib) may be an option for patients
unable to take nonselective NSAIDs, but cardiovascular risk must be considered.

Corticosteroids
• Corticosteroid efficacy is equivalent to NSAIDs; they can be used systemically or
by intra-articular (IA) injection. With systemic therapy, a hypothetical risk exists
for a rebound attack upon steroid withdrawal; therefore, gradual tapering is often
employed.

8
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Another Random Scribd Document
with Unrelated Content
even of his political opponents : " God knows I sorrow for them and
pity them in my heart, for I lived four years in the convent of Pisa a
good forty years since." (1284-306). Here also he was strengthened
in his Joachism by " a certain abbot of the Order of Fiore, an aged
and saintly man, who had placed in safety at Pisa all the books that
he had of Abbot Joachim's, fearing lest the Emperor Frederick should
destroy
The text on this page is estimated to be only 28.56%
accurate

76 From St. Francis to Dante. his abbey, which lay on the

road from Pisa to Lucca. For he believed that in the Emperor
Frederick all the mysteries of iniquity should be fulfilled. And Bro.
Rudolf of Saxony, our lector at Pisa, a great logician and theologian
and disputer, left the study of theology by reason of those books of
Joachim's, which were laid up in our convent, and became a most
eager Joachite " (236). As his stay at Lucca had been marked by an
eclipse, so at Pisa he was startled by an earthquake. An eclipse in
later years leads him to quote, more suo, a whole string of Bible
texts connecting such natural catastrophes with the signs of the Last
Judgment, after which he continues (1284-316), " I have multiplied
these texts because at one time the sun is darkened, and at another
time the moon, and at times the earth will quake ; and then some
preachers, having no texts ready prepared for this matter, fall into
confusion. I remember that I dwelt in the convent of Pisa forty years
since and more, and the earth quaked at night on St. Stephen's day
; and Bro. Chiaro of Florence of our Order, one of the greatest clerks
in the world, preached twice to the people in the cathedral church
there, and his first sermon pleased them, but the second displeased.
And this only because he founded both sermons on one and the
same text, which was a token of his mastery, since he drew
therefrom two discourses ; but the accursed and simple multitude
that knew not the law, thought that he had preached again the
same sermon, by reason of that same text which had been
repeated; wherefore he reaped confusion where he should have had
honour. Now his text was that word of Haggai, ' Yet a little while,
and I will move the heaven and the earth and the sea and the dry
land.' Note that earthquakes are wont to take place in cavernous
mountains, wherein the wind is enclosed and would fain come forth
; but since it hath no vent for escape, the earth is shaken and
trembles, and thence we feel an earthquake. Whereof we have a
plain example in the uncut chestnut, which leaps in the fire and
bursts forth with might and main to the dismay of all who sit by."
Pisa, of course, is a city of the plain, but it is interesting to know
what ideas were raised in Salimbene's mind by the mountains which
stand round it on the horizon. At Siena he had received the
subdiaconate (329) ; at Pisa he was ordained deacon (182) ; some
time during the year 1247 he left the province of Tuscany and went
to Cremona, where he soon found himself a close spectator of the
bloody struggle between Pope and Emperor. But before following
him into that world of
The text on this page is estimated to be only 28.26%
accurate

Frate Elia. 77 treasons, stratagems, and spoils, let us

glance at those memories of Tuscan convents which most haunted
his mind as an old man. The Order in its early days, under St.
Francis, had been specially distinguished by its unsacerdotal
character. The saint himself was never more than deacon ; and in a
letter to the Order he evidently contemplated the presence of two
priests in a single settlement of the Brethren as quite an exceptional
case. Of the twenty-five friars whom he sent to evangelize Germany
in 1221, thirteen were laymen, as were also five of the nine who
began the English mission in 1224 ; it was not until 1239 that a
priest, Agnello of Pisa, was elected Minister-General and could
exclaim in triumph to the assembled brethren, " Ye have now heard
the first Mass ever celebrated in this Order by a Minister- General."
St. Francis had been content to impose on his brethren a plain and
brief Rule, without " constitutions " or byelaws ; St. Francis and his
early friars had lived not in convents but in hermitages.* But in
fourteen years the ideal of the Order was already so changed that a
young and ambitious student like Salimbene, in spite of his close
personal intercourse with several of the earliest Brethren, could
count it among the worst crimes of Bro. Elias to have followed here
in the Founder's steps, though indeed he accuses him of having
done so with a far different intention.f He speaks of it as scandalous
that he should have had to associate with fifty lay brethren during
his six years at the two convents of Siena and Pisa, and that he, a
clerk, should have been subject at different times to a lay Gustos
and several lay Guardians. As to the lack of general Constitutions,
though Salimbene is perfectly aware that neither St. Francis nor his
immediate successor Giovanni Parenti had made any, yet he
complains that the absence of such hard-and-fast rules under Elias
resulted in a sort of anarchy ; " in those days there was no king in
Israel," he quotes (102) ; "but every one did that which seemed
right to himself. For under [Bro. Elias] many lay brethren wore the
tonsure, as I have seen * This was so at any rate till 1220, six years
before the Saint's death. Sabatier, p. 199. t Salimbene, pp. 100 foil.
Lempp. (p. 116) thinks that his opinions can scarcely be taken as
altogether typical on this point ; that the Order can scarcely have
drifted so far in so short a time. But it had undoubtedly drifted at
least as far from the Saint's purpose in the direction of extravagant
buildings and reception of money : and even the love of money is
not a more natural instinct than that the learned members of a
religious Order should resent such an equality, or even
preponderance, of the unlearned, as was the rule under St. Francis.
The text on this page is estimated to be only 28.14%
accurate

