An Eleventh-Century WebMD: The Viaticum of Constantine the African

Up until this point we’ve been somewhat abstract in talking about Constantine the African’s works, as a set of texts that had dramatic effects on other texts. But for a patient who has unexpectedly come down with an unknown illness, of course, the intellectual tradition behind their care is likely to be of little interest: they want to put a name to their affliction and, ideally, cure it. So from the perspective of this hypothetical patient, what good were Constantine’s translations?

To answer this question, we need to have some sense of the places in which medical care occurred, and to understand the kinds of medical training that were available. Medical care was undertaken in multiple settings in the medieval world: in homes, to be sure, and also in monasteries and other institutions that likely attended to both bodily as well as spiritual health. At the highest levels, medical practitioners could be deeply learned and highly skilled experts, but there must have been an entire world of practitioners that is only rarely visible in our written sources.

Only a handful of images depict or illustrate medical practice in the period before Constantine was active in southern Italy; the tenth-century images found in this manuscript, Florence, Biblioteca Laurenziana, MS Plut. 73.41 (here f. 122v), illustrate how to cauterize patients suffering from various illnesses.

If we assume that a practitioner from Constantine’s own eleventh century was literate, how did they approach the treatment of a disease they were unfamiliar with? The answer is surprising, and illuminates the ways that medical care has both changed and remained the same in the intervening centuries. Before the mid eleventh century, the textual resources for medical practice had some limitations: for theoretical medicine, only a handful of formal medical treatises or commentaries would have been available, and even these circulated in modest numbers.

On the other hand, a large, fluid, and fascinating set of remedies was in circulation, often written scrappily on the blank pages and in the margins of manuscripts. But even though the remedies from this period that have been passed down to us may appear humble, we should not discount the possibility that they contain hard-earned empirical wisdom, gleaned from long experience with disease prevalence and herbal and other remedies available in a particular region.

In the eleventh century this situation began to change. Of course, as we have discussed, Constantine the African translated a considerable number of works from Arabic into Latin; but renewed attention was also given to texts that already existed in Latin. A work called the Passionarius, for example, combined a group of earlier texts into a handbook of medical practice. This text circulated in considerable numbers in Europe (and especially in Italy) in the eleventh and twelfth centuries—it was about as popular as the Theorica Pantegni—and in some cases was even furnished with several sets of annotations that clarified and explicated the text. Though its earliest manuscripts lack clear authorial attribution, the work became associated with the prominent scholar Gariopontus (died perhaps before 1056), who was praised by the prominent reforming monk Peter Damian as “a most upright man, superbly educated in the arts and in medicine.”1

What made the Passionarius so popular? Some of the work’s popularity must result from the organization of its presentation. While the empirical remedies that accrued over time in a manuscript might be haphazardly organized, this text followed the time-honored anatomical “head to toe” (a capite ad calcem) organizational scheme. For example, the Passionarius began by describing and giving causal explanations for several different subtypes of headache. Additionally, it presented multiple remedies for a particular illness; for the first subtype of headache, these included environmental remedies (avoiding both bright light and deep darkness), bloodletting, dietary remedies, and multiple compound remedies.

The text and chapter lists of this manuscript of the Passionarius are written in Beneventan, a striking script that flourished in southern Italy in Gariopontus and Constantine’s eleventh century. Vatican, BAV, Archivio Capitolare San Pietro, MS H 44, f. 23r.

But for all its virtues, the Passionarius must have also been challenging. For one, Gariopontus’ terminology had to have been daunting for Greekless readers, describing illnesses with Greek words and phrases; the subtypes of headache it covers are cephalea, cephaloponia, and monopagia. Additionally, the same ailment was sometimes covered in successive chapters, with varying emphases and remedies. This resulted from the way that it combined multiple texts, but it must have stymied those readers who just wanted a quick, unambiguous explanation of a particular illness and some remedies.

