THE ST. IAUKE'S HOSPITAL GAZETTE

MALTA JUNE 1971 Vol. VI No. 1

Published for the Consultant Staff Comittee, St. Luke's Hospital, Malta, and the Medical and Dental Surgery Faculties of the Royal University of Malta. Editor: Dr. Emanuel Agius. Editorial Board: Dr. R. Attard, Prof. G. E. Camilleri, Dr. F. F. Fenech and Dr. L. Vassallo.

CONTENTS page Professor V. G. Griffiths is the presi­ M edical News 1 dent of the British Medical Association Medicine in Malta in 1800-1810 - P. Cassar ... 3 (Malta Branch) for this year, with Dr. R. Man's Erect Posture - J. L. Pace ... 21 L. Cheverton as Vice-President. Mr. J. L. A case of Ano-rectal Agenesis - C. J. Jaccarini, Pace of 50, St. Francis .itreet, Balzan has P. Vassallo Agius and R. Attard ... 26 once again accepted the duties of honorary Secretary and Treasurer. Hospital Mortality in Myocardial Infarction - F. F. Fenech ...... 31 The first meeting of the B.M.A. this year, on the 14th January, consisted of a Isolated Right Ventricular Hypoplasia with Atrial talk by Mr. Joseph Attard, newly returned Septal Defect - P. Vassallo-Agius 36 from England, on "Varicose Veins And Megaloblastic Anaemia due to Anticonvulsant Compression Sclerotherapy". This was Therapy - P. Mangion ... 43 followed by a film. Recurrent Tetanus - J. B. Pace and A. Busuttil 48 On the 28th January, Mr. J. V. Barber­ Some Aspects of Brucellosis - E. Agius and Lomax, one of our new residents, lectured Rosemary Pepper ... 53 on the "Historical collections of the Well­

Dr. C. De 'Lucca and his work as a Biologist - M. Gauci 56 come Institute" and also showed a large number of transparencies. Mr. Barber­ Retroperitoneal Tumours - J. Muscat and Marie Lomax, a qualified veterinarian, speaks Therese Podesta 59 with authority on "Wellcome" since he Emotional and Psychosomatic Disorders in General had been for many years the veterinary Practice - G. T. Fiorini . . 66 historian and the curator of the surgical Health Services in the U.s.s.R. - P. A. Fenech 73 instrument collection of the Institute. Moreover,it was through his great inte­ Medical News (cont.) 79 rest that the Well come foundation donated Publications List ... 80 to our Medical School a fine collection of Book Review 80 instruments of historical importance. 2

These have now been arranged in the bay On the 26th April, professor Diamant, on the top floor of the Medical School. Mr. of the University of Umea, Sweden, lec­ Barber-Lomax made the presentation of­ tured on "Modern Trends in Ear, Nose and ficially to Prof. V. G. Griffiths, deputising Throat Surgery". for the Dean of the Medical Faculty who Dr. H. B. Wright, the director of the was abroad. Our Medical School now has, London medical centre of the Institute of thanks to "Wellcome" and to Mr. Barber­ Directors lectured, on the 30th April on Lomax, the nucleus of a Museum of Medi­ "Automated Multiphasic Screening Cen­ cal History. tre". Since this was in the morning the At a Branch meeting on the 26th audience consisted mostly of medical March, a film entitled "Angiologia", pro­ students and at the end we noticed a look duced by the Firm Johann A. Wulfing of compounded of wonder and incredulity on Germany was shown. their faces, if our diagnosis was correct. On the 6th April, Dr. George Watkin­ We congratulate: son gave an address on "Some aspects of Dr. Frank Vella on his appointment Ulcerative Colitis". At another meeting as Professor in the Department of Bio­ on the 28th April, Dr. H. J. Barber, for­ chemistry at the University of Saskatche­ merly a Research Controller for May and wan, in Canada. Baker, spoke on "The Search for New Dr. Norman Griscti-Soler ('64) on his Drugs - Retrospect and Prospect". being awarded the Degree of Doctor of At a meeting on the 3rd May, Mr. Philosophy in Medicine by the University Harold Ludman an E.N.T. consultant at of Birmingham. the National Hospital, Queen Square and Dr. George Boffa ('60) on his being at King's College Hospital, London, spoke elected a Fellow of the Royal College of on "Neuro-Utology". Surgeons, in the Faculty of Anaesthesia; Under the auspices of "The Associa­ Dr. Francis Sammut ('62) on his at­ tion of Surgeons and Physicians of Malta". tainment of the Diploma in Ophthalmology Professor John Malins gave the Novo Lec­ (London) from Moorfields; ture on "Diabetes MeIlitus", on the 27th Professor Arthur P. Camilleri on his April. being invited to. serve as an external exa­ miner to the Royal CoHege of Obstetrics Professor Peter Curzen, of the West­ minster Medical School visited the Uni­ and Gynaecology. Dr. Edwin S. Grech ('55) on his elec­ versity between the 6th and the 13th tion to the Fellowship of the same College; March. He lectured on "The Immunolo­ Mr. Joseph Muscat ('49) on being gical Puzile of Pregnancy" on the 8th and appointed Senior Surgeon on the Consul­ on "Clinical Monitoring of the Foetus" on tant Staff of St. Luke's, with effect from the 10th. April 1968. Dr. N. F. C. GOWling of the depart­ Professor George Camilleri for whom ment of Morbid Anatomy at the Marsden wedding bells rang merrily on the 18th visited the Medical School at the invita­ April, when he married Miss Jo Ann Bon­ tion of the university, between the 17th nici at St. Ignatius Church in Sliema. and the 29th April. He lectured on the Baron Peter Rotschild M.D. and, a special pathology of the lymphoreticular little later, Professor Karl Ransberger system to medical students and took part lectured on aspects of Cancer research in a clinico-pathological conference, pre­ work, in February. senting three cases. As a member of the Mr. J.D. Morgan, principal lecturer council of the Royal Col'lege of Patholo­ in charge of City and Guilds Laboratory gists he also took the opportunity to meet Technicians Courses at Paddington Tech­ the members of the college in Malta. nical College, was in Malta for 6 days to Professor H. Lehmann of Cambridge, study and advise on the possibility of the weU known authority on the haemo­ starting such courses locally. globins, visited us and spoke on "Human Haemoglobin" on the 26th January. (continued on page 79) 3 MEDICINE IN MALTA IN 1800-1810 Contrasts, Concepts and Personalities

PAUL CASSAR S.B.ST.]., M.D., B.Sc., D.P.M., F.R.HrST.S.

Hon. Fellow of the Royal University of Malta, Consultant Psychiatrist Health Department, Teacher in Clinical Psychiatry Royal University of Malta

The British Medical Association (Mal­ shape. Its economic life was shattered, ta Branch) prize in the medical essay with impoverishment of the people. The competition for 1969 was awarded to Dr. organisation of the medical services that Paul Cassar for this paper. had evolved during the previous two cen­ turies was disrupted and replaced by The dawn of the 19th century stands makeshift hospital arrangements to meet out as a turning point in Maltese history the demand of the unexpected war crisis. -socially, politically, commercially and The period of readjustment that followed culturally. the end of the hostilities was long drawn In June 1798 there occurred an over­ out and difficult. night change from the centuries-old con­ The Royal Commissioner, Sir Charles servative and feudal government of the Cameron, who was charged with the ad­ Order of St. John of Jerusalem (1530- ministration of the Island was faced with 1798) to the short lived but hectic, liberal a daunting task. He was inundated with and egalitarian regime of the French under petitions for financial assistance from pri­ Napoleon (1798-1800). vate individuals and from public officials The Maltese masses were deeply to make good the losses they had suffered shaken as they were totally unprepared during the French occupation and to tide for this abrupt and radical transformation them over the hard times of the aftermath of their political, social and religious life of two years of war and destruction. which tore asunder their traditional atti­ tudes and beliefs. The reforms introduced The plight of medical men by the French, especially those touching the religious tenets of the Maltese, uproot­ The petitions submitted to Sir Charles ed the pattern of life of the people, ren­ Cameron included requests for the grant­ . dered the new masters unpopUlar and pro- ing of gratuities for dependents of de­ voked the islanders to rise in arms against ceased government employees; for re­ them. The outcome was two years of war, instatement to former medical posts disease and starvation and an invitation abolished by the French; for appointment from the Maltese to His Britannic Majes­ to vacant offices and for pensions follow­ ty George III to place the Island under ing retirement from the medical organisa­ his protection. Thus was ushered in the tion of the Order after many years service British period in our history (1800-1964). - even as long as fifty. There were also When the French finally capitulated requests for increases in stipends due to in September 1800 and Great Britain took the rise in the cost of living and for the over the civil and military administration removal of salary anomalies among the of Malta, the Island was in a very poor same category of medical men. Complaints 4