78 From St. Francis to Dante. with mine own eyes when I

dwelt in Tuscany, and yet they could not read a single letter ; some
dwelt in cities, hard by the churches of the Brethren, wholly
enclosed in hermits' cells, and they had a window through which
they talked with women ; and the laybrethren were useless to hear
confessions or to give counsel ; this have I seen at Pistoia and
elsewhere also. Moreover, some would dwell alone, without any
companion,* in hospitals ; this have I seen at Siena, where a certain
Bro. Martin of Spain, a little shrivelled old lay-brother, used to serve
the sick in the hospital, and went alone all day through the city,
wheresoever he would, without any Brother to bear him company ;
so also have I seen others wandering about the world. Some also
have I seen who ever wore a long beard, as do the Armenians and
Greeks, who foster and keep their beard ; moreover they had no
girdle ; some wore not the common cord, but one fantastically
woven of threads and curiously twisted, and happy was he who
could get himself the gayest girdle. Many other things I saw likewise,
more than I can relate here, which were most unbecoming to the
decency of the Franciscan habit. Moreover laymen were sent as
deputies to the Chapter, and thither also a mighty multitude of other
laymen would come, who had no proper place there whatsoever. I
myself saw in a general chapter held at Sens a full 300 brethren,
among whom the laymen were in the greater number, yet they did
nought but eat and sleep. And when I dwelt in the province of
Tuscany, which had been joined together out of three provinces, the
lay-brethren were not only equal in numbers to the clerics, but even
exceeded them by four. Ah God ! Elias, ' thou hast multiplied the
nation, and not increased the joy.' It would be a long and weary
labour to relate the rude customs and abuses which I have seen ;
perchance time and parchment would fail me, and it would be rather
a weariness to my hearers than a matter of edification. If a lay-
brother heard any youth speaking in the Latin tongue, he would
forthwith rebuke him, saying, ' Ha ! wretch ! wilt thou abandon holy
simplicity for thy book-learning ? ' f But I for my part would answer
them thus from St. Jerome, 4 Holy selfishness profiteth itself alone ;
and howsoever it may edify Christ's Church with the excellence of its
life, by so much it worketh harm if it resist not them who would
destroy her.' In truth, as saith the proverb, an ass would fain make
asses of all * Cf. Dante. Inf. xxiii. 3. t Pro tua sapientia scripturarum.
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accurate