If we turn to Constantine the African, whose career in southern Italy appears to have started in the 1070s, we might wonder: did Constantine know Gariopontus’ influential work? This question is harder to answer than we might think: though the Passionarius was listed in a booklist of the monastery of Monte Cassino shortly after Constantine was there, Constantine never referred to it explicitly, and the terminology that Constantine’s works share with Gariopontus was common to the longer history of Latin medicine.

It is tempting to suppose, however, that Constantine’s own handbook of practical medicine, the Viaticum, was intended as some kind of response to the Passionarius. Just as the Passionarius synthesized earlier works, the Viaticum was intended to serve as a handily sized, single-volume handbook of medical practice. Like the Passionarius, the Viaticum presents illnesses and remedies in “head to toe” order. (Instead of headaches, however, it begins with alopecia and hair loss.) The work’s title, Viaticum—which echoes the meaning of the work’s source text, Ibn al-Jazzar’s Zād al-musāfir wa-qūt al-ḥāḍir (meaning “Provisions for the Traveller and Nourishment for the Sedentary”)—suggests it was meant to serve as a portable medical reference for travelers. But where Ibn al-Jazzar’s Arabic text (and the Passionarius) often gave pages of remedies for each illness, Constantine’s translation often condensed these recipes to their essentials: to remedy hair loss from fasting, Constantine tersely lists temperate baths, a moderate diet, the avoidance of salty things, and anointing with poppy or iris oil. At times, however, Constantine’s zeal for compression appears to have led him to cut into the bone, and his text leaves out some of the steps—and sometimes even the quantities!—of the remedies in Ibn al-Jazzar’s text. Was it the case that Constantine felt that Ibn al-Jazzar’s text was a little too long to travel with comfortably? Given Constantine’s book-laden trip across the Mediterranean, he would have been a position to know.

In contrast to the Passionarius’ heavy use of Greek terminology, Constantine’s Viaticum may have been translated with the needs of non-specialist readers in mind. He gave the work a Latin title, and he used more Latin and less Greek terminology than Gariopontus and many of his other predecessors. Constantine spoke simply of “hair loss” (capilli cadentes) and trimmed down the Greek terms for headache’s subtypes. Where the Passionarius sometimes spread its discussion of a single illness over multiple chapters, the Viaticum’s coverage was more tightly focused, with chapters that were more clearly focused on a particular ailment.

The composition of the Viaticum appears to have encountered some “quality control” difficulties of its own. Beyond its occasionally odd Latin and a few nonsensical readings, the earliest copyists of the Viaticum appear to have made one major mistake in producing the earliest copies of the text. Its preface makes clear that Constantine had placed a comprehensive, “omnibus” list of all of the chapters of the entire work at the beginning of Book I (likely drawn from a similar chapter list in his Arabic source), but this preface also states that he intended for the seven books of the Viaticum to have their own lists (an organizational scheme that is found in the Passionarius and the earliest manuscripts of the Theorica Pantegni). In our earliest manuscript of the text, however, these subordinate chapter lists were not inserted; when they do begin to be inserted into later manuscripts, they can be cramped and awkward, given far less space than they really required. It is only in the course of the twelfth century that manuscript designers learned to give the Viaticum’s layout the space it required. We can also see evidence of this “retrofitting” of text and layout in the discrepancies between the tables of contents and the rubrics accompanying each chapter, something Mary Wack noticed some years ago when studying the Viaticum’s terminology for lovesickness.

In planning the layout of the Viaticum, Constantine wanted to emulate works like the Passionarius and the Pantegni, as well as the manuscripts of his Arabic source. Like this fragmentary copy of Ibn al-Jazzar’s text, Wellcome MS Arabic A406, the Viaticum gave a list of all of the chapters of the entire work at the beginning.

Even though the Viaticum may not have lived up to its creator’s intentions, this hardly hindered its popularity, and at least 35 full and partial copies of the Viaticum survive from the century and a half after the work’s translation. If it did not prove quite as popular as the Passionarius in this period, it eventually became a massive success: it survives in well over a hundred copies, and was read—and, to all appearances, used—in many of the settings of medieval medicine. It appears to have been used heavily by monks, for example, and received commentaries at universities.

