[p.187] THE MALTESE MEDICAL TRADITION
Overseas contacts that have influenced its development
Winston Churchill, when addressing the London Royal College of Physicians in March 1944, said that "The longer you can look back, the further you can look forward". Such a statement provides ample justification for my talk to you today, for the past has frequently been known to supply the key to the present as well as to the future. It is perhaps natural to regard the evolution and progress of medicine in Malta from earliest times, for such a background is essential to allow one to appreciate the state of present day medical education in Malta. Unfortunately, as has often happened in other fields of Science, the rapid and exciting advances and discoveries that are constantly taking place have tended to obscure somewhat the efforts and painstaking work of earlier pioneers. Frequently their contributions have been totally forgotten and unrecognized.
Malta's medical traditions may be traced back centuries before any attempt was made to formalize medical teaching and training. We have scanty evidence of Graeco - Roman or Byzantine influence on the development of local medical practice. There is little doubt however that skilled physicians practised in Malta during these periods of our history as may be seen from two tombstones, a Roman one showing surgical instruments and another dated around the sixth century A.D. There is no written evidence of direct Arabic influence but it must be safe to assume that during Malta's period of Islamic domination the island must have benefited from the Arabs' considerable medical knowledge. It appears that, throughout the Middle Ages, the local governmental authority, the UniversitÓ, saw to it that competent medical care was available at the island's main hospital, Santo Spirito, as well as for the island's population [p.188] at large. This hospital is probably Malta's earliest and its documented history goes back to at least the late fourteenth century, being known then as 'hospitale Sancti Francisci'. Doctors were appointed from neighbouring Sicily but also from other parts of Italy and Spain to work alongside Maltese medical practitioners trained in institutions overseas. Before the time of the School of Salerno, the seat of the first organized medical school in Europe, medicine in Europe was almost entirely in the hands of Jewish and Arab physicians. There is a great deal of documentary evidence showing that many of the local practitioners were Jews. In spite of the Decretum Gratiani forbidding Jewish physicians from practising amongst Christians, our medical services depended heavily upon them well into the fifteenth century. Some, like Leone da Malta and Simon Maltese, appear to have been Maltese Jews. It seems likely that they underwent their medical training in Sicily, where in 1466 Jews were even granted the right to found a University, although this does not seem to have materialized. Others, like Angelo Anello, stayed on as 'conversos' even after their co-religionists were banished in 1492. History also records the names of Maltese Christian physicians of the time, like the famous Joseph Callus. The latter, together with the surgeons Rayneri Bonello and Salvo Schembri worked in the sixteenth century, and are the first Maltese doctors mentioned in documents.
With the coming to Malta of the Knights of St John in 1530 Maltese medicine benefited from the expertise of doctors who had left Rhodes when the Knights were thrown out and accompanied them here. Medical men like the surgeon Leonardo Myriti and the medicus fisicus Joanni Raimundo Calamia soon made a name for themselves. There is no doubt that the Knights of St John had a marked positive influence on the development of Malta's medical traditions, not only in facilitating the training of our young men overseas, in the establishment of a medical faculty and later a University, but also, at least equally important, in the provision of hospital facilities first at Birgu and later on at the Sacra Infermeria in Valletta. Throughout the sixteenth and seventeenth centuries there appear to have been a large number of Italian doctors such as Antonio Tramontana, Francesco Saltalla and Camillo la Munda as well as [p.189] others from other Mediterranean countries, such as the Spaniard Francesco Iniques. During the great siege of 1565 the chief medical man on the island was the Italian Camillo Russo whom Bosio described as 'Huomo alla Republica utilissimo'. As happened in earlier centuries Maltese physicians appear to have worked quite happily alongside their foreign colleagues. Thus, when plague struck the island in 1592, one finds the Maltese Gregorio Mamo, who had graduated from the Medical School at Salerno in 1569, working alongside the physicians Saltalla and Parisi. Pietro Parisi had been purposely sent over from Sicily to co-ordinate sanitary measures against the plague, leaving us an account of the event. Parisi stayed on in the island and we are told Mamo became his 'compagno indivisibile'.
Although foreign doctors appear to have been necessary to cope with the medical needs of the island, it seems that the common man in the street did not always benefit fully from their expertise, largely through communication problems. This problem becomes evident from an application for a job with the UniversitÓ at Mdina in 1596 by Giovanni Domenico Mangion a doctor working in Birgu. He emphasizes that besides his qualifications and experience, he could also understand and speak Maltese;
et quel the importa pi¨ sendo Maltese intende et sa parlare in maltese nella quale lingua parlano tutti di detta Cita Notabile et Rabat.