on this score were especially heard from rista manufactured the hernia trusses the medici dei poveri (literally "doctors under the direction of the Principal Sur­ for the poor") corresponding to the pre­ geon whom he accompanied in the ward sent District Medical Officers. rounds, morning and afternoon. He was Some of these physicians had left the always on call for any adjustment needed towns at the begining of the revolt against to the trusses of hospital patients. He was the French and joined the insurgents in paid six tari (one tari was equal to about the countryside to give their professional 1 td) for every truss - "as at the time services to the poor sick and the men of of the old government of the Order" - the Maltese battalions without receiving after the appliance was examined and ap­ any salary or any other kind of remune­ proved by the Principal Surgeon or his ration (Ordini e decreti, 1805). prattico (assistant). A case, representative of the situation At least two medical men suffered a at this period, is that of Dr. Angelo Pace demotion in their careers with the return who had entered the medical service of of peace. One of them was a Dr. Lorenzo the Order of St. John in 1760 as a medico Cassar. On the 9th September 1800 he was dei poveri for Floriana. He later joined appointed medico del palazzo (Palace Phy­ the navy as a medical officer, serving on sician) by Sir Alexander Ball in accord­ the frigates and the galleys, until he was ance with the usage that had prevailed reappointed medico dei poveri for Birgu at the time of the Order of St. John when where he remained for twenty-one years. the Grand Master, who lived at the Palace On the advent of the French in Malta his at Valletta, had his personal physician. post was suppressed and Dr. Pace threw On the 19th August 1801, however, Dr. in his lot with the insurgents and settled Cassar's post was abolished by H.E. Sir at Mdina where he cared for the orphans Charles Cameron. The other was the sur­ received into the Seminary and treated geon Antonio Cutajar of Bormla who had the sick admitted to the emergency hos­ been licensed to practise as a physician pital set up in the Church of St. Sebastian by the Medical College during the French and its adjoining house at Rabat during blockade because all the doctors had left the fever epidemic of 1800. In December that town to join the insurgents in the of this year, on the return of peace, he countryside. In November 1801 his war­ was reinstated as medico dei poveri at rant to practise medicine was withdrawn Birgu but he was not paid a salary until as in the opinion of the protomedico a year later (Ordini e decreti, 1805b). (Chief Government Medical Officer), Luigi Another instance is furnished by the Caruana, the three physicians who by then petition of Giuseppe Stivala "first phar­ had returned to practise in Bormla were macy assistant" at the Civil Hospital for sufficient to meet the needs of the inha­ men at Valletta. "At the opening of the bitants (Ordini e decreti, 1805c). gates" of Valletta. i.e. on the capitulation of the French forces blockaded inside the Decline of Hospitals fortifications of Valletta and the other towns round the Grand Harbour, the hos­ Frantic appeals for financial help pital pharmacy was completely devoid of came from the administrators of various drugs and the administrator of the hos­ hospitals as their bequests and revenues pital instructed Stivala to supply the phar­ could no longer be counted upon to pro­ macy with the necessary medicaments vide sufficient income for their mainten­ which he did "with zeal and exactitude" ance. and at his own expense and without re­ In September 1801 Dr. Gregorio Ba­ ceiving any emoluments for his work for jada, the economo (treasurer) of St. John five months. Hospital for men at Gozo, remarked on A further plea for payment came the financial losses suffered by the hos­ from the bragherista of the same hospital, pital and the insufficiency of its funds to Giuseppe Spiteri, who held the licence of meet current expenditure; on the need for barberotto (barber-surgeon). The braghe- the replacement of the beds, planks, linen 5 and other items of equipment which had the Municipality of Mdina as this body been carried away by the French. MonGY was burdened with the expense of repair­ was also required to pay for the medica­ ing the road leading to Valletta and the ments supplied to the hospital by the phar­ conduits that drained away the waters macist Orazio Aquilina. In short the hos­ that would otherwise have accumulated pital "had been reduced