Nor, as we will see next time, was this one of Mark Twain’s little-read classics: as it grew in popularity, the Viaticum would reshape the ways that people thought about the body and its illnesses. More broadly—and although these practices hardly began with Gariopontus and Constantine—their works are echoed in modern attempts to understand and heal the body: like the imagined traveler who read Constantine’s Viaticum, we continue to use the parts of the body as an organizational rubric when we try to self-diagnose on WebMD; just as Gariopontus and Constantine’s readers must have known, words and names can still be sources of comfort to suffering readers.

Further Reading:

  • Demaitre, Luke E, Medieval Medicine: The Art of Healing from Head to Toe (Santa Barbara: Praeger, 2013).
  • Glaze, Florence Eliza, “Galen Refashioned: Gariopontus of Salerno’s Passionarius in the Later Middle Ages and Renaissance.” Ch. 3 in Textual Healing: Essays in Medieval and Early Modern Medicine, ed. Elizabeth Lane Furdell (Leiden: E.J. Brill, 2005): 53-77.
  • Glaze, Florence Eliza, “Gariopontus and the Salernitans: Textual Traditions in the Eleventh and Twelfth Centuries,” in La ‘Collectio Salernitana’ di Salvatore De Renzi, ed. Danielle Jacquart and Agostino Paravicini Bagliani (Firenze: SISMEL/Edizioni del Galluzzo, 2008), pp. 149-90.
  • Glaze, Florence Eliza, “Prolegomena: Scholastic Openings to Gariopontus of Salerno’s Passionarius,” in Between Text and Patient: The Medical Enterprise in Medieval and Early Modern Europe, ed. Florence Eliza Glaze and Brian Nance, Micrologus’ Library, 30 (Florence: SISMEL/Edizioni del Galluzzo, 2011), pp. 57-86.
  • Glaze, Florence Eliza, “Speaking in Tongues: Medical Wisdom and Glossing Practices in and around Salerno, c. 1040-1200,” in Herbs and Healers from the Ancient Mediterranean through the Medieval West, ed. Anne Van Arsdall and Timothy Graham (Aldershot: Ashgate, 2012), pp. 63-106.
  • Horden, Peregrine, Hospitals and Healing from Antiquity to the Later Middle Ages (Aldershot: Ashgate, 2008).
  • Wack, Mary, Lovesickness in the Middle Ages: The ‘Viaticum’ and Its Commentaries (Philadelphia: University of Pennsylvania Press, 1990).
  • Wack, Mary, “‘Alī ibn al-‘Abbās al-Maǧūsī and Constantine on Love, and the Evolution of the Practica Pantegni,” in Constantine the African and ‘Ali ibn al-’Abbas al-Maǧusi: The ‘Pantegni’ and Related Texts, ed. Charles Burnett and Danielle Jacquart (Leiden: E. J. Brill, 1994), pp. 161-202.

[1]Translated by Peter Blum, in the Letters of Saint Peter Damian(Washington, DC: Catholic University Press, 1989),p. 108.

“In Latin books, I found no author who gave certain and authentic information; therefore, I turned to the Arabic language…”

In our previous post, we stated that Constantine the African was one of the most important authors in the Latin (and thus the Western) medical tradition. But why? What did Constantine’s works offer that earlier texts in Latin– medical works that had been translated from Greek into Latin in late antiquity, for example– had lacked? This question takes us into the heart of the works that Constantine produced, the way he produced them, and the particular place in history that Constantine occupied. The answer, briefly, is that Constantine’s skillful and well-positioned translations drew on centuries of medical scholarship in the Islamic world that synthesized and surpassed the findings of the ancient medical tradition.

