Source: Melita historica. 8(1980)1(38-47)
 Grand Master Nicholas Cotoner and the foundations of the lectureship of anatomy and surgery 1676*
At the time of the institution of the Chair of Anatomy and Surgery in 1676, Malta had been under the rule of the Knights of the Hospitaller and Military Order of St John of Jerusalem for 140 years. By then they had withstood a siege by the Turks in 1565; they had built the fortified city of Valletta; they had grown into a naval power that was continually harassing the Barbary and Turkish fleets that preyed on European commerce in the Mediterranean; they had developed an arsenal for ship building and repair on the shores of the three cities of Senglea, Bormla and Birgu; and they had established the economy of the Island on the revenues derived from landed property of their priories and commanderies scattered over various parts of Europe and from the institution of corsairing and slavery. Thanks to the income obtained from these sources, Malta paid for the importation of its foodstuffs to sustain a population of 60,000 mouths.
The main educational establishment was the Jesuit College founded in 1593 in Valletta. The first press was introduced in 1644 but owing to a prolonged controversy between the Grand Masters, the Bishops and the Inquisitor over the question of censorship nothing was printed in Malta between 1656 and 1755.  No wonder that the people were illiterate and that even the rulers themselves, in spite of their aristocratic origins, could make no claim to learning and culture; but thanks to the Order’s diplomatic, political and commercial connections with Europe, the Maltese Islands came under the influence of the intellectual ferment that was agitating the continent at the time. From this stimulus there emerged various creative trends in several spheres of our national life by the mid-17th century. This, in brief, was the situation in Malta when the Spanish Knight Nicholas Cotoner succeeded his brother Raphael to the Grand Mastership of the Order of St John on 23rd October 1663.
The Cotoner family had emigrated to Spain from the neighbourhood of Siena (Italy).  Nicholas, born at Palma de Mallorca in 1605, was the son of [p.39] Antonio Cotoner y Santmarti and of Juana Oleza y Camfulles.  He received the habit of Knight in the Aragonese Langue of the Order of St John on 15th June 1627 in the Chapel of Our Lady of the Pilar in the Carmelite Church of Valletta. 
He held several posts in the Order’s organization among which the membership of the Commissione di Sanità (1640).  In 1643 he embarked on a very short naval career as Captain of the galley San Lorenzo when he distinguished himself in an engagement with a Turkish galleon in the stretch of sea between Malta and Rhodes. He left the navy after two years and in 1660 was appointed Bailiff of Mallorca and President of the Congregazione dei poveri mendicanti that had been set up in 1656 to provide financial relief for the indigent when the streets of Valletta were thronged with beggars.  As this Congregazione had no funds, he succeeded in persuading the government to provide the necessary revenues from the imposition of a tax on tobacco as an article of luxury. Later, in 1666, when he had become Grand Master he endeavoured to accommodate the beggars in a magazine “suitable for this purpose” to do away with the distressing sight which these men presented in the streets of the city.6 Mendacity was then a European-wide social problem and it is of interest to note that Cotoner was following the same trend adopted in Paris to solve the beggar problem, which was to intern the indigent in such institutions as the hôpital general created in 1656 by the French King. 
To protect Malta against a rumoured invasion by the Turks after the loss of Crete by the Venetians in 1667, Nicholas raised the Cottonera fortifications, added new bulwarks to the Floriana bastions and constructed Fort Ricasoli at the entrance of the Grand Harbour.
In the field of husbandry he earned the gratitude of the Maltese farmer by introducing in our Island the windmills for the grinding of corn. These windmills are identical in design to those of his homeland. In fact, he brought artisans from Mallorca to construct them. The importance of the windmills, at a time before other types of machinery replaced the agency of the wind, cannot be gainsaid. On them depended the manufacture of bread which has [p.40] always been the staple food of the population. Cotoner seems to have been very fond of our countryside and especially of the village of Zurrieq (where one of the windmills is still extant) so much so that he named one of his rural estates in Mallorca, Xorrigo, a name which is still borne by this property today. 
In the artistic sphere Nicholas’ rule marks the completion in 1666 of the greatest masterpiece that we possess in the art of painting – the brushwork that embellishes the vault of St John Co-Cathedral on which Mattia Preti laboured for 13 years. 
In the field of Maltese literature Grand Master Nicholas Cotoner holds the distinction of being the first Grand Master to have inspired the earliest published verse in the Maltese language. It is a sonnet in his honour from the pen of a contemporary physician, Dr Gio Francesco Bonamico (1639-1680), who also sang his eulogies in Latin verses. 