Throughout the following two centuries, even when a local medical school had been firmly established, young men continued to seek to improve their medical knowledge mainly at top Italian medical schools such as those of Salerno, Rome and Florence as well as at the foremost French universities of Paris, Montpellier and Aix-en-Provence. It is to be presumed that besides a good knowledge of Latin, the language in which the various medical theses were written, Maltese medical men could also speak Italian or French or both fluently.
Although the presence of foreign physicians on these islands may be deemed to have been a positive one, there have been instances where the local [p.190] population suffered because their advice was preferred to that of their Maltese colleagues. Two instances spring immediately to mind. The first was the plague of 1675 which was misdiagnosed as febbre maligna comunicable, ma non pestilenziale by the Italian doctor Giuseppe del Costo. In spite of repeated assertions to the contrary by the Maltese doctors Xiberras, Zammit and Bonamico, the Government unfortunately chose to believe del Costo. The consequences were tragic. A further episode was the cholera epidemic of 1837 which the British doctors on the island at first insisted was not cholera. We are told that the Maltese physicians correctly diagnosed the condition and that, I medici maltesi davano del ciuco agli inglesi.
Following the abatement of the plague of 1675, Grand Master Nicole Cotoner appointed Fra Dr Giuseppe Zammit as lettore in Anatomy and Surgery at the Sacra Infermeria on 19 October 1676. This attempt at formalizing medical teaching at the Order's hospital is considered by many as the beginning of our medical school. Zammit, who was 33 years old at the time, besides being a physician was also a priest, a chaplain in the Langue of Aragon. He enjoyed a great reputation as a doctor, being the personal physician of five successive Grand Masters. He is reputed to have founded the first medical library on the island which in 1797 became integrated with the main Public Library. Zammit also established a medicinal herbal garden in one of the ditches of Fort Saint Elmo which came to be known as Il giardino dei semplici. He was also instrumental in setting up our first Medical Academy in 1679 over which he presided for fifteen years. Unfortunately we know very little about Zammit. It is not known where he trained. His only writings that exist today are a collection of short biographies of prominent Maltese which he called De Melitensibus Viris Sanctitate et Sapientia Illustribus Elogia. I have stumbled across his signature on a medical certificate dated April 1697 (pl. 1). Other specimens of his writing may also be found in a number of books which he had given, dedit et donat, originally to the Sacra Infermeria.
Although little is known about Zammit, a great deal is documented about [p.191] a contemporary of his, Gian Francesco Bonamico. Bonamico was undoubtedly one of the most erudite intellectuals of his time and left behind him a large number of manuscripts and publications on various subjects ranging from Latin poetry and geography to medicine and botany. He began his medical studies when eighteen years old at the University of Aix-en-Provence and then spent ten years studying at various centres in Germany, Holland, Belgium, Switzerland and Italy, picking up a second doctorate at the University of Leyden. In the seventeenth century France seems to have attracted a number of Maltese young men amongst whom may be mentioned Giuseppe Cosseo who studied at Montpellier and published his thesis there in 1636.
Teaching at the medical school was further strengthened during the last century of the Order's rule in Malta. Grand Master Zondadori, realizing that clinical studies needed sound anatomical teaching, introduced compulsory cadaveric dissection. He paid for the further training of the surgeon Gabriele Henin at the Regio Arci-Spedale of Santa Maria Nuova in Florence. When Henin returned to Malta in 1723 Grand Master de Vilhena appointed him as head of the medical school with the title of Professore del Sacro Senocodio. Henin may be considered as our first anatomist. Throughout the eighteenth century other Maltese doctors who achieved fame beyond these shores received their postgraduate medical education in Florence. Amongst these were Michelangelo Magri who was eventually appointed as Maestro of Anatomy and Physiology at the Regio Spedale in Messina and Malta's perhaps most famous surgeon, Michelangelo Grima. During the same period in which Magri was working in Messina, other Maltese doctors held chairs in Sicily. Emmanuele Grillet was professor of obstetrics at the University of Palermo whilst Giuseppe Zahra was the professor of Mathematics in Catania. Zahra had earlier qualified as a doctor from the University of Naples. During the time that Maltese medical men where occupying chairs in neigh-[p.192]-bouring Sicily, a Maltese doctor had established a reputation of being one of the leading ophthalmologists in Europe. His name was Joseph Barth. In 1774, when only twenty eight years of age, Barth was appointed Professor of Ophthalmology and Anatomy and two years later ophthalmologist to Emperor Joseph II. Barth went on to have a splendid career in Vienna, training a number of ent ophthalmologists including Joseph .