to such misery in the valley round Mdina (Ordini e de­ that even the issue of the little quantity creti, 1B05d). of wine which is often necessary for the In Valletta the erstwhile Holy Infir­ sick has had to be suspended". Dr. Bajada mary of the Knights of St. John was turn­ had become so disheartened by these ed into a military hospital by the French. shortages that "a thousand times" he had Under British rule the Infirmary conti­ considered giving up his post because of nued to be used for the treatment and care the difficulties he was encountering in of sick troops. At first it received sick sol­ making good the deficiencies of his hos­ diers from Egypt and from units of the pital. British Army in Italy under Sir James On the 20th July 1B02 it was the turn Craig. It was later (lB05-B) reduced to a of the Procurator of St. Joseph Hospital regimental hospital and to a deposit of at Zebbug, Malta, to complain. During the hospital stores, the rest of the building revolt of the Maltese the hospital "had remaining unused (Domeier, 1BlO). been obliged to admit and treat all the On the conversion of the Infirmary sick and wounded that were brought to into a military hospital, the male civilian it in great numbers". Mattresses and sheets patients were transferred to the nearby had been consumed; debts had been con­ nunnery and church of Mary Magdalen tracted for the maintence of the patients which came to be known as the Civil and no funds were to hand to replace its Hospital for men. In 1B02 this institution equipment. and the Women's Hospital, that dated The jurats of Mdina, who were res­ since the seventeenth century, were re­ ponsible for the administration of the organised and detailed rules and regula­ Hospital of the Holy Spirit at Rabat, tions were published for their better run­ Malta, wrote on the 12th February 1B02 ning (Piano per il regolamento dell'Ospe­ that at the time of the insurrection so dale di Malta, 1B02a). many patients had been received "that When Samuel Taylor Coleridge visit­ even the church was full of beds". All the ed the Civil Hospital during his stay in linen and clothing had been depleted Malta (lB04-5) he was struck by the pre­ having either been consumed for the use sence of a child of twelve years lying in of the patients or been requisitioned by the same bed with a man of seventy years the French troops of Mdina. It was in need in the Venereal Wards and also by the of one hundred sheets and pillows, fifty great number of holy images hanging on palliasses and twenty-five mattresses, the walls in "every staircase, by every twenty-five "white blankets for summer" bedside, in every chamber" (Coburn and thirty woollen blankets. The hospital 1962a). A British Army doctor of the time, had lost "almost all its silverware - in­ Dr. WiIliam Domeier, is more informative cluding thirty-eight bowls, twelve plates about this hospital which had to cater for and other utensils" - which had to be a population of 94,000 souls (Malta and disposed of to help finance the war effort. Gozo). It had to borrow money to buy the medi­ The set up of the hospital came under caments and pay for the maintence of the the censure of Domeier who found it ill­ sick but, what was worse, it had not re­ adapted as a healing establishment. In ceived any interests on the capital invest­ accordance with the ideas held by a sec­ ed with the bank of the MuniCipality of tion of the profession at that time, the Valletta. In fact it had been reduced to windows were kept closed to exclude such straits that it was no longer in a fresh air in the belief that air was harm­ position to admit the usual number of ful for surgical patients. Thus surgeons patients. No funds could be obtained from had to dress the sick by candle light even 6 at two o'clock in the afternnon in summer. A naval hospital was established in The professional staff consisted of 1800 in the former Armoury of the Knights four physicians and four surgeons work­ of St. John at Birgu in Strada Dietro il ing on a monthly roster. This system had Quartiere. There is no doubt, however, the disadvantage that patients entering that seamen of the Royal Navy were also the wards in the last days of the month, received into the Military General Hos­ passed, after a few days, into the care of pital at Valletta. In fact on the 19th August a different physician who often altered 1803 sick crew on H.M.S. Madras, who the whole plan of treatment. It also af­ were suffering from "infectious or inflam­ lorded occasion for rivalry among the matory fevers" were ordered by Lord