[p.35]

The Order of St John’s approach to plague after Rhodes

Monique J. Grech[1]

Historically there have been reports of plague since biblical times. It may have been plague which afflicted the Philistines in 320 B.C (1 Samuel 5:6-12).[2] In the sixth century A.D. plague spread to Europe in a cycle which lasted 50 years and came to be known as the plague of Justinian, afflicting the eastern Mediterranean and causing the death of a quarter of the population.[3] The Black Death which enveloped Europe between 1346 and 1353 was no less ferocious, where out of a population of 80 million, an estimate of about 50 million Europeans died.[4]

Rhodes fell to Suleiman the Magnificent in 1522. The Grand Master of the Order, Frà Philippe Villiers de l’Isle-Adam left with full military honours on 1 January 1523.[5] The Christian galleys sailed away with their precious holy relics and part of their archives, together with hundreds of Rhodian refugees. As the Order travelled around the Mediterranean it set up temporary hospitals. Reaching Sicily in April 1523, the Order installed its conventual hospital in the priory at Messina, but with the increased number of sick and plague-stricken, in the summer of 1523, the conventual hospital was transferred to the galleon of the prior of [p.36] Saint Gilles.[6] Travelling further northwards with the plague showing no signs of abating, the Grand Master and the crew were kept out of Naples harbour. They were consequently allowed to install themselves at a distant malarial spot by the shore, west of Naples, called Baia. There, the sick and the healthy were relocated in an old building described as a ‘grotto’ and known as the Sibyl at Cuma, which was defended by ditches and artillery. Eventually the hospital moved with the Convent to Civitavecchia, to Viterbo, to Comito, to Villefranche, to Nice (where it established itself in the Commandery), then to Syracuse and finally, to Malta in 1530.[7]

In Malta an epidemic of plague raged between 1427 and 1428 but not a great deal is known about it.[8] In 1523, an epidemic broke out in Birgu. A plague-stricken galleon proceeding from the Barbary Coast arrived in Malta. Owing to the strict measures taken, the plague remained confined to Birgu.[9] The present paper is an attempt to give an insight into how the Order of St John dealt with outbreaks of plague epidemics during its time in Malta.

General measures to combat plague

The Order of St John applied strict controls to ships entering and leaving Malta, adopting very rigid quarantine laws and procedures which had evolved during the institution’s long stay on Rhodes. A Health Commission was set up when the Knights arrived in Malta in 1530.[10] [p.37] Composed of two Knights, it was entrusted with the task of preventing disease from entering the island. Both Knights formed part of the Order’s Council, the highest legislative body on Hospitaller Malta. When an outbreak of plague or any other epidemic was feared, four other Grand Crosses were added to the original two health commissioners. Quarantine and isolation of infected or suspect cases was the standard practice in early modern times to try and contain the spread of plague.[11] The rules of ship movements were strictly applied.[12] Infringement of these rules could result in the death penalty in severe cases, or several years on the oar-benches of the galleys.[13] Hospitaller vessels were also subject to strict quarantine control, as more often than not these returned from some engagement with Ottoman or pirate ships, generally with casualties on board. Wounded men received surgical treatment at the lazaretto while under quarantine. A surgeon from the Holy Infirmary was transferred to the lazaretto for the purpose. As the surgeon was in close contact with infected crew and passengers, he too was confined to the lazaretto until the quarantine period was terminated.[14] Besides isolation at the lazaretto, private houses were sometimes barricaded: this was done when those infected or those who had come into contact with them could not be sent to a separate isolation place, or indeed when social privilege demanded it. In such cases, the authorities ensured that no members of the household had any contact with the people outside; they were provided with the necessary supplies for survival, together with materials for the disinfection of the house.[15]

[p.38] When plague broke out in Malta, the island within Marsamxett harbour, until the early eighteenth century known as Bishop’s Island, was used for isolation purposes, for victims and suspects. In 1643, the island passed from the Mdina Cathedral to the Order’s possession and quarantine facilities were improved upon at different stages by various Grand Masters.[16] Letters coming from overseas were disinfected either by smoking or perfuming at the lazaretto. Paper money was treated in the same manner, while loose change was dipped into a receptacle containing vinegar and after a few minutes’ immersion was allowed back into circulation. When Napoleon took over Malta from the Knights in 1798, he changed most of the old regulations governing the island, but left the quarantine rules intact. In fact, he ordered that ‘Les lois de la santé à Malte ne seront ni plus ni moins rigoureuses que les lois de la santé de Marseille.’[17] During its stay in Malta, the Order had to deal with several outbreaks of plague epidemics. Two were severe cases: that of 1592-3 and that of 1676. The rest of the paper will focus on these.