In antiquity, Greek authors– and the Greek-speaking Roman physician Galen (d. ca. 216 CE) above all– had produced a sophisticated body of medical knowledge, a set of texts that made substantial improvements upon earlier knowledge of anatomy, physiology, and, to a somewhat lesser extent, therapeutics. In the 600 years after Galen’s death, the production of scientific and medical works in Greek waned to a trickle, but this medical tradition was taken up with avidity by writers in Arabic and Persian after the rise of Islam in the seventh century. More than merely repeating or harmonizing what Galen had already said, this Islamic medical tradition added to and even disputed Galen’s findings in works of considerable sophistication.1 It described illnesses, such as smallpox, that had only been mentioned briefly (or not at all) by Galen; attempted to resolve inconsistencies in his works; and even disparaged Galen’s philosophical pretensions.

Nor was this all. Islamic writers, writing in the richest, most vibrant cities in the Islamic world (and indeed, some of the greatest cities in the Middle Ages), had access to medicinal substances and medical learning that Galen did not. Where cane sugar had been known to ancient medical writers as a rare import, it was readily available to Islamic physicians; where Roman scholars had some vague notions of India, scholars in the Islamic tradition were able to consult Arabic translations of Sanskrit medicine. The medical works that were produced in the Islamic world, then, were not warmed-over compilations of ancient medicine, but works that often broadened the tradition with new resources, observations, and reasoned debate.

Constantine the African’s translations played a central role in introducing medicinal substances from Islamic medicine such as sugar cane into the Latin medical tradition, here pictured in a thirteenth-century copy of the Tractatus de herbis, an expanded version of the Salernitan pharmaceutical treatise, Circa instans. British Library, MS Egerton 747, f. 106r.

On the other hand, the very vitality of the Islamic medical tradition posed its own set of challenges. After short centuries of conquest, Islamic rule was firmly established from the Iberian peninsula (modern Spain) in the west to beyond Persia in the east, and medical writers across this broad territory developed their own traditions. We can easily understand why: practitioners in Córdoba might need to treat illnesses differently from those encountered in Ghazna (in modern Afghanistan) and might draw upon different plant, animal, and mineral substances from which to confect remedies. What resulted was not unchecked chaos: medical scholars shared the same theoretical and methodological framework: Islamic medical writers agreed on the fundamental importance of the four humors, for example, and that humoral imbalance was one of the principal causes of disease. Once you scratched the surface of this tradition, however, its complexities became apparent: Arabic terminology jostled with loan words from Greek, Persian, Syriac, and even Sanskrit, while authors gave varying explanations and remedies for a wide range of illnesses.

Islamic medicine, then, was always characterized by a tension between its centrifugal tendencies and the desire of some scholars to make its complexities orderly and systematic. The great systematizer ʻAlī ibn al-ʻAbbās al-Majūsī (d. after 977), for example, who spent much of his career in Shiraz (in modern Iran), self-consciously tried to improve the overwhelmingly long and disorganized works of his predecessors with a rigorously organized overview of medical theory and practice in twenty books. But medical scholarship did not stand still while al-Majūsī worked, and medical scholarship also flourished elsewhere, as in the vibrant medical tradition of the North African city of Kairouan. Where al-Majūsī’s overview of medicine sought to systematize Islamic medicine, the Muslim physician Ibn al-Jazzār (d. ca. 979) put forward his own view of medicine in works that explained diseases and therapeutics for lay readers while also subtly delineating the moral ramifications of health and disease.

