#Valletta2018, Wednesday Talks

Disease and Dissection: A history of surgery in Malta

Museum of the Order of St John Sharda Rozena, Museum Assistant

When the Order of St John was granted the island of Malta in 1530, surgical techniques and practices radically improved. The Order’s Sacred Infirmary Hospital produced one of the most talented surgeons of eighteenth century Europe, Michel Angelo Grima, who was renowned for his speed and efficiency during some of the most complex operations.

Medieval Malta was a small naval island vulnerable to attack and a country that practiced the ruthless profession of corsairing. Corsairs were authorised to attack merchant ships. Goods seized on the ships were sold and the crew was often enslaved. Because of this dangerous profession, the Order’s galley ships never left the island’s shores without a barber-surgeon on board.

Barber-surgeons tended to war wounds, bloodletting and amputations but they also practiced small surgical operations such as tooth extractions and removing cataracts.

Xema Girbi was one of the first documented surgeons on the island of Malta. A Jewish barber-surgeon, Girbi was so proficient during his operations that his patients forced him to stand down as President of the Jewish community in 1486, so that he would have more time to treat them.

Barber surgeons such as Girbi employed rudimentary techniques introduced by the crusaders from the East including using vinegar as an antiseptic. Opium or mandragora mixed with hot water and then inhaled by the patient was an early anaesthetic used during surgery operations.

In 1530 when the Order of St John was given the island of Malta by the Holy Roman Emperor Charles V, the Order immediately started to build a Hospital, the Sacra Infermia or Sacred Infirmary, on the newly fortified town of Valletta.

The Sacred Infirmary gained an outstanding reputation of medical practice where patients were given excellent treatment and care. Patients had separate beds and were provided with woollen mattresses, cloaks and sandals to protect their feet and keep them warm. On its completion in 1574 the Sacred Infirmary’s Great Ward was 155 metres in length. This soon became one of the largest hospital wards in Europe. Reverend Henry Teonge noted in 1675 that the Great Ward was ‘so broad that twelve men may with ease walk up the middle of it’ and ‘the sick are served all in silver plate’. The Hospitallers believed that all patients, regardless of their faith or ethnicity, should be given excellent care and this would, in turn, lead to their own recovery.

The Great Ward of the Sacred Infirmary. Statuta Hospitalis Hierusalem, 1588.

The Hopsitallers Order of St John employed and trained their own physicians, nurses, bloodletters and surgeons at the Sacred Infirmary Hospital. Apprenticeship surgeons from nearby regions such as Sicily, travelled to Malta to train at the renowned Hospital. Trainee surgeons also had to work on the Order’s galleys before being able to secure a position in the Hospital. On the ships they demonstrated their capability by carrying out amputations of the legs, feet and arms as well as successfully removing cataracts and removing the stone from the bladder or kidney (lithotomy).

It was not just wounds inflicted during warfare that led to surgical operations. The surgeons working for the Order treated everyone, including Knights, civilians and slaves. Diseases they encountered included cancerous tumours in the bone or muscle, serious infection, gangrene, frostbite, septic exhaustion and erysipelas.

In October 1676 the Grand Master of the Order Nicolas Cotoner founded the School of Anatomy and Surgery in Valletta. The School was situated next to the Sacred Infirmary Hospital; Cotoner paid for this establishment at his own expense. Recognising the need for professional surgeons on the fortress of Valletta, Cotoner financially supported the most talented surgeons and anatomy teachers to work at the School. Students were required to attend anatomical dissections each Thursday and weekly post-mortems carried out at the Sacred Infirmary. After six years working at the Hospital, students were given a licence to practice surgery. Michel Angelo Grima, a Maltese-born surgeon, became one of the most renowned surgeons to train and teach at the School of Anatomy and Surgery.

Grandmaster Nicolas Cotoner, 1663-1680. Copyright Museum of the Order of St John, London

 

Michel Angelo Grima started his apprenticeship at the Sacred Infirmary in 1743 at the age of 14. He was taught by Gabriele Henin, a Master of Surgery from Florence. Recognising his talents, the Order of St John paid for Grima to travel to Europe to continue his training as a surgeon.

Grima received a doctorate in Philosophy and Medicine from the University of Pisa and was appointed as a dissector in Florence. In Paris, Grima completed his studies and served in the French Army as a surgeon during the Seven Years War in a hospital in Cassell, Germany. The Order however, only supported Grima on the condition that he returned to Malta after his training. On Grima’s return to Valletta he became chief surgeon at the Sacred Infirmary where he became renowned for his speed and accuracy. He was able to conduct a mastectomy in three minutes and lithotomy in two and half minutes.