Frate Elia. 79 that he seeth. For in those days not only were
laymen set above priests, but in one hermitage, where all were
laymen save one scholar and one priest, they made the priest work
his day in the kitchen in turn with the rest. So it chanced on a
season that the Lord's day came to the priest's turn ; wherefore,
entering the kitchen and diligently closing the door after him, he set
himself to cook the potherbs as best he could. Then certain secular
folk, Frenchmen, passed that way and earnestly desired to hear
Mass, but there was none to celebrate. The lay-brethren therefore
came in haste and knocked at the kitchen door that the priest might
come out and celebrate. But he answered and spake unto them, ' Go
ye and sing Mass, for I am busied in the work of the kitchen, which
ye have refused.' Then were they sore ashamed, perceiving their
own boorishness. For it was boorish folly to pay no reverence to the
priest who confessed them ; wherefore in process of time the lay-
brethren were brought to nought, as they deserved, for their
reception was almost utterly forbidden,* since they comprehended
not the honour paid them, and since the Order of Friars Minor hath
no need of so great a multitude of laymen, for they were ever lying
in wait for us [clerics]. For I remember how, when I was in the
convent of Pisa, they would have sent to the Chapter to demand
that, whensoever one cleric was admitted to the Order, one lay-
brother should be admitted at the same time, but they were not
listened to — nay, they were not even heard to the end — for their
demand was most unseemly. Yet in the days when I entered the
Order, I found there men of great sanctity, mighty in prayer and
devotion and contemplation and learning ; for there was this one
good in Bro. Elias, that he fostered the study of theology in the
Order." If the clerics of the Order smarted under Bro. Elias'
encourage ment of the lay-brethren, all alike groaned under his
masterful government. Even in St. Francis's lifetime we can see a
natural tendency to more mechanical methods of discipline as the
Order grew in size ; in the Saint's " Epistle to a Minister " of 1223 the
conception of discipline is still paternal, and the Minister's authority
mainly moral ; but in the " Testament " of only three years later we
find already a stern insistence on the necessity of imprisonment for
heresy or certain forms of disobedience among the Brethren. Again,
among the Constitutions passed at Padua in 1277 we find : " item,
the General Chapter commands that there * By the General Haymo
of Faversham. (1240-1244: see xxiv. Gen., p. 251.) 
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8o From St. Francis to Dante. be strong prisons in great

numbers (multiplices), and at the same time humane." Salimbene's
Tuscan recollections of the years 1239-1247 fill in these bare notices
admirably, and show the friction caused within the Order by the
strong-willed, unscrupulous man who did more than any other to
discipline these spiritual volunteers into a rigidly organized papal
militia. (104) " The sixth defect of Bro. Elias was that he afflicted and
reviled the Ministers Provincial, unless they would redeem their
vexation by paying tribute and giving him gifts. For he was covetous
and received gifts, doing contrary to the Scripture (Deut. xvi. 19) ;
whereof we have an example in Alberto Balzolano, the judge of
Faenza, who changed his judgment on hearing that a countryman
had given him a pig. Moreover the aforesaid Bro. Elias kept the
Ministers Provincial so utterly under his rod that they trembled at
him as a rush trembles when it is shaken under the water, or as a
lark fears when a hawk pursues and strives to take him. And this is
no wonder, for he himself was a son of Belial, so that no man could
speak with him. In very deed none dared to tell him the truth nor to
rebuke his evil deeds and words, save only Bro. Agostino da
Recanati and Bro. Bonaventura da Iseo.* For he would lightly revile
such Ministers as were falsely accused to him by certain malicious,
pestilent, and hot-headed lay-brethren (his accomplices), whom he
had scattered abroad throughout the Provinces of the Order. He
would depose them from their office of Minister even without fault of
theirs, and would deprive them of their books, and of their licence to
preach and hear confessions, and of all the lawful acts of their office.
Moreover, he would give to some a long hood f and send them from
east to west, that is from Sicily or Apulia to Spain or England, or
contrariwise. Moreover, he deposed from his Ministership Bro. Albert
of Parma, Minister of the Province of Bologna, a man of most holy
life ; and he bade Bro. Gerard of Modena, whom he appointed by
letter into the place of the deposed Minister, to bring him to himself
at Assisi clad in the hood of probation. But Bro. Gerard, who was a
most courteous man, said nought of this matter to the Minister, only
praying him that he would be his companion on a pilgrimage to the
shrine of the blessed father Francis. When therefore Bro. Gerard was
come with Bro. Albert near to Bro. Elias' chamber, he brought forth *
Not to be identified with Dante's Agostino or Bonaventura. t I.e.,
degrade them to wear the novice's hood.
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Frate Elia. 81 from his bosom two hoods of probation,