Following the expulsion of the Jesuit order from Malta in 1768, Grand Master Pinto appropriated all the revenue accruing from its property in the island with the aim of founding a University of Studies. The decree constituting the University was signed by Pinto on 22 November 1769. On the 25th May 1771 a Collegio Medico was set up as one of the faculties making up the University. At the time of the foundation of the University, the Principe dell Accademia dei Medici was the surgeon Michelangelo Grima who also held the combined chair of Anatomy and Surgery at the medical school. Grima graduated in Medicine and Philosophy at the University of Pisa in 1754 having started his surgical training under Henin. Grima then carried out further postgraduate surgical training and research in Florence presenting his work to the Sacra Accademia Fiorentina and being approved as a surgeon by the Collegio dell'Arte Medica of the same city in 1758. After an eight-year period in Florence, Grima went to Paris to gain further experience in surgery where he won a competition sponsored by the Surgical Academy of Paris with his work De cranii repercussione. There is no doubt that Grima was more than amply qualified to head the new faculty of medicine. Together with Grima the faculty was made up of the following doctors, Gaetano Azzopardi, Giorgio Locano, Giorgio Imbert, Gio Domenico Biagio, Giuseppe Bigeni and Lorenzo Thien. Locano, a great rival of Grima's, was a graduate of the University of Montpellier. Whilst the Rector, Padre Ranieri Maria Costaguti, and the university professors in most other faculties were foreigners, it appears that the medical staff making up the faculty of medicine were all Maltese.
Maltese medical students, wishing to complete their medical education abroad or doctors planning to undergo postgraduate training often found it difficult to do so. There were a number, it is true, who had their training abroad [p.193] financed by the Grand Master, for instance Henin was sent to Florence whilst the brothers Emmanuele and Michele Grigliet went to Montpellier. In fact, in a letter written by Grand Master Pinto to the Collegio del Sacro Ospedale di Messina on 6 September 1746 he refers to ".... alcuni Giovani che la mia Religione vi mantiene [in France] allo studio". Others, like Michelangelo Grima had a more difficult time. Grima, after the first two years of his stay in Florence, received no further financial help from his family in Malta. Writing to his friend the historian Agius de Soldanis in 1752, he confesses how depressed and disheartened he felt at times: ed in questo intervallo di tempo ho provato piu angustie di cuore, o colere e saette che mi posso spiegare...". It appears that financing one's medical education abroad was, as it is now, a difficult proposition. On the 1 December 1768 Dr Giorgio Imbert, one of the principal physicians on the island, later to become the Protomedicus, wrote to the Grand Master asking for a loan of five hundred scudi to allow his son to finish his medical studies at Montpellier where he had already been for the three previous years. Giorgio Imbert, himself a graduate of Montpellier, pledges all his possessions as collateral to cover the loan. From his letter it transpires that such a request was not at all uncommon, "essendo stati simili ricorsi altre volte ammessi".
On the other hand, foreign students have often undergone their medical training in Malta. During the period of the Order's rule students frequently came from neighbouring Sicily and from as far away as Greece. In the nineteenth century these were often children of British servicemen or civil servants stationed in Malta or else Italian political refugees. Later this century foreign students came mainly from other Commonwealth countries.
