THE OLD HOSPITALS

The ()ld Hospitals The Order Of St. John

] OSEPH GALEA,* FREDERICK F. FENECH **

B ETWEEN 1048 and 1070 in , After the decline and fall of the Latin King­ the Order of St. John was founded for the dom the Knights repaired to to establish direct purpose of helping pilgrims who had themselves first at Tyre and afterwards at the become lost, weary, or beset by other diffi­ of Margat, the "." culties while en route to the . Later they moved to Acre in modern Israel They opened both hostels and hospitals for where they remained until the continuing en­ this purpose, though hospitals formed the emy pressure drove them completely away main outlet of their activities; in fact, their from the mainland. organization was, and still is, referred to as Their next home was the Island of Rhodes "hospitaller." In 1113 they received a charter which they had conquered in 1310 and where as one of the Orders of Knighthood by Pope they remained for over 200 years. Their hos­ Paschal n. Within a few years these Knights pital there, best known as "The Infirmary," undertook the active responsibility for pro­ earned fame throughout Europe for its meth­ tecting those travelling to the Holy Land, ods of treatment as well as for the care and which gave the Order a military character attention bestowed on patients. In 1523, after also. Suleiman the Magnificent drove them from The individual Knights, volunteers from this Island stronghold, they wandered about many different European countries, were or­ Europe for some years in search of a new ganized within the Order according to their home, until Emperor Charles V granted to origins into groups known as "langaages" : the Order the Islands of Malta and the For­ 1. Provence, 2. Auvergne, 3. France, 4. , tress of Tripoli, as a noble fief free and 5. Aragon, Catalonia, Navarre, 6. England, 7. unencumbered. Germany, and 8. Castille, Leon, Portugal. On October 26, 1530, Philip Villiers de A Bull issued by Pope Paschal n on the l'Isle Adam, the Grand Master who had 15th of February, 1113, refers to the first hos­ pleaded the cause of the Order at the various pital of the Order in Jerusalem. During the Courts of Europe, arrived in Malta to estab­ Latin this hospital was reputed to be able to accommodate 2,000 pa­ lish himself as Sovereign Ruler of the Maltese tients. Islands and Head of the Order of St. John. Patients were always admitted to the Or­ Though the resources of the Order were der's hospitals without discrimination on the practically exhausted when the Knights first basis of their origin, color or creed, and there came to Malta, one of their first acts was to were no fees [or the services rendered. erect a hospital in , the little seaboard town on the south of the Grand Harbour. • M.B.E., K.M. , M.D., D.P.H., F.R.S.H. .. M.D., M.R.e.p. (London), M.R.e.p. (Edinburgh), The spacious building, started in November D.e.H. 1532 and completed in six years, soon became Mailing address: St. Luke's Hospital, Guardamangia, Malta. overcrowded and more extensions had to be

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made. Thronging here came patients of every In 1660, the Knights began to enlarge the nationality, class and status. hospital. This task was started under Grand This hospital was divided into two main Master Raphael Cottoner and completed divisions, medical and surgical. Each division under his brother and successor N icholas, who had different wards for clinical grouping of in 1674 founded a School of Anatomy and Sur­ cases-for example, there were fever wards gery attached to the Infirmary. The newly separated into high and low fevers, a dysen­ built section called the Great Ward, and the tery ward, a renal disease ward, a ward for old section called the Old ward, were joined syphilitic affections. There was a section for together into a single unit measuring 563 feet psychiatry and one for orthopedics. A tunnel in length and 34 feet 10 inches in width, led from the harbor shore directly into the forming one of the largest interiors in the basement of the hospital. world. At one end of this large ward was an During this time the Order had been ac­ open window with a revolving cradle, called quiring extensive properties called "Com­ "ruota," where unwanted babies could be de­ manderies," scattered all over Europe. The posited to be taken care of by the institution. revenues from these "Commanderies" were In 1679 an isolation ward was built, apart considerable. Moreover the Treasury of the from the rest of the hospital although inte­ Order received rents, taxes and other emolu­ grated with it, and in 1687, a library was ments and dues from the administration of added. Malta and Gozo. Citizens, travellers and freemen in general In 1566 the city of was founded were accommodated in the Great Ward. Slaves by Grand Master Jean de la Vallette. The and criminals were taken care of in the big Knights then transferred their Headquarters ward underneath the Great one. A separate to the new capital of the Island, giving up ward served for pilgrims and Members of the old Infirmary at Birgu. Religious Orders. Each Knight and Member The new hospital or Sacred Infirmary was of the Order had a separate room. built on the southeastern part of Valletta Within the hospital there was an attempt promontory facing the Grand Harbour. The at clinical classification, a procedure in ad­ main feature of the original structure, com­ vance of what was happening in other hos­ menced in 1574 and taking four years to pitals of Europe. Fevers and other ailments build, were two large wards, one superimposed of a medical nature were grouped in the large on the other. ward; serioas cases and patients in a mori-