whereof he placed one on his own shoulders, and gave the other to
the Minister of Bologna, saying 4 Place this on thine, father, and
await my return to thee.' So Bro. Gerard went in to Elias and fell at
his feet saying, ' I have fulfilled thine obedience, in bringing to thee
the Minister of Bologna with a hood of probation, and behold he
watcheth without and is willing to do whatsoever ye command.'
When Elias heard this, all his indignation left him, and the spirit sank
wherewith he had swelled against him. So Bro. Albert was brought in
and restored to his former rank ; moreover, he obtained many
favours also for his Province by the mediation of Bro Gerard.
Wherefore on account of this and other deeds of that wicked man
Elias, thoughts of revenge were bred in the hearts of the Ministers,
but they waited for the time when they might answer a fool
according to his folly. For Bro. Elias was a most evil man, to whom
we may fitly apply those words which Daniel saith of
Nebuchadnezzar, ' And for the greatness that he gave to him, all
people, tribes, and languages trembled, and were afraid of him ;
whom he would, he slew ; and whom he would, he destroyed ; and
whom he would, he set up ; and whom he would, he brought down.'
Moreover, he sent Visitors who were rather exactors than correctors,
and who solicited the Provinces and Ministers to pay tributes and
grant gifts ; and if a man gave not something into their mouth, they
prepared war against him. Hence it came about that the Ministers
Provincial in his time caused to be made at Assisi, at their own
expense, for the church of the blessed Francis, a great and fair and
sonorous bell, which I myself have seen, together with five others
like unto it, whereby that whole valley was filled with delightful
harmony. So likewise, while I dwelt as a novice in the convent of
Fano, I saw two brethren coming from Hungary and bearing on
sumpter-mules a great and precious salt fish, bound up in canvas,
which the Minister of Hungary was sending to Bro. Elias. Moreover at
the same time, by the Minister's mediation, the King of Hungary sent
to Assisi a great goblet of gold wherein the head of the blessed
Francis might be honourably preserved. On the way, in Siena, where
it was laid one night in the sacristy for safety, certain Brethren, led
by curiosity and levity, drank therefrom a most excellent wine, that
they might boast thenceforward of having drunk with their own lips
from the King of Hungary's goblet. But the Guardian of the convent,
Giovannetto by name, a man zealous for justice, a lover of honesty,
and a native of Assisi,
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82 From St. Francis to Dante. hearing this, bade the

refectorer, a man of Belfort who likewise was named Giovannetto —
he bade him, I say, at the morrow's dinner, to place before each of
those who had drunk from the goblet one of those little pots called
pignatta, black and stained, wherefrom each must drink will he nill
he, in order that, if he would boast henceforward of having once
drunk from the King's goblet, he might remember also how for that
fault he had drunk from a foul pipkin." Not content with these liberal
contributions from all quarters, the General sought also for the
Philosopher's Stone. (160) "He was publicly reported of dealing in
alchemy, and it is certain that, whenever he heard of Brethren in the
Order who, while yet in the world, had known aught of that matter
or craft, he would send for them and keep them by him in the
Gregorian Palace — for Pope Gregory IX had built himself a great
palace in the convent of Friars Minor at Assisi, both in honour of St.
Francis and that he himself might dwell there when he came to
Assisi. In this palace therefore were divers chambers and many
lodgings, wherein Elias would keep the aforesaid craftsmen, and
many others also, which was as much as to consult a pythonic spirit
(Deut. xviii. 11). Let it be imputed to him ; let him see to it ! " It
may be that Elias' dealings in the black art were merely a popular
fiction, but there was no doubt that the liberal contribu tions of the
faithful were very often diverted from their proper object — a
malpractice common everywhere in the 13th century, when pope
after pope set the example of collecting money for the Crusades and
spending it in private wars or in worldly pomp (157) " The seventh
defect of Elias was that he would live in too great splendour and
luxury and pomp. For he seldom went anywhither save to Pope
Gregory IX and the Emperor Frederick II, whose intimate friend he
was, and to Santa Maria della Porziuncula (where the Blessed Francis
instituted his Order and where also he died), and to the convent of
Assisi, where the body of the Blessed Francis is held in veneration,
and to the House of Celle by Cortona, which is a most fair and
delightful convent, and which he caused to be specially built for
himself in the Bishopric of Arezzo, for he was to be found either
there or in the convent of Assisi. And he had fat and big-boned
palfreys, and rode ever on horseback, even if he did but pass a half-
mile from one church to another, thus breaking the rule which saith
that Friars Minor must not ride save of manifest necessity, or under
stress of infirmity. Moreover he had secular youths to
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Frate Elia. 83 wait on him as pages, even as the Bishops