Nel­ physicians and surgeons who, we are told, son to be admitted to the General Military endeavoured "to acquire practice by con­ Hospital by arrangement with Major Ge­ tradicting and blaming one another and neral Villettes, the Officer Commanding acting otherwise than their colleagues the Troops in Malta. though no better". Nelson felt that if Britain was to keep The rest of the professional staff con­ Malta, the Admiralty had to provide "a sisted of four assistant physicians and four proper naval hospital". He again returned assistant surgeons; an apothecary, a num­ to the subject on the 7th November 1803 ber of dressers and a "person who only as he did not wish "to have thrown the bleeds and cups, even one person who trouble of attending our seamen on the carries smelling bottles at the medical medical skill of the Army"; so much so visits for fear that anybody might faint that he sent Dr. John Snipe, Physician to away - and really the atmosphere is, in the Fleet, to Malta to inspect Villa Bichi some wards, in such a state that the fear with the view of establishing there a naval is not ill founded". Conditions in the hospital. Following Dr. Snipe's visit, Nel­ Women's Hospital were no better. son declared on the 20th December 1803 Commenting on the results of the that Bichi was "the fittest situation at methods of treatment employed at that Malta for a naval hospital". time in these establishments, Domeier In the meantime seamen continued to makes an observation that still holds good be treated in the Military Hospital under today anywhere in the world: "It is a ne­ the Naval Surgeon, Mr John Gray, until cessary· distinction to be' made, whether they were removed to the erstwhile Slave a patient recovers through the remedy he Prison in Strada San Cristoforo (St. Chris­ has taken or only during the time he takes top her Street), Valletta. The date of the a remedy which is not efficacious enough transfer may have been the 1st January to prevent his recovery. Physicians are 1805 as on this day sick naval personnel often too much honoured as in both cases ceased to be admitted into the Military the recovery is attributed to their skill". Hospital (Nicolas, 1845). In May 1804 Lord Nelson was again British Naval Medicine pressing for the acquisition and enlarge­ ment of Villa Bichi and its conversion into Malta's connexion with the British a naval hospital (Nicolas, 1846) but no Crown eventually led to the growth of steps were taken for many years after­ the Island into one of the most formidable wards; on the contrary, sick seamen were naval bases of the Mediterranean. This re-transferred across the Grand Harbour development not only determined the po­ to the Armoury at Birgu in 1819. litical orientation in world affairs and the Dr. J. Hennen, Inspector of Military economic pattern of the Island but also Hospitals (1821-25), describes the place as brought Maltese medicine, for the first being "an airy building ... well adapted to time in our history, in close touch with its purpose". It was capable of accom­ British medical thought and practice. At modating about one hundred and twenty this period this influence was exerted patients but in an emergency there was mainly by the medical personnel of the enough room for eighty or one hund­ navy. red or more men. In wartime all its beds 7 were occupied but in peacetime the num­ Fever was towards the end of the decade ber of patients rarely exceeded twenty supplanting the local nomenclature as a (Hennen, 1830a). more appropriate appellation. From 1804 to 1827 the hospital was At a time when the physician lacked under the direction of Dr. John Allen the refined diagnostic aids of to-day and R.N., the Principal Medical Officer. Be had nothing to go by except the subjective had been appointed surgeon to the Navy complaints of the patient, his skill as an in 1784, served under Lord Nelson and observer and his own personal experience, was superannuated in 1827. He died in it is not surprising to find that there were Malta on the 14th January 1849 at ninety­ great differences of opinion among medical four years of age, and was buried in the men with regard to the nature and aetio­ Msida Bastion Cemetery. logy of these fevers and the criteria to be J ohu AlIen was renowned for his followed in their prevention and treat­ treatment of gun shot wounds. It has ment. been sai d of him that his dexterity "in Among the physicians who at­ using his knife was equalled by, what is tempted to elucidate these problems was of equal importance, his knowledge of William Burnett - one of the first of a discerning when not to use it". He also long line of British naval doctors to worY enjoyed a good reputation for his treat­ in Malta. He was Physician and Inspec­ ment of fevers in whiCh he resorted to tor of Hospitals to His Majesty's Fleet in the lancet, "that minute instrument of the Mediterranean and Honorary Fellow mighty mischief", very sparingly (Malta of the Imperial Medico-Chirurgical Aca­ Times, 1849) demy of St. Petersburg (Burnett, 1816 a). Sick seamen of the Royal Navy con­ In May 1810 he was appointed Physician tinued to be cared for at the Birgu Ar­ to the Mediterranean Fleet which post he moury until 1832 when Villa Bichi was relinquished in October 1813 because of finally opened as an ad hoc naval hospital ill health. (Cassar, 1965a). His accounts of these fevers abound in clinical histories and reports of post­ Fevers mortem examinations. The medical know­ ledge of the time, however, was still too A survey of the diseases with which ,meagre to allow him to understand thE' naval surgeons of the British Mediterra­ aetiological factors involved arid to dif·· nean Fleet had to deal in the first decade ferentiate among the various specific of the nineteenth century reveals that pathological conditions masquerading scurvy had become almost unknown under the common phenomenon of fever among sailors thanks to the "excellent and to prescribe a rational method of regulations and unceasing care of the management and therapy. Commander-in-Chief in providing liberal Burnett's first encounter with thE' supplies of fresh meat, vegetables and fevers of Malta occurred in May 1799 lemon juice". Pneumonia and dysentery when units of the British navy came to were endemic but "fever epidemics" the aid of the Maltese to blockade from constituted the most frequent and most the sea the French troops that had been serious conditions that afflicted seamen penned by the Maltese insurgents inside and civilians alike in the British naval the fortifications around the Grand Har­ stations of Malta, Gibraltar, Port Mahon bour. He was then serving in the Goliath (Minorca) and Carthagena. when the ships company was attacked by These fevers appeared especially to­ a fever "similar to one then prevalent in wards the close of summer (end of June the Island". The Goliath's boats had been and beginning of July) and during autumn. employed in watering at Marsascala, 8. They were known by the name of the small harbour to the south east of Vallet­ place where they prevailed such as Car­ ta, when on account of a strong wind the thagena or Gibraltar Fever, etc., although boat's crew had to remain ashore all night. the more generic name of Mediterranean A few days later several of the men feH 8 ill with fever which eventually spread to lower limbs. In 1812, between the 1st some forty of the ship's company. The April and the 23rd May, one hundred and most prominent disturbances were nausea fifty-three men from the Victorious and and vomiting, headache, thirst and deli­ the Trident were treated at the naval rium; in two or three instances the paro­ hospital for fever with eight fatalities. tid glands suppurated. The ship proceded Burnett has recorded the symtomato­ north to St. Paul's Bay and the sick were logy of the then so-called "bilious remit­ landed and placed "in a large castle ... tent fever". His account of it is given in where the whole recovered". such terms as to enable the medical prac­ In the summer of 1800, Burnett titioner of to-day to pick Olit in it m.ost of joined the Maltese built ship Athenian. the clinical features of brucellosis (Report While she was being careened and fitted of the Committee ... for the Suppression at the Malta Dockyard there were many of Mediterranean Fever, 1909). Burnett cases of fever which Burnett was inclined has the merit, therefore, of being the first to ascribe to the crew's exposure to the investigator to record the clinical picture sun; however, "by a proper use of the of brucellosis or undulant fever. As lancet in the early stages joined to pur­ Burnett's book is not now readily avail­ gation, they all speedily recovered; none able it is worthwhile reproducing his died nor was one sent to the hospital description at length as it is of paramount during two years" that Burnett was sur­ importance in the history of human bru­ geon on that ship which "always continued cellosis. remarkably healthy". "The patient", writes Burnett, "com­ In October 1810, as Physician to the plains· of considerable headache with Mediterranean Fleet, he was sent by the nausea and