Maltese physicians were at times sent abroad by the Order following requests for medical help. Such requests did not only come from Christian Europe but also from Malta's Muslim neighbours in North Africa. Thus in May of 1726 Grand Master de Vilhena in response to a request by the Senate of Catania for a surgeon to treat the Principe del Pardo, one of the chief notables on the island, sent the surgeon Giuseppe Grillet. In his reply de[p.194] Vilhena expressed his hope that the operation would have a successful out-come as it had on a previous occasion. In September 1746, it is the turn of Giuseppe's son, the lithotomist Michele Grillet to be sent to the hospital in Messina following a request for help. Pinto writes that he was sending Michele as "....di lui padre la di cui avanzata etÓ comincia a renderlo inabile." In July 1754 Grand Master Pinto wrote to Mahmud, Bey of Benghazi, thanking him for his offer of trade and asking him to forward his price list with the surgeon Capagna. This was the time when King Carlos of the Two Sicilies had closed the ports of his kingdom to all ships of the Order. At the time the Bey, as well as his brother, must have required medical attention for Pinto also promised to send Mahmud one of the best doctors at the hospital. We are not told who was the physician chosen to attend to the Bey of Benghazi. On 15 October 1770 a similar request is recorded in the Archives of the Order, this time from Venice; "La Republica di Venezia mando chiedere al Gran Maestro un bon Professore Chirurgo, e fu scelto it Signor Antonio Grigliet venuto l'altro ieri dalla Prattica del Ospedale di Pariggi". It is interesting to note that the Grand Master did not send his best surgeon, Grima, nor did he choose one from amongst the established surgeons at the Sacra Infermeria. Perhaps, as Grigliet had only just got back from Paris, it may have been thought that he was the one most familiar with the latest surgical advances. Michelangelo Grima had in fact left the island on a previous occasion to treat a patient. Thus on 26 January 1755 he successfully pleaded with the Grand Master to allow him to go abroad to treat Duca Floridia. Moreover he asks to be given paid leave for the whole period necessary to look after the Duke as had happened before in similar cases with other Professors working at the hospital. In 1788, Grand Master de Rohan chose Dr Giuseppe De Marco to go and attend to Mustapha, the Pasha of Tripoli. This was the same Mustapha who years earlier had been involved in the famous planned uprising by the slaves during Pinto's reign.
During the brief French interregnum formal medical teaching came to an end as Napoleon abolished the University on 1S June 1798. Fortunately, a few weeks after the French were forced to leave Malta, Sir Alexander Ball [p.195] re-instituted the University and appointed as rector Canon F.X. Caruana on 28 October 1800, at the same time appointing Dottor Fisico Ludovico Abela as Professor of Medicine and Aurelio Badat as Professor of Anatomy and Surgery. However it was not until 12 November 1825 that a Collegio medico was formally set up and not till 1839 that a Statute for the University was promulgated and faculties instituted. In the early decades of the nineteenth century medicine was often taught by private tutors, prominent amongst whom were Dr Agostino Naudi and Dr Gavino Patrizio Portelli. Both enjoyed a great reputation both as doctors as well as clinical teachers. Naudi had trained in Naples and it is said that he was later offered the chair of medicine of his alma mater which for some unknown reason he declined. Portelli, on the other hand, seems to have had a British background as he is said to have followed the teaching methods of Professor Carpue of London. He had also been assistant to the famous surgeon Samuel Cooper during the 1813-14 British campaign in Holland.
Our medical school underwent further reforms and both the standard of teaching and the curriculum were brought in line with those of medical schools in Britain. It is interesting to note that, in an otherwise almost totally negative report on the educational system of Malta drawn up by Keenan, a specially sent Royal Commissioner from Britain, and published in 1879, the medical faculty was the only one singled out for praise.
On 5 June 1901 our medical degrees became recognized throughout the British Empire. From the middle of the nineteenth century onwards, Maltese students started seeking places in British medical schools, the first two re-corded going to Edinburgh. The following figure (Figure 1) shows the number of Maltese doctors practising in Malta who had graduated abroad compared to the number of those who had completed their training locally. These ranged from around 6% in the 1970s to 18% in the 1940s, an overall average figure of 12%. The 1980 figures have been vitiated by the well known medical crisis occurring in Malta then. The second figure (Figure 2) shows the countries in which these doctors trained.
During the first decades of British rule a not inconsiderable number of [p.196] Maltese students still sought training at Italian medical schools, mainly those of Naples and Rome. This trend continued right up to the Second World War although subsequently only three Maltese doctors trained in Italy. However, British medicine had an ever increasing influence on Maltese medical development throughout the nineteenth and twentieth centuries. Mainly after the Second World War, instead of seeking undergraduate medical education, a greater number of Maltese students went to Britain for postgraduate training and our medical specialists today are almost all trained in Britain. A large number of medical graduates are to be found practising, at all levels, overseas. Some have achieved top positions in the medical academic world, acting as excellent ambassadors for our centuries-old medical tradition - a medical tradition distilled through the interchange of ideas and men between our medical school and a number of prominent institutions in Western Europe. It is fitting to pay tribute not only to those who have carved a niche for themselves in the annals of our medical history but perhaps even more so to those whose name has been lost and is no longer recorded. As George Eliot wrote in Middlemarch: For the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs".
To such a number too do we owe Malta's medical heritage.
Specimen of the signature of Dr Giuseppe Zammit.