have, and these were clad in raiment of many colours to wait on him
and minister to him in all things. Moreover, he seldom ate in the
convent with the other brethren, but ever alone in his own privy
chamber, which in my judgment was great boorishness, for ^ The
sweetest joys are vain as air Unless our friend may claim his share.
Moreover, he had his special cook in the convent of Assisi, Bro.
Bartholomew of Padua, whom I have seen and known, and who
made most delicate dishes." An anecdote in the Chronicle of the xxiv
Generals (p. 229) at once corroborates Salimbene here, and
suggests that much of his information about Elias may have come
from his old comrade at Siena, the earliest disciple of St. Francis. "
Bro. Bernard of Quintavalle, when he saw Bro. Elias on his horse,
would pant hard after him and cry ' This is too tall and big ; this is
not as the Rule saith ! ' and would smite the horse's crupper with his
hand, repeating the same again. And when Elias fared sumptuously
in his own chamber, Bro. Bernard aforesaid would at times rise up in
great zeal from the table of the refectory, bearing in his hand a loaf
of bread, a fleshhook and a bowl, and would knock at the door of
Bro. Elias's chamber. When therefore the door was opened he would
sit down beside the Minister at his table, saying, ' I will eat with thee
of these good gifts of God : ' whereat the General was inwardly
tormented, yet for that Bernard was held in the utmost reverence
throughout the Order, he dissembled altogether." Elias, whose
despotic rule and contempt of early traditions made him so widely
unpopular, had yet the magnetic attraction of a born ruler of men.
He enjoyed the love of St. Francis, the close confidence of Emperor
and Pope, even while they were at war with each other, and the
loyal attachment of his humble intimates. As Salimbene continues,
speaking of the special cook, (157) " this man clung inseparably to
Elias until the last day of his life, and so also did all they of his
household. For he had a special household of twelve or fourteen
brethren, whom he kept by him in the convent of Celle, and they
never changed the habit of the Order " — i.e. they never
acknowledged themselves truly excommunicate for their adherence
to an excommunicated man. " And after the death of their evil
pastor, or rather their seducer, having understood that they were
deceived, they returned to the Order. Moreover, Elias had in his
company one John, whose
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84 From St. Francis to Dante. sirname was de Laudibus [of

Lodi ?], a lay-brother, hard and keen, and a torturer and most evil
butcher, for at Elias's bidding he would scourge the brethren without
mercy. And [just before the Chapter of 1239] Elias, knowing that the
Provincial Ministers were gathered together against him, sent
commands to all robust lay-brethren throughout Italy whom he
counted as his friends, that they should not fail to come to the
General Chapter ; for he hoped that they might defend him with
their cudgels." This plan was frustrated, however ; and after a
stormy meeting, in which the Pope had to remind the friars that " it
was not the fashion of Religious " to shout each other down with
Thou liest and other abusive cries, Elias was deposed. His Man
Friday, John of Lodi, whose great bodily strength is spoken of by
another chronicler, died in the odour of sanctity, and miracles were
wrought at his tomb : he had enjoyed the supreme privilege of
touching the wound in the side of St. Francis. This is not in the least
inconsistent with Salimbene's account ; miracles were commonly
worked at the tombs of men who in any way struck the medieval
imagination, even as champions of a popular cause in purely secular
politics, like Simon de Montfort or Thomas of Lancaster. St. Thomas
a Becket would have done all that Salimbene here describes for the
cause of discipline in a matter where his convictions were fixed.
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CHAPTER VIII. The Bitter Cry of a Subject Friar. SO Elias

was deposed ; yet still he troubled Israel. Not only was his life in his
first retirement at Celle a scandal to the Rule, but presently he
joined the Emperor's camp openly, as we have already seen.
Salimbene has much to say of this : — and, when he describes the
difficulties created by this single man, we must remember also how
many more of the same sort would be created by the numerous
supporters who had once raised him to the Generalship and had
nearly succeeded in procuring his re-election in 1239. Indeed, the
deposition of Elias marks only the beginning of the most serious
Franciscan dissensions. Salimbene tells how he went about justifying
his apostasy, and how one friar withstood him to his face, finally
dismissing him with St. Francis's contemptuous farewell, " Go thy
way, Brother Fly." (161). Salimbene's dear friend, Gerard of Modena,
who had known Elias well, went once to Celle, and laboured all day
long to bring him back to the Order : but in vain. Moreover, as
Gerard tossed on his sleepless pallet that night, " it seemed to him
that devils like bats fluttered all night long through the convent
buildings : for he heard the sound of their voices, and fear and
trembling seized him, and all his bones were affrighted, and the hair
of his flesh stood up. Wherefore, when morning was come, he took
his leave and departed in all haste with his companion. So in process
of time Bro. Elias died : he had been excommunicated aforetime by
Pope Gregory IX : whether he was absolved and whether he ordered
things well with his soul, he himself knoweth now : let him look to it
! But in course of time (since, as the Wise Man saith, there is a time
and opportunity for every business), a certain Custode dug up his
bones and cast them upon a dunghill. Now if any would fain know
whereunto this Bro. Elias was like
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86 From St. Francis to Dante. in bodily aspect, I say that he