Apart from the measures we have just considered for the promotion of social welfare, military preparedness and art, Cotoner was keenly sensitive to the medical needs of Malta. In 1666 he brought to an end the extension of the Old Ward of the Holy Infirmary of Valletta that had been initiated by his brother Raphael in 1662 prolonging the length of the original ward to over 153 meters (500 feet) which thus became the longest hall in Europe.  To realise the importance which the Holy Infirmary had come to occupy in the time of Nicholas Cotoner it is sufficient to point out that its administration represented the most expensive item (over 29,000 scudi) in the Order’s budget after the navy (over 200,000 scudi) the money being spent on salaries of staff, the supply of provisions and medicaments and maintenance of the building.  Foreign travellers who visited this hospital in his time were full of admiration for the way it was run describing it as being “the very glory of Malta” and “one of the most beautiful in the world.”  In 1675 he enlarged the lazaretto which was the first line of defence against the introduction and spread of [p.41] epidemic diseases in Malta. 
In 1670-80 Nicholas enacted a number of regulations for the administration of the infirmary aiming at the separation of infectious cases from other patients, the prohibition of smoking, the keeping of proper records of the reception of the sick, the medical examination of patients suspected of suffering from leprosy to ascertain the diagnosis before their entry into hospital, and the care and upbringing of the foundlings deposited in the infirmary. To avoid blocking the wards with patients suffering from long standing illnesses he granted them financial relief to enable them to be looked after in their own homes. 
Previous to 1669 there was only one physician to care for the inmates of the Slaves Prison and of the patients at the Women’s Hospital but in that year Cotoner separated the two assignments and created the post of physician to treat, exclusively, the women patients  thus improving the facilities for their medical care.
As the Order of St John was first and foremost a Catholic institution, the care of the souls was as important in the hospital regime as that of the body. It must also be remembered that in those days disease was still regarded as being the result of sin and patients were, therefore, enjoined to confess and receive Holy Communion before they were assigned a bed in hospital. In conformity with these ideas a young English Protestant was expelled from the Infirmary in October 1667 because he declined to confess. As soon as Grand Master Nicholas Cotoner came to know of this occurrence he ordered the Hospitaller to re-admit the Englishman – an order that was promptly carried out with an apology from the hospital authorities.  This occurrence, which involved him into a conflict with the Inquisitor who reported the incident to Rome, shows that Cotoner was an enlightened administrator who would not allow religious discrimination to prejudice the treatment of a sick man.
Philosophy, Theology and Letters were being taught at the Jesuit College of higher education of Valletta since 1593 but there was as yet no university or medical school in Malta so that young Maltese men interested in following a medical career had to proceed abroad to pursue their studies and obtain their qualifications. It was in this respect that Nicholas Cotoner has set his stamp on our medical history when on 19th December 1676 he founded and [p.42] endowed the Lectureship of Anatomy and Surgery at the Holy Infirmary of Valletta.
The foundation is recorded in Italian in the minute book of the Council of State of the Order of St. John. The entry reads (in translation): “The Most Eminent and Reverend Grand Master informed the Council that he has instituted at his own expense the study of Surgery and Anatomy at the Holy Infirmary. He appointed a physician to give lessons not only to the barber surgeons of the said infirmary but also to any others who wish to attend. The Grand Master intends to ensure the existence of this study, if it turns out to be profitable, by means of the revenues derived from his foundation and wishes that, in future, the teacher would be chosen by his successors in the Grand Mastership. The announcement met with the approval of the whole Venerable Council who highly commended such a necessary and important innovation.” 
In this brief and terse entry there is no mention as to what induced the Grand Master to establish the lectureship and we are left guessing as to his motives. It was certainly not the result of his erudition for “he lacked all knowledge of the affairs of the world and literature so much so that he himself used to admit that he had never read a book in all his life”;  nor was it because he entertained a high opinion of the medical profession in which he seems to have had no trust. In fact, he refused to see any doctor in his last illness and it was only after much cajoling from his entourage that he finally consented to be visited by the Physician-in-Chief; and when the latter suggested a consultation, this was held without the consultants seeing or examining the patient.
Other circumstances may have influenced Grand Master Cotoner to found the lectureship not least among them being the events impinging upon the government and the people as they struggled to cope with the plague that visited Malta in December 1675 and came to an end on 24th September 1676. Initially the medical profession was not unanimous about the nature of the malady. The majority of Maltese practitioners, headed by the Physician-in-Chief, Dr Gio Domenico Xeberras, diagnosed the disease as plague but a foreign physician and a few others maintained that the illness had no pestilential character. The government favoured this opinion but as the epidemic continued to make progress, the more thoughtful medical men of the Island entrusted [p.43] the Maltese physician, Dr Gian Francesco Bonamico, to write a description of its clinical features and send it to the medical academies of Paris, Florence, Pisa, Valencia and Rome for their opinion. All these bodies concurred that the malady was none other than plague. This epidemic turned out to be the worst visitation on record in our medical history. So many knights died that the navy was seriously handicapped as a fighting force while the medical profession suffered a severe reduction of its personnel with the loss of ten physicians and sixteen surgeons. 