 P. Cassar, "Surgical Instruments on a Tomb Slab in Roman Malta", Medical History, xviii (1974), 89-93.
 I. X. Mifsud, Stromatum Melitensium, Liber xiv (1759), 439.
 S. Fiorini, Santo Spirito Hospital at Rabat, Malta. The early years to 1575 ( Malta, 1989).
 G. Wettinger, The Jews of Malta in the Late Middle Ages (Malta, 1985).
 Encyclopedia Judaica, vol. vii (Jerusalem, 1971), 858.
 B. and G. Lagumina, Codice diplomatico dei giudei in Sicilia, vol. i (Palermo, 1844), Document 491.
 M. Fsadni, Id-Dumnikani fir-Rabat u fil-Birgu sa l-1620 (Malta, 1974).
 G. Bosio, Dell'Istoria della Sacra Religione et illustrissima Melita di San Giovanni Gerosolimitano (Napoli, 1684), 514.
 V. Borg, "Medical Practitioners in 16th Century Malta", Proceedings of History Week 1981, ed. M. Buhagiar (Malta, 1982), 82-85.
 I.S. Mifsud, Biblioteca Maltese, pt. i (Malta, 1764), 100-102.
 NLM Univ. 115, f. 486.
 G. del Costo, Storia della SocietÓ Medica d'Incoraggiamento (Malta, 1845), iv.
 G. Gulia, Biografia di Tommaso Chetcuti (Malta, 1863), 11.
 AOM 262, f. 61; ibid. 279, vol. ii f. 833, Caruso Decr. del Cons. Tom II.
 AOM 275, ff. 64v-65v: "La Libreria del Sacro Ospedale sia trasferita nella Biblioteca Publica".
 G. F. Abela and G.A. Ciantar, Malta Illustrata (Malta, 1772), 582.
 Fra Giuseppe Zammit, De Melitensibus Viris sanctitate et sapientia illustribus Elogia: NLM AOM, Ms 1143.
 AOM 1186, ff. 55-56.
 Abela/Ciantar, 539-544.
 Mifsud, 175, 208.
 M.A. Grima, Instruzione d'Anatomia (Venezia, 1781), 32-34.
 G. Gulia, Cenni Storici dell'Istruzione superiore principalmente della scuola medica nei tempi dell'ordine (Malta , 1886), 10.
 Grima, loc. cit.
 G. Cassar Pullicino, "Michel'Angelo Grima Chirurgo Maltese del Settecento", Rivista di Storia delle Scienze Mediche e Naturali, xl, 1 (1949), 1-39.
 Gulia, 15.
 R. Grillo, "Giuseppe Zahra, Professore nell'UniversitÓ di Catania", MH, vii, 3 (1978), 234-236.
 J. , "Biographie des Prof Barths", Medizinischen Jahrbiicher des kk Osterreichischen Staats, v (1819), 169-184.
 L. Manche, "La prima cattedra oftalmologica", Clinica Oculista, vii (Palermo, 1907), 1433.
 AOM 573, ff. 155-156; AOM 272, ff. 178v-180v.
 AOM 575, ff. 459-498; f. 500.
 AOM 1504. Lettera Alli Confrati del Colleggio Del Sacro Spedale di Messina; dated 6 September 1746.
 AOM 146, vol 1, ff. 115-118.
 AOM 654L (1768-1774), f. 28.
 AIM Processi 131B, f. 771v.
 P. Cassar, "Overseas Medical Graduates and Students at the University of Malta in the nineteenth century", MH, viii, 2 (1981), 93-100.
 AOM 1484, 11.v.1726, n.p.
 AOM 1504. Lettera Alli Confrati del Colleggio Del Sacro Spedale di Messina; dated 6 September 1746.
 AOM 1511, 8.vi.1754.
 AOM 1146 Vol 2, f. 72.
 AOM 1192, f. 36.
 J. Galea, "Dr Giuseppe De Marco", St Luke's Hospital Gazette, vii (1972), 3-13
 Gulia, 20.
 T. Zammit, L'UniversitÓ di Malta, Sua origine e sviluppo (Malta, 1913).
 D.C. Camilleri, Elogio funebre del chiarissimo Dr Agostino Naudi (Malta, 1802).
 Il Filogo, (3.xii.1839).
 Il Portafoglio Maltese, (9.xi.1840), 1105; (4.x.1841), 1515.
 P.J. Keenan, Report upon the Educational System of Malta (Dublin, 1879).