may be exactly compared to Bro. Ugo of Reggio, surnamed
Pocapaglia, who in the world had been a master of grammar, and a
great jester and a ready speaker : and in the Order of the Friars
Minor he was an excellent and mighty preacher, who by his sermons
and his parables confuted and confounded those v.rho attacked our
Order. For a certain Master Guido Bonatti of Forli* who called himself
a philosopher and astrologer, and who reviled the preaching of the
Friars Minor and Friars Preachers, was so confounded by Bro. Ugo
before the whole people of Forli that he not only feared to speak,
but durst not even show himself during all the time that the Brother
was in those parts. For he was brimful of proverbs, stories, and
instances ; and they sounded excellently in his mouth, for he ever
suited them to men's manners ; and he had a ready and gracious
tongue, that the people were glad to hear him. Yet the ministers and
prelates of the Order loved him not, for that he spake in parables,
and would confound them with his instances and proverbs : but he
cared little for them, since he was a man of excellent life. Let it
suffice me to have said thus much of Bro. Elias." (163). The fall of
Elias leads Salimbene to moralize on the advantages of constitutional
as compared with absolute government in a religious Order. The
Friars differed from the older Orders in their frequent change and re-
election of officials, a system in which we find one of the many
strong points of similarity between the Revival of the XHIth century
and the Wesleyan Revival. This frequent change had Salimbene's
hearty approval. For one thing, familiarity was apt to breed
contempt. (146) " I have seen in mine own Order certain Lectors of
excellent learning and great sanctity who had yet some foul blemish
(merditatem), which caused others to judge lightly of them. For they
love to play with a cat or a whelp or with some small fowl, but not
as the Blessed Francis was wont to play with a pheasant and a
cicada, rejoicing the while in the Lord."f Again, the official might
have some strange defect which * Inf. xx. 118. t Cf. his Life by
Bonaventura, viii. 9, 10. I have already noted (Independent Review,
Feb. 1905), how little the Order in general seems to have shared
Francis's love of animals. From the time of the General Chapter of
Narbonne, at least (1260), it was a strict rule " that no animal be
kept, for any Brother or any convent, whether by the Order or by
some person in the Order's name, except cats and certain birds for
the removal of unclean things."
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The Bitter Cry of a Subject Friar. 87 forbade his inspiring

proper veneration : for instance (137) "I was once under a minister
named Bro. Aldebrando, of whom Bro. Albertino of Verona (whose
sayings are much remembered) was wont to say in jest that there
must have been a hideous idea of him in God's mind.* For his head
was misshapen after the fashion of an ancient helmet, with thick
hair on his forehead : so that whenever it fell to him, in the service
for the octave of the Epiphany, to begin that antiphon ' caput
draconis ' (the dragon's head), then the brethren would laugh, and
he himself would be troubled and ashamed. But I used to recall that
saying of Seneca, ' Of what sort, thinkest thou, is the soul within,
where the outward semblance is so hideous ? ' Furthermore, a once
vigorous prelate may fall into his second childhood, as (150) " I have
ofttimes read in the Liber Pontificalis of Ravenna that a certain
Archbishop of that see became so old as to speak childishly, for he
was grown a babe among babes. So when the Emperor
Charlemagne should come to Ravenna and dine with him, his clergy
besought him to abstain from levity for his honour's sake, and for a
good example in the great Emperor's presence : to whom he made
answer, ' Well said, my sons, well said ; and I will do as ye say.' So
when they were seated side by side at table, he patted the
Emperor's shoulders familiarly with his hand, saying, ' Pappa,t
pappa, Lord Emperor ! ' The Emperor therefore asked of those who
stood by what this might mean : and they answered him, ' He would
invite you in childish fashion to eat with him ; for he is in his dotage.'
Then with a cheerful face the Emperor embraced him, saying, '
Behold an Israelite indeed, in whom there is no guile.' ' Therefore
the Prelates (i.e., officials) of religious Orders should be regularly
and frequently changed, as the Captains and Podestas of the cities,
in whose case the plan works admirably. It works admirably also
amongst the Friars ; for (112) 'k let it be noted that the conservation
of religious Orders lieth in the frequent change of Prelates, and this
for three reasons. First, lest they wax too insolent with their long
prelacy, as we see in the abbots of the Order of St. Benedict, who,
since they hold * Quod turpem ideam in Deo habuerat, an allusion
to Plato's doctrine of ideas, according to which everything in the
visible universe had its eternal exemplar in the Divine mind : so at
least Plato was understood in the Middle Ages. t Cf. Dante, Purg., xi.
105.
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8 8 From St. Francis to Dante. office for life and are not
deposed, treat their subject monks as a mere rabble (vilificant
subditos suos), and esteem them no more than the fifth wheel of a
waggon, which is a thing of nought ; and the abbots eat flesh with
lay folk while the monks eat pulse in their refectory ; and many
other burdensome and unseemly things they do to their subjects,
which they should not do, since they themselves choose to live in
splendour and in the greatest liberty.* Moreover, not only do nature
and human courtesy bid them not afflict their subjects nor do them
evil, but Holy Scripture also, and the example of the Father, the Son,
and the Holy Ghost. Of courtesy we have an example in a certain
King of England, to whom, as he was at supper with his knights by a
spring in a wood, a vessel of wine was brought such as the Tuscans
call fiascone, and the Lombards bottaccio. Having asked, and
received an answer that there was no more wine than this, he said ;
' Here then is enough for all,' and poured the whole vessel into the
spring, saying, ' Let all drink in common ' ; which was held to be a
great courtesy in him.f Not so doth the miser who saith, ' I have
found me rest, and now I will eat of my goods alone ' : not so do
those Prelates who eat the finest white bread and drink the best and
choicest wine in the presence of their subjects and of those who eat
with them in the same house, and who give nought thereof to their
subjects (which is held to be utter boorishness) ; and so also they do
with other meats. More over some Prelates drink choice wine, yet
give nought thereof to their subjects who are present, though these
would as gladly drink as they ; for all throats are sisters one to
another.! But the Prelates of our time, who are Lombards, gladly
take to them selves all that their throats and appetites crave, and
will not give thereof to others. Yet after Christ's example the Prelates
should minister to their subjects : as is indeed done in the Order of
Pietro Peccatore ; for on fast days at Collation the priors pour * Such
assertions as that in Mr. F. S. Stevenson's Grosseteste (p. 148), that
the early part of the XHIth century was the " golden age of English
monasticism cannot be taken without very considerable qualification.
There is a strong tendency among modern writers to ignore the
large body of irreproachable evidence as to widespread and serious
abuses in all, or nearly all, the Orders long before 1250. t This was
probably the Re Giovane of /??/. xxviii. 135, who was a bye word for
courtesy and liberality : cf. Novellino 15, 16, 87. J Among the witty
and improper pieces of prose and verse contained in the Franciscan
MS. Harl. 913, is one on the Abbot of Gloucester's Feast, in which
the Brethren make this complaint. See Reliquiae Antiquce, i. 140.
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The Bitter Cry of a Subject Friar. 89 out drink to their