Lithotomies were incredibly complex, and physicians were advised to only allow surgeons to operate. In the ancient Greek Hippocratic Oath, it states ‘I will not cut for stone, even for the patients in whom the disease is manifest; I will leave this operation to be performed by practitioners.’ The difficulty attributed to this operation was evident from the method of treatment: bladder stones were removed thorough the perineum. As the image below from 1768 reveals, the patient would be placed in the lithotomy position with their legs up or suspended on an examination table. Without anaesthetics this operation was incredibly painful, especially because of the special surgical instruments that were used, including dilators of the canal, forceps, tweezers, stone cutters (lithotomes), bladder cutters (cystotomes) and conductors (grooved probes for stone extraction).

Operation for Lithotomy, 1768. Credit: Wellcome Collection.

 

Surgical instruments for lithotomy, 1730. Credit: Wellcome Collection.

Lithotomies were not the only complicated operations performed by surgeons in Malta. Surgeons experimented with amputation methods. This included cauterising wounds: burning the skin or flesh with a heated instrument or caustic substance, such as hot oil, to stop bleeding or prevent infection. Aboard ships, if there were no barber surgeons, often the carpenter would have the responsibility of removing the leg. Some of these operations involved sealing the wound with hot tar.

But by the eighteenth century, surgeons used more innovative methods. Grima frowned upon cauterising the wound as a barbaric method of treatment. Instead Grima advocated ligatures which involved using a piece of thread and binding the wounded area incredibly tightly. This would cut off a blood vessel and control bleeding after amputations. Bandages were then used to cover the wounds.

Engraving, 1646 by Matthaeus Merian. Credit: Wellcome Collection CC BY

Despite these developments in surgery, Grima still advocated techniques such as bloodletting for many of his patients. Leeches were applied to the temple to reduce inflammation and sometimes as much as sixteen ounces of blood was drained from one patient each day.

Michel Angelo Grima was richly awarded by the Order. Grandmaster Pinto presented the surgeon with a horse-drawn carriage, so he could travel quickly, and in relative comfort, to his next operation. The surgeon was also celebrated by his contemporaries. In 1764, after successfully treating Fr. G. Ingurdo for a kidney operation, Ingurdo wrote four sonnets praising Grima for his achievement. After dissecting live dogs, Grima later published papers about head injuries and abdominal surgery. His book Della medicina traumatica from 1773 details how various types of wounds sustained from injury should be treated by the surgeon.

Michel Angelo Grima. National Museum of Fine Arts, Valletta.

Grima died in Valetta in 1798 aged 69. His last will and testament reveals that he died a wealthy man. His possessions included large amounts of silverware, over three hundred medical and literary books, gold buttons and a walking stick adorned with a golden globe as a symbol of his medical profession.

While we know more about Grima and his male contemporaries, women did train as barber surgeons in Malta in the seventeenth century. Female surgeons were also needed to care for the Hospital’s female wards. Yet when anatomy universities were established in the 1700’s, women were banned from attending. As a result, fewer women officially practiced surgery as a profession. However, in 1765 the president of the Anatomy School Bali Sigismondo Piccolomini proposed that training nurses should learn the duties of surgeons. This was accepted and in 1772 the Order paid for a female student to study surgery in Florence.

After 1798, when the Order of St John were forced out of Malta by Napoleon Bonaparte, the Sacred Infirmary Hospital served as a station hospital for wounded servicemen that could not be moved any further from their ships. The Order’s Anatomy and Surgery school in Malta continued to train student surgeons from across Europe. Anaesthesia, in the form of ether, was introduced to Malta in March 1847 by assistant surgeon Sir Thomas Spencer Wells. This was four months after the anaesthetic was first employed in the United States.

Today the Sacred Infirmary has been transformed into the Mediterranean Conference Centre. The Great Ward is used for international conferences, banquets, theatre performances and weddings. The University of Malta’s Department of Surgery has moved to a new location in Mater Dei but continues to train surgeons from across the globe. With exciting developments in surgical practices and a brand-new hospital, Malta still exceeds in surgical teaching.

The influence of the Order of St John on the history of surgery in Malta is remembered on the island, especially the reputation of Michel Angelo Grima whose portraits hangs in the hall of the surgery school today.

The entrance of Mater Dei Hospital in Malta, Image courtesy of Johan Pihlemark, 2012. CC BY-SA 3.0.
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