prostration of strength; the Commander-in-Chief to Sicily and to Mal­ eyes are somewhat suffused and the ta to examine the state of health of His countenance a little flushed; the tongue Majesty's ships and the running of the is white and moist with considerable hospitals ashore. He found that the men thirst; the skin is at times moist and the of the Eagle had been quartered in a bar­ temperature but little increased; at other rack while the ship was careening. "They times it is dry and the heat pungent. The had easy access to spirits and wine", he pulse is in some cases full and strong recorded, "and committed the usual ex­ beating at the rate of 120 in the minute; cesses of sailors when on shore. The in others it is less so and in some the in­ effects of this were soon visible for about crease in velocity is scarcely perceptible; the middle of December a fever made its there is commonly constipation of the appearance amongst them and ultimately bowels and loss of appetite". This is the extended to nearly sixty of her men. The symptomatology in the type of fever which surgeon considered it at first to be purely appeared in summer. of a typhoid nature". They were admitted A more severe form occurred in the to the naval hospital where they all re­ autumn. "The patient feels a degree of covered thanks to the use of early and re­ lassitude and prostration of strength (in peated bleedings, purgation and epigast­ some the latter symptom appears very ric blistering. considerable); this is succeeded by a sense The frigate Alceste and the sloop of chillines extending along the spine and Scout also had many of their men down lumbar region which is followed by in­ with fever, involvement of the abdominal creased heat and severe headache, re­ viscera and frequent stools but they, too, ferred chiefly by the patient to the fore­ did well on the same regimen. head and temples; and in the severer cases In June 1811 it was the turn of the it extends in the course of the longitudinal men of the Pomone and the Weazle to sinus. A deep seated pain in the orbit is suffer from "the bilious and yellow fever also experienced; the eyes are sometimes of the Island" characterised by a deep unnaturally prominent with a watery in­ yellow suffusion of the skin, vomiting, flammatory appearance and impatience of pain in the epigastric region, loins and light ... There is a sense of uneasiness in 9 the epigastric region with nausea and, in tention - temperature and pulse varia-. some patients, a vomiting of a matter re­ tions, headache, pains behind the eyes, sembling bile; pains in the joints, back, profuse sweating, subicteric tinge, epi­ calves of the legs, disturbed sleep and gastric discomfort, vomiting, constipation, constipation of the bowels are amongst rheumatic pains and "typhoidal" state in the symptoms usually observed. The the more severe cases. However there is pulse for the most part is full and hard, no mention of the physical signs of the though not always, particularly when the disease, elicited by what to-day would be gastric symptoms are severe... There is the commonplace method of palpation, generally a throbbing of the carotid and such as the enlarged and tender spleen and temporal arteries with great thirst and liver; but he . refers to the lung involve­ considerable anxiety. The superior parts ment and in fact he did observe, in some of the body are sometimes covered with of the post-mortem examinations he per­ a profuse perspiration but generally the formed, the "lungs inflamed with effu­ skin is dry... If the disease be advanced sion", "adhesions to the pleura", enlarged the heat is often pungent and there is liver and, on one occasion, "spleen rather through its whole course a loathing of large" (Bumett, 1816 b). food. Severe rigors, sometimes, but not Cases of fevers of various descrip­ very commonly, precede the hot stage of tions remained the bugbear of the physi­ the disease. When the attack is violent. .. cian for a very long time. One sixth of the headache is still severe but accom­ all admissions to the military hospitals panied by stupor, disinclination to answer from 1816 to 1823 were fever cases with questions and indifference to surrounding a mortality of one in forty-five. The most objects: the eyes have... a slight yellow­ frequent was the "common continued ness; the tongue is now covered with a fever" which included the "idiopathic" or thick yelow coat or is brown and dry in "summer fever". This was so called be­ the middle, the edges having a red inflam­ cause it made its appearance with the on­ matory