subjects in memory of the Lord's example. Now the head of the
Order of Pietro Peccatore is in the church of Santa Maria in Porto at
Ravenna ; and of the same Order is the convent of Santa Felicula
near Montilio in the Bishopric of Parma, and several other houses in
divers parts of the world."* Salimbene goes on to complain that,
whereas the Apostles and the first Church had all things in common,
"it is not so nowadays " even in Franciscan convents. St. Francis's
Rule prescribes that the Minister should be a servant to all his
brethren, and Christ rebukes the Pharisees for taking the foremost
places in the synagogues, etc. : " Yet the prelates of our time do
this, to the very letter." Our Lord, again, likened His care for mankind
to that of a hen for her chickens : but the evil prelate of to-day
rather resembles that ostrich of which Job writes, " she is hardened
against her young ones, as though they were not hers." The hen
defends her chickens against the fox, " which is a stinking and
fraudulent beast " : so should the prelate defend his fellow-friars
against the Devil or worldly tyrants. The hen, " finding a grain of
corn, hideth it not, but rather crieth aloud that her brood may flock
to her : and when they are come she casteth the grain before them
without distinction of white or black or brown, but giving to each
alike : yet the prelates of our days love not their subjects equally,
but with a private love : some they count as sons, others as
stepsons or spurious : and the same whom they invite to share their
good cheer to-day, to the same they give just as freely on the
morrow. But the rest who sing the invitatorium and whose place is in
the refectory (i.e. who do not eat apart with the prelate,) stand all
the while idle and grumble and murmur, saying with the Poet, ' The
wild boar is feared for his tusks, the stag is defended by his horns ;
while we the peaceful antelopes are a helpless prey ' : which is as
much as to say, 'the flies flock to the lean horse' " (118). This
favouritism of our modern prelates in their invitations to good cheer
is contrary both to our Lord's words (Luke xiv. 12) and to the
example of St. Lawrence, which Salimbene quotes at length. " But
[modern prelates] have loved the glory of men more than the glory
of God, and therefore shall they be confounded. For they say, ' To-
day I will give you a good * For Pietro Peccatore see Dante, Par., xxi.
122, and Toynbee's Dante Dictionary s.v. Damiano and Pietro degli
Onesti. It is very possible that Dante confused the two men ; but
these words of Salimbene's seem to show conclusively that the
second was the real Pietro Peccatore.
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90 From St. Francis to Dante. dinner in the hope that ye