The plague of 1592 and the use of seawater and lime as purification agents

The epidemic of 1592 broke out in Malta when four galleys of the Grand Duke of Tuscany or the Order of St Stefano, proceeded to the island following a corsairing expedition in the eastern Mediterranean. They had captured two vessels coming out of the port of Alexandria bound for Constantinople, laden with merchandise and 150 Turks. Finding the port of Alexandria contaminated with plague, the galleys sailed to Malta. It was on their return journey that it was realised that there was plague on board: 20 members of the crew had died on the way.[18] Once in Malta the [p.39] plague spread rapidly. In April 1593, when the situation was growing worse, Grand Master Frà Hughes Loubenx de Verdalle sought help from the Viceroy of Sicily. Dr Pietro Parisi, from Trapani, an excellent physician with great experience in contagious disease, reached Malta on 15 May 1593.[19]

With the assistance of the Health Commissioners and a Maltese doctor, Gregorio Mamo, who had graduated from the medical school of Salerno, Parisi took immediate steps to control the epidemic. First, he set up isolation facilities on the little island of Marsamxett where all the infected cases were transferred. The suspected ones were also transferred there, but kept separate for observation. The lazaretto soon filled up with 900 patients. Then he ordered everyone else to stay indoors for forty days with the exception of one person per family who was allowed to carry out the necessary daily errands.[20] To prevent the disease from spreading further, three large washing places were installed in Valletta, Birgu and Senglea, all near the sea so that purification could easily be undertaken by everyone. On the least suspicion, anyone could go and wash, hang out clothes, and purify their own clothing.[21] Sanitary measures were applied to the infected houses as well as the suspected ones. The walls were washed with seawater and whitewashed with lime. The land where the corpses were buried was saturated with seawater and lime and the earth was compressed to make sure that no contaminated material would escape.[22] By September 1593, after two lots of quarantine during which nobody was infected, it was realised that the harsh scourge which had swept the island for almost two years had ended. The plague which had run in three successive waves (see Table 1), with increasing mortality, had ended.[23] A sense of the scale of this disaster can be inferred when one [p.40] considers that the total death toll was equivalent to the 1590 population of Valletta of 3,250.[24]

 

Period

Death toll

First wave

June to September 1592

300

Second wave

November 1592 to January 1593

500

Third wave

March to September 1593

3,000

Table 1: Death toll of the plague of 1592 (Source: Pietro Parisi, Aggiunta agli Avvenimenti sopra la peste, Palermo 1603, 6).

The plague of 1676 and the use of profumatori as disinfecting agents

The first case of the plague epidemic of 1676 was on 24 December 1675, in the house of Matteo Bonnici, an inhabitant of Valletta.[25] By the end of January 1676, several members of Matteo’s household had died and by February cases were reported in Valletta, Senglea, Birgu and in the village of Attard.[26] The authorities were in a quandary, for although immediate steps to isolate the cases had been taken, a group of four doctors in the employment of the Order did not agree that it was plague and declared that it was malignant fever attributed to some celestial influence.[27] The authorities decided to send letters to Marseille, Rome, Florence, Valencia and Paris addressing medical specialists in the respective cities asking for their opinion whether it was plague or not. Replies from all these places [p.41] confirmed that it was indeed, plague, but by this time, it had spread all over the island.[28]

The Health Commissioners, realising that the epidemic was rampant, decided to divide Valletta into 24 quarters each headed by a Knight, who within two hours of the inspection of his quarter every morning, would report what was happening. This service operated from February to July. Doctors and surgeons assessed patients and reported to the Protomedico.[29] In order to prevent the Holy Infirmary from being infected, a special area within the premises named Probatorio was set up on 18 March, where patients were monitored for three days. If no sign of plague was detected, admission to the hospital was allowed; if signs of plague developed, cases were transferred to the Lazaretto.[30] On 27 April Grand Master Nicolo Cotoner and the Council decided to ask for help from abroad. One request was for the Capuchin Father who served in the last plague of Genoa or others who had served with him. Similar requests were made for some surgeons from Genoa who had offered to come over. Another request was made to Marseille for a doctor or a surgeon who had practice in dealing with plague.[31] Within a month of the request for foreign doctors, three surgeons arrived in Malta, a Neapolitan doctor and two French doctors from Marseille. The first one was a volunteer who offered his services freely, giving himself to the care of the sick, night and day. The other two were on a contract of 700 livres per month.[32] They acted quickly. All the patients and the suspected ones at the warehouses at St Elmo were evacuated and transferred immediately to the newly erected barracks at Bishop’s Island. They advised that the general curfew proclaimed on 25 May be strictly observed. Everybody had to stay indoors. The Manderaggio, the Archipelago and the Strada [p.42] dei Francesi were isolated from the rest of the city of Valletta where the epidemic had spread so rapidly.[33]