In those days a clean cut distinction was made between the physician and the surgeon as regards professional qualifications, practice and status; thus while the physician had to undergo an academic course of studies abroad, the surgeon’s training was limited to the practice of surgery alone and took the form of an apprenticeship with a senior surgeon.
Very likely it was the sudden and unexpected depletion of surgeons by the plague, already remarked upon, that impelled Grand Master Cotoner to provide the necessary training facilities to fill up the void as soon as possible especially when it is recalled that a long period of training was considered essential for a fully fledged surgeon. 
At first only theoretical anatomy and surgery were taught as was still the custom in parts of Europe. Lessons were held daily in the afternoon at the Holy Infirmary from October to the end of June. Lectures in physiology, pathology, semeiotics, hygiene and therapeutics, in so far as these subjects had a bearing on the practice of surgery, were added in later years. Only those youths who knew how to read and write, presumably Italian, were eligible to follow the course in surgery which in 1682 was fixed at ten years to ensure that the surgeons who qualified from the school were proficient in their craft. 
Cotoner’s interest and concern for his foundation persisted to the end of his life. In fact, when he drew up his will on his deathbed on 26th April 1680, he stipulated that,
(a) the lecturer in Anatomy and Surgery was to continue to receive his salary of four scudi per month after Cotoner’s death;
(b) the future successors in the Chair were to be chosen by the ruling Grand Master; and
(c) the revenues accruing from one-fifth of his estate were to be applied for the provision of the Lecturer’s salary “in perpetuity.”  The “fifth” was the maximum that Cotoner could legally bequeath to ensure the continued existence of the Lectureship as, according to the Statutes of the Order, four-fifths of the personal estate of its members became the property of the Common Treasury on their demise.
The 60 year old Cotoner was described in 1667 by the Inquisitor of Malta, Mgr Angelo Ranucci, as a man intent on promoting the good administration of the Order and the government of the country. He served the sick in the Infirmary, gave generously to the poor and attended to his religious obligations. Though affable and courteous, he was touchy and fond of flattery to such an extent that he took offence when his portrait was not exhibited in churches on the occasion of religious feasts and ceremonial.
As an authoritarian he was intolerant of opposition and was prone to fits of rage when contradicted; however, quickly acknowledging his quick temper, he made amends to those he had affronted and offended.
He kept himself informed of the affairs of state and of the views and feelings of his subjects about their conditions of life. He possessed a good grasp of the working of the law courts but had hardly any esteem for his legal advisers whom he regarded as being “mere clerks whose only use was to register his decrees and pronouncements.”
He lived in an extravagant style so much so that his critics upbraided him for his wasteful expenditure on vain luxuries that should have been usefully spent for the benefit of the Order and of the country. 
A historian of the Order of St John has drawn this profile of Cotoner’s personality:
“He owed his own advancement to his merits only ... He had an excellent talent at negotiations; was bold in his enterprises and prudent in the choice [p.45] of proper means to execute them; he had all his fellow knights for his friends; communicated his designs to very few among them and never had a confidant.” 
To form a balanced view of Cotoner’s way of life, we must bear in mind that he lived in an age when heads of state were very sensitive to prestige and to their rank in the social hierarchy; when the pomp and ostentation which he displayed were rooted in the contemporary behaviour of European aristocracy, and when the tinge of absolutism in his character reflected the expected rôle of the ruler at the time.
In the last years of his life Cotoner suffered a great deal from ill health due to vesicle stones, gout and a pulmonary affection which his doctors attributed to his excessive eating; in fact, he had become very obese. Added to these complaints he suffered from paralysis of one of his lower limbs for eight years previous to his death so that he had to be carried about in a sedan chair.  However, he retained his vigour of mind to the end which came on 29th April, 1680, at the age of 75 years after a rule of almost 17 years. He is buried near his brother Raphael in the Chapel of St George in St John’s Co-Cathedral  but his heart, like that of Raphael, was interred in Palma, at Majorca, beneath a stone-slab in a side chapel in the Church of St James which once belonged to the neighbouring Cotoner Palace. 