will give me the same to-morrow ' : of whom the Lord saith, ' Amen
I say unto you, they have received their reward.' ' To these faults of
unfairness and self-seeking the Prelates too often add that of
discourtesy : which Salimbene rebukes by three Scriptural examples.
Our Lord desired (not commanded) Simon to draw back a little from
the land : Simon himself said to Cornelius, * Arise, I myself also am
a man ' : and the Angel of the Apocalypse said the same to St. John.
" Lo therefore how our Lord and the Apostle Peter and the Angel
honour God's servants ; and how these boorish Prelates raise
themselves above them in their pride ! " It may well be (he pursues)
that the subordinate friar is of far better and wealthier family, more
learned, more religious, older, and in short better in every way than
his Prelate. Yet the latter will lord it over him, and thee and ihou him
as if he were a child. We learn incidentally how little the use of the
pronouns was as yet fixed in Italian : for " the Apulians and Sicilians
and Romans say ihou to the Emperor or the Pope himself, while the
Lombards say you not only to a child but even to a hen or a cat or a
piece of wood." He admits, indeed, that " even good Prelates have
their persecutors and evil-speakers and scorners," for there are
always sons of Belial, unbridled and uncontrolled, like those who
despised Saul. But he harks back to the same complaint : (115) "
Whereas Christ saith of Himself, ' The Son of Man is come to seek
and to save that which is lost ' : the Prelates of our day are mostly '
come for to steal and to kill and to destroy,' as St. John saith : or in
Micah's words, ' the best of them is as a briar, the most upright is
sharper than a thorn hedge.' So that if any man would fain write a
dialogue of modern Prelates, as Gregory did, he would rather find
dregs [of men] than holy Prelates : for as Micah saith, ' the good
man is perished out of the earth, and there is none upright among
men.' ' Nowadays, indeed, as often in the past, a man risks his
immortal soul by accepting promotion in the Church (142) : a saint
of old once cut off his own ears to avoid being made Bishop, and,
when this proved an insufficient protection, swore that he would cut
out his tongue also unless they left him in peace. This holy man,
continues our chronicler, resembled the beaver, who will mutilate
himself to escape from his pursuers. He next goes on to quote many
shining examples of the past who might well shame the authorities
of his day into something better. For post-Biblical times he chooses
as typical
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The Bitter Cry of a Subject Friar. 9 1 heroes Saints Silvester,

Nicholas, and Thomas of Canterbury. The mention of St. Nicholas
leads him into a tirade which reads like a fragment of the Wife of
Bath's Prologue. It may well be commended to the notice of those
who have hastily inferred that, because the Franciscans exaggerated
the already exag gerated devotion to the Virgin Mary, they were
therefore possessed with a " chivalric respect for women " and "
restored woman to her rightful position in Christian society."*
Salimbene, it must be remembered, was no farouche ascetic : he
tells us more than once of the charming ladies whose director he has
been ; he was far from holding, with St. Bonaventura's cherished
secretary, that women are not fit objects for a friar even to gaze
upon. The quotations which he here heaps together are simply
commonplaces of the Middle Ages, and represent the ordinary
clerical attitude towards the fair sex. " Note," he writes, " that it is
said of St Nicholas, ' he avoided the company of women ' : and
herein he was wise ; for it was women who deceived the children of
Israel (Num. xxxi.). Wherefore it is written in Ecclesiasticus, ' Behold
not every body's beauty ; and tarry not among women. For from
garments cometh a moth, and from a woman the iniquity of a man.'
Again, in Ecclesiastes, ' I have found a woman more bitter than
death, who is the hunter's snare, and her heart is a net, and her
hands are bands. He that pleaseth God shall escape from her : but
he that is a sinner, shall be caught by her.' In Proverbs again, ' Why
art thou seduced, my son, by a strange woman, and art cherished in
the bosom of another ? ' Again in the sixth chapter, ' Let not thy
heart covet her beauty, be not caught with her winks : For the price
of a harlot is scarce one loaf : but the woman catcheth the precious
soul of a man.' And again in the twenty-third, ' For * Cf. TJie Friars,
and Iww they came to England, pp. 105, 106, in which a doubtful
sentence of Prof. Brewer's is exaggerated out of all moderation and
reason. Apart from such passages as this of Salimbene's, and
hundreds of other briefer testimonies to the same spirit among the
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