CLINICAL PEDIATRICS December 1967 729 FENECH AND GALEA

"At one end of this large ward was an open window with a revolving cradle, called 'ruota,' where unwanted babies could be deposited to be taken care of by the institution."

The Great Ward tures, medicaments, application of ball stop­ of the Sacred In­ firmary as it ap­ pers, and packing were all used in the man­ peared in the 17th agement of hemorrhages. century. Their pharmacy was well stocked with sur­ gicaJ appliances including crutches and arm ho~ks. Contemporary descriptions speak of rows of shelves lined with splendid Majolica jars filled with medicaments, drugs and herbs of many kinds. Two powders popular at that time were St. Paul's Powder and the Maltese Fungus Powder; the former was obtained by crushing stone dug from St. Paul's Grotto in buncl state were placed in a special unit; Rabat and was reputed to possess astringent, dysentery cases and other enteric affections sudorific and antifebrile properties, whilst were also kept separately; two rooms were the latter was held to be effective against dys­ reserved for patients undergoing lithotomy. entery and other enteric affections. The surgical division comprised the casualty, Ointments, lubricants and poultices were the operations and the bleeding sections. much in use. A supply of leeches was always There was a separate ward for the insane, available. The pharmacy staff included fe­ separate rooms for those undergoing mer­ male attendants who distributed supplies to curial in unctions, and other rooms for those outpatients and also paid domiciliary visits to requiring hot baths. Curiously, in 1758 a the sick, a primitive form of district nursing. ward was opened which was reserved for Brit­ Every patient had a bed for himself, a com­ ish sailors. There was also an isolation ward modity which was nonexistent in other hos­ for reception of suspected cases of smallpox pitals of Europe (at that time in the Hotel and other infections pending their removal Dieu, the famous hospital of Paris, patients to the Lazzarretto or isolation hospital on were being placed in twos in each bed, and Manoel Island. in time of emergency, were even laid on At the peak of its activity this hospital of frames placed on top of fourposter beds). the Knights was the best known institution Mosquito nets were provided for each bed. of its kind in the world. The methods of treat­ ment were of the highest type. The operative procedures were far in advance of the times, including premedications and collaborative teamwork by the surgeon and his assistants. Both chest and abdominal surgery were car­ ried out. Patients and military casualties came to Malta from all parts of Europe. The operation of enterorrhaphy was first performed here with success by the Maltese surgeon Grima. Lithotomies, amputations and disarticulations were frequent. Head injuries were common Tablets made from stone dragged from St. Paul's and trephining was highly developed. Liga- Grotto in R abat.

