The Middle Ages found the Maltese Islands under Arab dominion. The Arab conquest of Malta occurred around 870 AD. In spite of a dominion of over two centuries, the Arabs have left little trace of their achievements in the arts and sciences, including medicine on the Islands. Arab dominion saw its end with the arrival of the Normans from Sicily, first in 1090 and then more definitely in 1127. The Normans were a practical race having their origins in Scandinavia. The cosmopolitan character of their expanded empire and the distance of its new frontiers from their land led them to adopt a tolerant policy which assured the liberties and customs of their new subjects, thus rarely interfering with the traditions, laws and religions. The Arabs, Greeks, Jews and Berbers were allowed to remain in Malta, but the arrival of the Normans to the Islands resulted in a cultural and political connection with Sicily which lasted throughout the Middle Ages and after. During the Medieval period the Islands passed through Norman and Hohenstaufen rule, the Angevins and the Aragonese, until they were ceded to the hospitaller Order of St. John of Jerusalem in 1530.

The medical history of the Islands during this period starts off scantily, and it is only in the thirteenth century that definite items of medical history appear. However medical practice probably fell under the ordinances published by Roger II in 1140 and later expanded by Frederick II in 1224. These ordinances controlled the licence to practice and teach medicine, the relationship of the physician to apothecaries, regulated the tariff of fees, controlled apothecary practice and managed public hygiene. Regulations relating to the practice of midwifery by physicians were however not contained in these laws since the operative portion of that art, so far as it was practised by man, belonged to the surgeon. Midwives were probably not classed among medical persons [1]. Public health in Malta during the fifteenth century became the responsibility of the elected local government known as "Universitas". This municipality was initiated in 1397, but it was only in the beginning of the fifteenth century that it was charged with the maintenance of public health. Petitions and proclamations of this Popular Council in 1409, 1472 and 1476 confirm that the municipality was well aware of its duties, attempting to control the disposal of waste material of Mdina and preventing the contamination of the public water supply [2].

The Middle Ages in Europe saw a revival of the union between medicine and religion so that everything that could be called medicine in the Christian West fell by degrees into the hands of the church ministers. The Council of Le Mans in 1247 forbade all burning and cutting, ie surgery, to the monkish practitioners on the principle of "the Church shuns bloodshed". The practice of surgery thus fell into the hands of the lay physicians who were often regarded as mechanics and tradesmen, and inferior in birth to the learned. The Jewish lay physicians were on the other hand regarded in good esteem [3]. The Jewish community had become an important aspect of Maltese life being considered as the learned elite. Towards the close of the fifteenth century, Malta's population has been put at around 17000, of whom 3% were Jews. A number of Jewish doctors and surgeons are known to have been practising in Malta during the fifteenth century while some Maltese Jews were known to have been practising their profession in the Kingdom of Sicily. The earliest and most noteworthy known Jewish physician who practised in Malta was Abram or Brahoni Safaradi who until 1446 practised in Gozo. He was subsequently appointed to the post of lieutenant of the Dienheleli for the Maltese Islands. In 1450 he was receiving a salary from the town authorities in Malta as physician, for which he was obliged to attend the sick poor without charge. In 1462 moves were made to replace him with a Christian doctor, but he retained his post well into the 1480's when he was replaced by another Jewish doctor Abias Sebaha. A contemporary doctor to Safaradi included Gaspar de Monbron who in 1476 was also receiving a salary from the town hospital. Xema/Zemah Girbi was the contemporary surgeon, while the town council also employed an apothecary. The Jews taught their children in the synagogue until they were of age to go to the medical school run for Jews in Sicily. Theacademic standing of the Jews was well accepted by theauthorities, so that in 1462, it was suggested that Jewish apothecaries and doctors should be obtained cheaply from Syracuse. The Jews were subsequently expelled from the Islands in 1493 in accordance to an edict ordering their expulsion from the Kingdom of Sicily. The expulsion of the Jews from the Islands left a void in the professional services which was apparently filled by two conversos Andreas de Avula and Angelus Anello who apparently helped to tide the island's need for a doctor until local or foreign Old Christians were ready to take over. The post of surgeon was filled by the Christian Micael Ferriolu, a post he had filled for the previous ten years [4].

Other non-Jewish practitioners are know to have practised on the Islands. In 1283, a legal document records the residence in Malta of a Florentine physician named Jacobus Finus. After the expulsion of the Jews there apparently was a lack of a physician in the town. Thus in 1517 the town council expressed its worry that "in this city and island there is no physician".The post was subsequently filled by medico cirurgico Rayneli Bonellis and medicus fisicus Bernardo de Munda. These two doctors retained their posts till well after the arrival of the Order of St. John. The town authorities also employed an apothecary who also served the hospital. During 1495 and 1520, the town apothecary was Hieronimus Callus [5].