The French doctors brought with them special profumatori. They disinfected houses with this very powerful mixture of drugs and minerals containing no less than 14 ingredients, such as sulphur, orpiment, arsenic, Sal ammoniac, litharge, asafoetida and others. This kind of fumigation entered the pores and penetrated the solid walls of the houses and was most effective. Prescriptions called ‘excellent preservative to cure plague’, ‘ripening the bubo’ and ‘to cure a carbuncle’, including dietary recipes, were advised to prevent the plague.[34] For months, the plague raged throughout the island with the same sequence of events: sickness, death, terror, panic and demoralisation. Plague struck suddenly and carried away whole families within a few days. However, the strict quarantine measures imposed by the French doctors between 12 June and 9 August seemed to have produced a general remission, if not a total extinction of the plague. By 24 September, the whole island was given a clean bill of health.[35] In this epidemic the total number of deaths amounted to over 11,000.[36] However, the archives of the Order give a total figure of 8,726, with Valletta having one sixth of its population wiped out and about half the population of Senglea, Birgu and Bormla being decimated.[37]

[p.43]

Conclusion

Over the centuries, the Order of Saint John faced outbreaks of plague which caused terror and devastation in the population and which required management with varying degrees of intensity.[38] Throughout history, the plague has killed an estimated 200 million people.[39] During the time of the Order’s presence in Malta, relatively little was known about the plague. Since the Knights knew that there was no cure for it at the time, their efforts in dealing with the disease were focused on containment as opposed to curing those infected. It was thought that plague was transmitted by ‘contagion’, hence their ruthless enforcement of quarantine. Innovative measures in dealing with epidemics evolved over time, but the Knights relied on outside help for such measures. It was primarily their wealth and influence that allowed them to seek and employ the services of the most eminent experts from around Europe.

It was not until 1894 that the microbe that causes plague, Yersina pestis, an illness that may manifest itself in bubonic, pneumonic or septicaemic form, was discovered. The infectious source of the disease was not understood until Alexandre Yersin investigated the Hong Kong epidemic of the mid-1890s. The exact route of transmission came to light a few years later when Paul-Louis Simond, an army physician, furthered Yersin’s research in Indochina. It was originally thought to be transmitted from rats through the flea xenophilla cheopis to man.[40] However, it was subsequently discovered that for the disease to become an epidemic, a suitable environment must exist to support the transfer mechanism. Specifically fleas, rats and humans must exist in close proximity to each other, conditions that must have been prevalent at the time of the Order in Malta.[41] The techniques of quarantine, purification and disinfection were thus appropriate measures taken by the Order to contain epidemics. [p.44] Today the disease is treatable with antibiotics and such strict quarantine measures are no longer necessary.

Plague still exists today and is endemic in many parts of the world including Madagascar, East and South Africa, South East Asia, the western United States, central Asia, Mongolia and Northern China, South Asia and Russia. The majority of human plague cases nowadays are the result of cross infection occurring from wild animal reservoirs, including prairie dogs, squirrels, marmots and other small rodents or larger mammals which have become infected such as cats and coyotes. Approximately 2,000 cases of plague are reported each year to the World Health Organisation[42] and concern has been raised about the possible use of Yersina pestis as an agent of bioterrorism. Advances have been made in rapid diagnosis, the understanding of immune responses during plague and vaccine development. Accelerating research into genetic sequencing of ancient specimens and comparing with contemporary pathogens is having a dramatic impact on the understanding of historical epidemics.

The DNA sequence from samples of Yersinia pestis from the Black Death compared with the genome of the contemporary organism has confirmed that the epidemic was indeed caused by a variant of Yersinia pestis.[43] The Plague of Justinian is also likely to have been caused by Yersina pestis.[44]



[1] Monique J. Grech was born in France. She is a State Registered Nurse, a Certified Midwife and a Family Planning and Parentcraft Practitioner. She has worked in New Zealand, France, England and Nigeria. She gained a Bachelor’s Degree in History (Hons) in 2006 and a Master in Hospitaller Studies in 2011, both from the University of Malta. She retired in Gozo where she lives with her husband. She has three children.

[2] J.M. Hiesberger (ed.), The Catholic Bible, New York and Oxford 2007, 327.