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The administration of the hospital was reg­ ulated by statute. The Supreme Head was the Grand Master himself, one of whose titles Knights Hospitallers min­ was that of Servant of the Sick. Another high istering to the patients in dignitary was the Grand Hospitaller, who was the Great 'Ward of the Sa­ the senior amongst the French Knights and cred Infirmary at Valletta, Malta. exercised over-all control in hospital matters. His authority was unlimited. Not even the Inquisitor or the Grand Marshall who was in command of the forces could be admitted to the Infirmary without the consent of the obtain knowledge and experience by follow­ Grand Hospitaller, though this was usually ing the senior physicians and surgeons on granted on condition that they should deposit their ward rounds. These were allowed to their insignia of office at the hall. practice dissection and to attend postmortem The day to day services were under the su­ examinations. In 1674, medical studies were pervision of the Infirmarian, usually a senior reorganized and formulated more systemati­ Knight. He resided in a separate apartment, cally. Grand Master N icholas Cottoner and every morning would go around the wards founded a School of Anatomy which taught to ensure that all hospital staff were fulfilling botany, anatomy, medicine and surgery and their duties and that all patients were receiv­ appointed Dr. Joseph Zammit as Head of ing proper attention. the School. Cotton er ordered that all doctors The medical staff of the hospital consisted employed in the service of the Order receive of three senior physicians and two other phy­ their training at this School, and that they sicians. There were three resident surgeons should attend lectures on each Thursday assisted by two other surgeons. There were throughout the year. The School of Anatomy also six junior wrgeons, called "Barberotti," developed into a proper School of Medicine, who resided in the hospital and were on call from which is derived the present Faculty of in rotation; these were allowed to perform Medicine of the Royal University of Malta. minor surgery. A barber surgeon or "phle­ The teachers of the old School of Anatomy botomist" was in charge of the leeches, cata­ usually belonged to the consultant staff of plasms and vesicants which he applied in ac­ the infirmary; most of them had taken post­ cordance with the physicians' and surgeons' graduate studies at Pisa, , or Mont­ orders. A chief dispenser was in charge of the pellier. pharmacy. Many of the doctors of the Valletta In­ To ensure a continuing qualified profes­ firmary became well known throughout Eu­ sional staff, arrangements were made at the rope. Grima was acknowledged as one of the Valletta hospital for medical apprentices to leading surgeons of his time. Earth, a pupil of Grima, went on to occupy the first chair of Ophthalmology at Vienna and to establish the first University Eye Clinic, where pupils from all over Europe were trained to lay the foun­ dations of similar eye clinics in their own countries. The Infirmary for a long time was a male institution; female patients were not admitted. This deplorable state of affairs was remedied by the generosity of a noble lady, Catherine Scappi, who some time previous to the year 1625 had donated a house in Valletta for the reception of sick and destitute women. When The Knights first Infirmary in Malta. this became too small a larger house close to

CLINICAL PEDIATRICS December 1967 731 FENECH AND GALEA

The mechanism [or admission of unwanted infants into the Infirmary has been alluded to. Each when received was registered in a special book and a metal tag hung around his neck. Infants were kept in special rooms under the care of two matrons who resided there, and other employed women as needed. The infants were nourished by breast milk from wet nurses; when the numcer of foster mothers was inadequate the sick babies were Fed goat's milk. 'Well babies left at the Infirmary would be given out to approved foster mothers for care, and be visited once every two months by one of the Comptrollers of the Infirmary. Each year on St. Martin's eve, the Patron Saint of the poor and destitute, two Comptrollers would visit the children to determine their progress and to give them presents. Any child who became ill would be trans­ ferred for treatment to the hospital for women, where he would be given a separate cot and Grand Floor Plan of the Hospital of the Knights of a special diet. Saint John at Rhodes. These orphan children remained under the care of the Infirmary until maturity. ''''hen the Infirmary was acquired, to be known as eight years of age, the boys would be appren­ the "Ospedaletto," the little hospital. ticed in some trade or craft to which they had The Order soon realized that a hospital for shown some inclination. Some of them joined women was an essential service, with the result the navy or the army of the Knights as boy that the Scappi hospital was developed as a sailors or soldiers. The boy apprentices were department of the Infirmary. A medical staff under the supervision of a priest who looked consisting of two physicians and two surgeons after their welfare; they were allowed only were entrusted with the care and treatment pocket money un til they reached the age of of the female patients. When fully completed 18 years when they were deemed capable of this hospital housed a surgical ward, a ve­ looking after themselves. nereal disease clinic, a maternity ward and The girls on reaching eight years were ad­ a general medical ward. Its activities were mitted into a special institution called "Con­ under the direct supervision of a lady called servatoria," and trained to be maid servants the Governess. The sick were attended by or attendants in the hospital for women. At female employees. There were maid servants the age of 20, they usually became nuns or for general duties as well as the usual ancil­ got married. If the latter, a dowry was pro­ lary staff consisting of dispensers, laundry vided for each by a pious foundation. A sys­ women and cooks. Female slaves were utilized tem for adoption was also in existence; the for menial work. good character and financial means of the Spittoons were provided for the tubercu­ foster-parents was ascertained before the adop­ lous patients, a precautionary measure which hardly existed in other hospitals at that time. tion was permitted. The treatment of mental patients followed Other institutions or services of a medical the same pattern as in other hospitals, with or public health character were linked with excited and restless patients being chained the Infirmary, such as the district medical to the wall. service, the care for the aged and infirm,