Through his foundation of the Lectureship in Anatomy and Surgery, Cotoner bestowed an invaluable gift on Malta but a lectureship does not develop into a school simply by the financial endowment and interest of its founder. It has to grow in accordance with the needs of the times and to evolve by a slow process, its development being fostered by a variety of circumstances and opportunities. Among these was the example of Cotoner himself for his generous patronage of medical studies induced others to further anatomical and surgical progress in later years in our Island. In mid-March 1766, Antonio Maijer (or Mayer), a Senior Surgeon of a Swiss regiment stationed in Sicily, donated 19 anatomical models in coloured wax with “an entire human body of the same material” to the School of Anatomy and Surgery which were [p.46] exhibited in the Library of Dr Zammit in the Holy Infirmary. These models ensured the uninterrupted study of practical anatomy during the summer months when human dissection used to be suspended owing to the dangers that were believed to arise from the cutting and handling of corpses during the hot season. As a sign of the appreciation of his gift, Maijer was decorated with the half-cross of the Order. 
In 1771 Grand Master Emanuel Pinto de Fonceca was instrumental in raising Cotoner’s lectureship to academic status when he incorporated it in the newly created Faculty of Medicine of the University set up on 22nd May of that year. 
In 1775 Bali Fra Clemente Ressegnier set up a second foundation for the teaching of surgery entrusting the direction of studies to an outstanding surgeon, Michel’ Angelo Grima, who was enjoined to give lectures in the morning so as not to interfere with those of the Cotoner lectureship which were delivered in the afternoon. Another foundation was established in 1794 by a countryman of Cotoner, the Majorcan Bali Fra Nicholas Abri-Dezcallar y Dameto, Grand Prior of Catalonia, who donated funds to support an additional Teacher of Dissection. He sent the selected candidate to study anatomy and surgery at Florence at his own expense. Through the efforts of Abri-Dezcallar the anatomical theatre was rebuilt on a better plan adjacent to Nibbia’s Chapel and furnished with the necessary instruments. A few years later, owing to the financial straits in which the Order of St John found itself, the Abri-Dezcallar foundation was incorporated with that of Cotoner on 2nd April 1797. 
It has been said that the Cotoner period represents the “Renaissance of Malta” and that the cotton plant decorating his family crest is a symbol of those progressive years. Strange as it may seem, however, the creation of the Chair of Anatomy and Surgery was only of passing interest to his contemporaries who failed to grasp its significance for themselves and its potentialities for the future of Malta. In fact, the Latin inscription on his monumental tomb which records, in its effusiveness of eulogistic language, the outstanding events and achievements of his rule evoke no mention of him as a medical innovator and as founder of the Lectureship of Anatomy and Surgery.  The painter Mattia Preti, too, in his glorification of Nicholas Cotoner in the painting on the west wall of St John’s Co-Cathedral depicted him in the act of proudly [p.47] pointing with his baton to the Order’s fleet on its way to the relief of the Venetians in Crete, which, in spite of the Order’ efforts, was eventually lost to the Turks in 1670. Yet, the Knights of St John persisted in overestimating their worth as a combatant organization in spite of their steady decline as a fighting force; so much so that the writer of another commemorative tablet – the one over Zabbar Gate in the Cottonera fortifications – prophesied that Cotoner’ fame would endure for all time because of the massive strength of those “solid bulwarks of Christianity” which Nicholas Cotoner had erected at very great expense. In fact, however, these mighty bastions which were raised to keep the Turks at bay were never actually used against them because the Turks never came in force after 1565. When a new enemy did invade our shores in 1798 – the French under Napoleon – the Cotoner Lines with the rest of the fortifications of Malta surrendered without a struggle after a day of panic. By a quirk of history the Cotoner Lines were in that contingency under the command of a Cotoner knight who, in giving up the fort, tore down the colours bearing the Cotoner crest from their mast to spare them the indignity of falling into the hands of the enemy and managed to take them to Spain where they were still preserved until the late twenties of this century. 
Thus the rôle accorded by history to Cotoner is quite out of gear with that envisaged by his shortsighted contemporaries. Indeed his place in the history of Malta is definitely that of medical innovator because his most outstanding and lasting achievement has been and remains the institution of the Lectureship of Anatomy and Surgery; it was from that seed sown by Cotoner three hundred years ago that our present Medical School has germinated, flourished and prospered and that the Maltese medical profession derived its origin, identity and vitality.
[*] Paper read on 19th December 1976 on the occasion of the Tercentenary Celebrations of the Foundation of the School of Anatomy and Surgery in the Assembly Hall of the University, Tal Qroqq.
 Book Week Exhibition 1975, University of Malta.
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