With the increasing spread of Christianity and the passage of medical practice into the hands of the Church, sick-nursing became a Christian duty and, as communities dedicated to service were founded, the infirmary formed an essential part of community life. In the late Middle Ages the care of the sick passed again into the hands of the laity. The first hospital recorded in Malta was already functioning by 1372, while in Gozo a hospital was founded in 1454. Both hospitals were on occasion referred to as Santo Spirito Hospital. The name of Santo Spirito was given to several medieval hospitals which were particularly intended for foundlings and maternity cases.The first recorded hospital in Malta - Hospital of St.Francis at Rabat - was already functioning by 1372 under the rectorship of a Franciscan appointed by the King. During the same period the earliest known woman's hospital - St. Peter's Hospital - was functioning at Mdina. This hospital ceased to function in 1418 when it was converted into a monastery for nuns. After its closure a bequest for the foundation of a hospital was left by Margaret of Aragon who was the daughter of William the natural son of King Frederick III of Sicily and wife of the Governor of Malta. In 1433 the management of St. Francis Hospital was transferred to the Universita` since it was being mismanaged and its name changed to Santo Spirito Hospital. From the middle of the fifteenth century onwards the hospital functioned normally caring for a number of persons, mainly too old or too poor or otherwise incapable of caring for themselves, foundlings, and patients. The hospital continued to serve the Rabat area until it was changed into a convalescent sanatorium in 1883, a role it maintained well into the twentieth century. The first hospital in Gozo owed its origin to a bequest made by Francesco Bonnici on the 22 February 1454. The establishment dedicated to St. Julian (but also known as the Hospital of St. John the Evangelist and of St Cosmos and St Damian) consisted of a few dwellings near the gates of the citadel at Rabat/Victoria [6].

A number of diseases are known to have affected the Maltese population during the medieval years. The Middle Ages in Europe can be referred to as the epoch of plagues and epidemic disease because of the number of outbreaks of widespread epidemics which left massive devastationin their wake. The Maltese Islands may have made their first contact with Plague or the Black Death in the late thirteenth century. An ancient cemetery at Rabat/Victoria in Gozo contained the remains of many illustrious personages. The cemetery's establishment has been ascribed to the thirteenth century and was said to contain the corpses of the followers of King Louis IX of France who died of plague in 1270.

In 1348 the Black Death in known to have reached the Islands in its march across Europe, while other epidemics are recorded in 1427-28 and in 1453. Other epidemics were recorded during the early years of the sixteenth century in 1501, 1519 and 1523. In the latter epidemic, introduced by a captured galleon, the Mdina municipality attempted to contain the disease by burning the cargo, isolating the crew and submersing the ship. When the owners refused to comply with these instructions, the municipality was compelled to set fire the ship. Cases of plague broke out at Birgu, the maritime centre of the Island, and the town was cordoned off from the rest of the country by special guards. The disease apparently remained limited to the town. In 1453 an epidemic of "morbus di la gula et di la punta" possibly one of Scarlet Fever lasting until November 1455 affected the Islands with widespread mortality [7].

The Christian concept of physical resurrection after death resulted in the further expansion of the funeral chapels concept to cemeterial Basilicas and church burials. Burials in churches remained until well into the eighteenth century. Skeletal remains excavated from a number of Maltese late medieval-early modern period churches have shown the remains of a number of pathological lesions. Traumatic lesions in the form of fractures are again encountered with in sixteenth century bone remains from St. Gregory Church at Zejtun, Malta. Thus examination of these remains yielded the presence of healed fractures of two ribs, a left femoral shaft, a right first metatarsal, a right Colles fracture with callus formation, and dental trauma. Osteo-arthritic changes and vertebral osteophytic growths were also evident in these remains and others from Hal Millieri Church, Malta. These abundant remains showing arthritic changes, together evidence of prominent muscular ridges may reflect the occupational status of some of the individuals buried in these churches. Periostitis at two locations in a tibia has been assumed to be the result of varicose veins. One female skeleton from St. Gregory Church showed osteolytic lesions possibly caused by a metastatic malignant tumour. Congenital anomalies included a number of sacral anomalies including spina bifida and other skeletal minor anatomical variations. Some female bones showed evidence of osteoporosis, possibly senile. The incidence of dental caries was low with the ratio of healthy to carious teeth being 19:1. Skeletal lesions possibly a result of infection included ankylosis of the thoracic vertebrae with shortening of the intervertebral spaces possibly a result of brucellosis infection, and bone erosions in a parietal bone possibly of syphilitic origin [8]. The origins of syphilis is still disputed, but it has been suggested that it was originally an American disease which was introduced into Europe after Columbus discovered the Americas and his infected crew brought it back from Haitito Portugal and Spain in March 1493 at the end of the first voyage. Thereafter it attacked an unprotected population with devastating effect and rapidity. Brucellosis is an endemic disease in the Maltese Islands which was identified as transmitted by the goat early in the twentieth century.