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the Lazzaretto, and the quarantine service, though supplemental to the scope and work of the Infirmary. These activities earned the international fame for the Infirmary of the Knights. During the second half of the 18th century, the threat of Turkish domination of the Medi­ terranean passed, and the reason for the ex­ istence of the Order declined. Then came the French Revolution and the Napoleonic ' !\Tars which shocked old regimes and undermined the power and very existence of ancient insti­ tutions based on privilege and prerogative. The Knights of Malta lost their power and The Great Hall of the Infirmeria of the Hospitallers influence in France, their property was con­ at Rhodes. fiscated and their priories were suppressed. In other countries the income of the Knights was new city of Valletta, confirmed the early Stat­ severely taxed. But the most serious difficulty ute and made hospitality mandatory to all was that the loyalty of many of the Knights Knights. As stated in Title IV of the Statute: towards their Order was shaken by the social and religious ideas spreading through Europe. "Hospitality is one of the most eminent acts of The Order of Malta was essentially a hos­ piety and humanity; all Christian people agree in this opinion, because it comprehends all other acts. pitaller Order; and it never deviated from It ought to be exercised and esteemed by all good that primary purpose. Indeed the Grand men, much more by such as are for distinguishing Chapter of the Order, held in 1588 in the themselves by the name of knights hospitallers."

P hilatelic Note

In March 1966 a set of stamps was issued in plan the city and supervise the initial stages. Lapa­ Malta to commemorate the Fourth Centenary of relli (one shilling stamp) had been 's the Foundation of Valletta by the Knights. assistant in the building of St. Peter's dome in The two-penny stamp shows Grand Master Jean and prepared the plans for Valetta in three Parisot de la Vallette who had proposed the build­ days. ing of a fortified city on the promontory of Mount The six-penny stamp reproduces the plan of Val­ Sciberras years before the Turkish invasion and letta. When Laparelli left the Island in 1569, his the Great Siege of 1565. Maltese assistant, , was entrusted , depicted on the three-penny stamp with its completion. with his coat-of-arms, helped to finance the proj­ The two shillings and sixpence stamp shows Cas­ ect and sent his architect, Francesco Laparelli, to sar, with two assistants, examining plans for the

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CLIN ICAL PEDIATRICS December 1967 733 FENECH AND GALEA 4. Erskine Hume, E.: Medical WOl'k of the Knights exterior 'of the Conventual Church of St. John, Hospitaller of Saint John of Jerusalem. Balti­ shown in the background. more, 1940. Sketch depicting the Mediterranean and show­ 5. Fedeli, C.: L'Ordine Di Malta e Le Scienze Me- ing how the Knights were forced by the Turks diche. Pisa, 1913. farther westwards from Jerusalem to Acre, , 6. Gillenls, J.: L'Ordre Souverain De Malte Et Son Oeuvre Humanitaire. Congres International De Rhodes and Malta is taken from the book "Knights La Neutralite De La Medicine En Temps De of St. John," by Gerhart Ellert. Guerre, Paris, 1959. 7. Grima, M. A.: Della Medicina Traumatica. Firenze, References 1773. 8. Mifsud, A. : Knights Hospitallers of The Ven. 1. Bedford, W. K. R.: The Regulations of the Old Tongue of England in Malta. Malta, 1914. Hospital of the Knights of St. John at Valletta. 9. Pappalardo, 1.: Storia Sanitaria dell'Ordine Geroso­ Edinburgh, 1882. limitano di Malta. Roma, 1958. 2. Bosio, G.: Istoria della Sacra Religione di San Gio­ 10. Pantalaleon, H .: Militaris Ordinis Johannitarum, vanni di Gerusalemme, 3 vol. Roma, Tipografia Rhodiourum aut Melitensium Equitum .... Vaticana, 1594. Basiliae, 1581. 3. Cassar, P.: Medical History of Malta. London, 1964.

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