[3] R. Potter, The Greatest Benefit to Mankind. A Medical History of Humanity from Antiquity to the Present, London 1997, 25-26.

[4] J.N. Hays, Epidemics and Pandemics – Their Impacts on Human History, Oxford 2006, 41-43.

[5] Joseph Muscat and Andrew Cuschieri, Naval Activities of the Knights of St John 1530-1798, Malta 2002, 2.

[6] A. Luttrell, ‘The Hospitallers’ medical tradition 1291-1530’, The Military Orders. Fighting for the faith and caring for the sick, ed. M. Barber, Alderhsot 1994, 80.

[7] Luttrell, 80.

[8] In Sir Temi Zammit’s book, Malta, The Islands and their History, Malta 1926, reprinted (Third Edition) by A.C. Aquilina 1971, pages 93-94, we find that the islands had been invaded by the Barbary Corsairs and this was followed by an epidemic of plague which raged between 1427 and 1428. No other details are given regarding the plague. P. Cassar in his book, Medical History of Malta, London 1964, page 164 mentions that an epidemic of plague raged in 1427-28.

[9] G. A. Vassallo, Storia di Malta, Malta 1854, 251-252.

[10] Cassar, 273.

[11] Cassar, 273.

[12] These rules are updated in the publication in 1784, Del Diritto Municiplale Di Malta, Nuova Compilazione con diverse Altre Constituzioini. It is in Chapter 3, Di Varj Regolamenti Riguardo Porto ed alla Sanita, pages 269-282, where the rules detail exactly how ship movements are carried out and the punishments incurred if the rules are broken.

[13] Legge e costituzioni Prammaticali, Malta, 1724; Del Diritto Municipale di Malta con diverse altre Constituzioni, Malta 1784.

[14] Cassar, 287.

[15] cf. C.M. Cipolla, Cristofano and the plague – A study in the history of public health in the age of Galileo, London 1973, 29-30.

[16] J. Galea, ‘The Quarantine Service and the Lazzaretto of Malta’, Melita Historica, 4, 3, 1966, 187.

[17] Galea, 193.

[18] B. dal Pozzo, Historia Della Sacra Religione Militare Gerosolimitano, detta di Malta, Verona 1703; Venezia 1715, 336-337.

[19] Dal Pozzo, 338-339.

[20] Cassar, 167.

[21] Pietro Parisi, Aggiunta agli Avvenimenti sopra la peste, Palermo 1603, 11-15.

[22] Parisi, 11-15.

[23] Parisi, 11-15.

[24] A. Williams, ‘Xenodochium to Sacred Infirmary: The changing role of the Hospital of the Order of Saint John 1522-1631’, The Military Orders. Fighting for the Faith and Caring for the Sick, ed. Malcolm Barber, Aldershot 1994, 99.

[25] J. Micallef, The plague of 1676: 11,300 deaths, Malta 1985.

[26] National Library of Malta (NLM), Archives of the Order of Malta (AOM) 262, f. 42.

[27] NLM, AOM 262, f.47.

[28] NLM, AOM 645, f.281.

[29] NLM, AOM 645, f.283.

[30] NLM, AOM 645, f.283.

[31] NLM, AOM 262, f.51.

[32] NLM, AOM 645, f.284v.

[33] NLM, AOM 645, ff.284-285.

[34] Dal Pozzo, 447.

[35] NLM, AOM 262, f.58.

[36] Dal Pozzo, 449.

[37] NLM, AOM 645, f.292.

[38] Williams, 98.

[39] Sarah E. Rollins, Sea M. Rollins, and Edward T. Ryan, Yersina Pestis and the plague, Boston MA 2003, 78.

[40] L. F. Hirst, The Conquest of Plague, Oxford 1953, 107.

[41] cf. M. Lindemann, Medicine and Society in Early Modern Europe, Cambridge 1999.

[42] S.E. Rollins, S.M. Rollins and E.T. Ryan, Yersina Pestis and the Plague, Boston MA 2003, 78-75.

[43] V.J. Schuenemann et al., ‘Targeted enrichment of ancient pathogens yielding the pPCP1 plasmid of Yersinia pestis form victims of the Black Death’, Proceedings of the National Academy of Sciences in the United States of America, 108, 38, 2011, 746-52. K.I. Bos et al., ‘A draft genome of Yersinia pestis from victims of the Black Death’, Nature 478, 2011, 506–510.

[44] K.I. Bos et al., ‘Yersinia pestis: New evidence for an old infection’, PLoS ONE, 7, 11, 2012.