The practice of medicine in Malta at the close of the Middle Ages was based on the teachings of the ancient and medieval medical authors. In a medico-legal report dated 1542 where a case for marriage annulment was presented to the Ecclesiastical Court, the two medical experts nominated by the court - Joseph Callus and Rayneri Bonellis - referred to the works of Galen (c.131-200 AD), Rhazes (860-932 AD), Avicenna (980-1037 AD) and Avenzoar (1072-1162 AD). The basis for the annulment was an anatomical defect of the male genital organ probably a case of hypospadias glandis. The marriage was declared null and void since because of the anomaly the male was infertile. A sixteenth century certificate records the knight Gianbattista Calerari to be suffering from gout which caused him severe pain, depriving him of the use of his legs, and was accompanied by fever. A case of foot presentation managed unsuccessfully by the midwife in 1598 is also recorded. Further insight to the pharmaceutical treatment can be obtained by two sixteenth century inventories of two pharmacies serving Santo Spirito Hospital [9].

The Middle Ages are frequently underrated and misunderstood, or at least misjudged, as regards their importance to the history of civilization, being often considered the dark epoch of absolute barbarity or semi-barbarism. This view is erroneous, for the Middle Ages served not to repress, nor even simply to maintain undisturbed, but actually to advance the development of humanity and civilization, and thus promoted the development of medicine. The period served to amalgamate Ancient medical practices of the Greeks with Arabian, Jewish, and Latin concepts until the last half of the Middle Ages when a vigorous impulse was made to found a new science of medicine. Among the historical phenomenon which comprise medical practice of the Middle Ages we must first consider Byzantine medicine founded entirely upon Ancient practices, the transplanting of Greek medicine among the Arabs and the influence of Jewish medicine, and finally the Christian labours in the care of the sick. As in other areas of medieval science, researchers in the field of medieval medicine must consider not only the ancient Greek and Latin sources, but also the mutual influences and exchange of medical information among the Muslim, Jewish, and Christian cultures, more so in Malta where the three communities lived together.

1. J.H. Bass: Outlines of the history of medicine and the medical profession. Krieger Publ Co., Huntington, 1971, vol.1, p.274-276

2. E.R. Leopardi: Bandi of the XV century. Melita Historica, 1957, ii:126; 1958: ii:191,194; P. Cassar: Medical History of Malta. Wellcome Hist Med Libr, London, 1964, p.12-13

3. J.H. Bass: op. cit. note 1, p.253

4. P. Cassar: op. cit. note 2, p.14-17; G. Wettinger: The Jews of Malta in the late middle Ages. Midsea Books Ltd, Malta, 1985, p.104-115,138

5. J. Galea: Documenti per servire alla storia medievale maltese. Melita Historica, 1958, ii:199; G. Wettinger: ibid, p.138; S. Fiorini: A prescription list of 1546. Maltese Medical Journal, 1988-89, 1(1):20

6. F.F. Cartwright and M.D. Biddiss: Disease and History. Rupert Hart-Davis, London, 1972, p.23-24; P. Cassar: op. cit. note 2, p.13,23-36; S. Fiorini: Santo Spirito Hospital at Rabat, Malta - the early years to 1575. Dept of Information, Malta, 1989, +199p.

7. P. Cassar: ibid, p.11-13,164-165

8. S. Ramaswamy and J.L. Pace: The Medieval Skeleton remains from St. Gregory's Church at Zejtun (Malta): Part I. Paleopathological Studies. Arch Ital Anat Embriol, 1979, lxxxiv(1):43-53; J.L. Pace and S. Ramaswamy: Skeletal Remains. Excavations at Hal Millieri, Malta: a report of the 1977 campaign conducted on behalf of the National Museum of Malta and the University of Malta. eds. T.F.C. Blagg, A. Bonanno, and A.T. Luttrell. University Press, Malta, 1990, p.84-95

9. P. Cassar: A Medico-legal report of the sixteenth century from Malta. Medical History, 1974, 18:354-359; P. Falcone: La nunziatura di Malta nell'Archivo Segreto della Santa Sede. Rome, 1936, p.59; P. Cassar: The Maltese Midwife in History. Midwives Assoc Malta, Malta, 1978, p.11; P. Cassar: Inventory of a sixteenth century pharmacy in Malta. St. Luke's Hospital Gazette, 1976, 11(1):26-34; S. Fiorini: op. cit. note 5