In the tenth and eleventh centuries, the Islamic territories covering a huge swathe of Eurasia, North Africa, and beyond were renowned for their power, wealth, and cultural refinement. But even more than the breadth of the territory controlled, however, the vitality of Islamic civilization is suggested by the fact that centers of major cultural importance could be found at opposite ends of this territory, from Córdoba in Al-Andalus (now modern Spain) to Ghazna (Ghazni, in modern Afghanistan). Map © Ian Mladjov

In contrast with the Islamic medical tradition, the Latin medical tradition was a far more modest affair. The Benedictine Rule, which structured monastic life for much of the Middle Ages, enjoined the care of the sick, but few monasteries took this as encouragement to systematically collect and study the works of medicine then available. Some medical practitioners were highly skilled (and those in Salerno in southern Italy were especially famed), but few efforts had been made before the eleventh century to harmonize their insights with theoretical works of ancient medicine. There can be little surprise, then, that when Constantine the African traveled from North Africa to southern Italy in the mid-eleventh century, he was unimpressed by what he found. What is likely to be one of his earliest works gives his appraisal: he had looked for a book on urines in Latin, Constantine explained, but found no author who gave “certain and authentic information,” and so he turned to Arabic instead.

As in his work on urines, Constantine’s other texts describe the difficulty of mastering medicine from Latin texts in vivid detail. Here, in his translation of a work on fevers (the Liber febrium) from a work of Ishaq al-Isra’ili’s, Constantine explains that the sad state of his student John (including “continual tears” and “the extreme scarcity of want”) had finally convinced him to translate a work on the subject. Kassel, MS Med. 15, f. 1r.

But for all of their virtues, presenting Arabic texts to Latin readers in a comprehensible way was a tall order. For one, Constantine was compelled to bring the rich and diverse Islamic medical tradition into some kind of harmony. At the same time, Constantine had to make these works accessible to his Latin readers. In the Pantegni and the Viaticum, two of his major translations, Constantine was judicious– and sometimes even severe– in pruning what he found in al-Majūsī’s systematized overview of Islamic medicine and Ibn al-Jazzār’s handbook of practical medicine, respectively. At times, Constantine was meticulous in rendering his sources into pithy Latin. In other cases, his compressions are startling: in translating the Viaticum, for example, Constantine occasionally leaves out the quantities in his medical recipes! But despite his omissions– and we will discuss the significance of Constantine’s omissions of the names of al-Majūsī, Ibn al-Jazzār, and his other Arabic sources in a later post– Constantine made a huge amount of medicine accessible and comprehensible to his contemporaries and successors.

When we consider the comprehensive body of texts that Constantine produced (the topic of next month’s post) and the specialized vocabulary he constructed to render them into Latin (which we will also address soon), it is perfectly comprehensible that generations of earlier scholars claimed, with some grandiosity, that Constantine had taught his contemporaries to speak. It might be more accurate, however, to claim that his copious translations presented Latin readers with a synthesis of some of the most refined works of medicine then in existence.

Further Reading:

  • Françoise Micheau, “‘Alī ibn Al-‘Abbās al-Maǧūsī et son milieu,” in: Constantine the African and ‘Ali ibn al-Abbas al-Maǧusi: The ‘Pantegni’ and Related Texts, ed. Charles Burnett and Danielle Jacquart, Studies in Ancient Medicine 10.  (Leiden: Brill, 1994), pp. 1-15.
  • Francis Newton, “Arabic Medicine and Other Arabic Cultural Influences in Southern Italy in the Time of Constantinus Africanus (saec. XI²),” in Between Text and Patient: The Medical Enterprise in Medieval and Early Modern Europe, ed. Florence Eliza Glaze and Brian Nance, Micrologus’ Library, 30 (Florence: SISMEL/Edizioni del Galuzzo, 2011), pp. 25-55.
  • Emilie Savage-Smith, ‘Were the Four Humours Fundamental to Medieval Islamic Medical Practice?’ In: The Body in Balance: Humoral Theory in Practice, ed. by Elisabeth Hsu and Peregrine Horden (Oxford: Berghahn Books, 2013), pp. 89–106.

1. By convention, modern scholars refer to medicine under Islamic rule as “Islamic,” even though Christians and Jews also played a major role in the tradition. Non-Muslims, in fact, wrote a number of the texts that Constantine translated. For further discussion, see Peter E. Pormann and Emilie Savage Smith, Medieval Islamic Medicine, Georgetown University Press (Washington, DC: 2007).