appearance; the prostration of set of hot weather (July to September) strength is considerable; the anxiety and and subsided as the heat diminished. It pain in the limbs greater; the uneasiness was marked by severe headache, suffused in the epigastric region is urgent; and eyes, acute pains in the chest, tenderness there is frequent vomiting of a matter re­ in the upper abdomen and bilious vomit­ sembling bile and most harassing singul­ ing. It lasted six days. tus; the pulse under these circumstances Among the civilian population fever is commonly much smaller varying from cases also formed a good proportion of 100 to 120 and often is more frequent. admissions into the Civil Hospital con­ The skin is at time moist or there are stituting one-seventh of all admissions in partial sweats and commonly a dis­ 1821-23 (1300 out of 8736) while among agreeable faector is exhaled from the per­ those treated at home deaths from fever son or linen of the patient ... There is oc­ bore to deaths for all other diseases the casionally considerable delirium which proportion of one to ten, the villages of commonly terminates in a state of coma" Mosta and Naxxar being the most heavily and death. "The train of symptoms which hit by this mortality (Hennen, 1830 b). have been first enumerated will not al­ ways be observed in the same patient... Aetiological theories In the winter months this disease is often accompanied by severe and evident inflam­ The influence of offensive exhalations mation of the lungs. In the summer and or miasma arising from marshy grounds autumn slighter affections of the lungs was invoked to explain certain outbreaks are occasionally observed but the patient of fevers in Port Mahon and in Malta. seldom complains of Ithis unless when With regard to Malta, an extensive marsh asked". did exist at the Marsa or upper part of None of the cardinal symptoms G; the harbour during the previoU3 centuries undulant fever has escaped Burnett's at- at the time of the Order of St. John; so 10 much so that the inhabitants of the near­ epidemiological ideas concerning the na­ by Casal Nuovo (Rahal Gdid, literally ture of the various fevers of the Mediter­ "New Village") had been obliged to aban­ ranean was Dr. (later Sir) William Pym don the village on account of the unheal­ (1772-1861). Pym had studied medicine at thiness of the area. At the beginning of Edinburgh University and, after a brief the 19th century this marshland was al­ period in the navy, had joined the army. most completely drained during the In 1794 he was in the West Indies where government of Sir Alexander Ball but he became familiar with the manifestations apart from distilleries established there of yellow fever during an outbreak in Mar­ by British merchants the Marsa was still tinique (1794-96) when 16,000 troops died deserted. of the disease. He then served in Sicily Sir William Burnett wrote that it had (about 1806), Malta and Gibraltar. Here been observed that ships fitting at the he was Superintendent of Quarantine at dockyard in the Marsa part of the harbour a time when it was suspected that yellow "are more subject to attacks of fever than fever had gained a foothold from Cadiz those lying out at their anchors; and in and Malaga. In 1811 he was back in Malta moving a ship, where it was prevalent, as President of the Board of Health. He into Bighi Bay (Le. near the mouth of the went to England the following year but harbour) the disease has uniformly volunteered to return to Malta in 1813 ceased". It is not unlikely that the crews when plague broke out in the Island. In of these ships were victims of malaria. 1815 he published the Observations upon In fact it was discovered, very much Bulam Fever which has been acclaimed later, that mosquitoes of the genus Ano­ as the first clear account of the disease pheles occurred in Malta and it is prob­ also known as yellow fever. He died on able that when affected ships were moved the 18th March 1861 (Dktionary of Na­ out of the range of flight of the insects tional Biography, 1896; Hennen 1830c). no further cases appeared. Pym favoured the adoption of qua­ Apart from the factor of terrain, it rantine measures while Burnett held the was also believed that attacks of fever view that the fevers of the Mediterranean were precipitated by such "exciting were "non-contagious" and that, therefore, causes" as intemperance in the use of wine quarantine could not prevent their disse­ and spirits, exposure to the sun and to mination. This provoked a reproach from night dews. Pym who, referring to Burnett's publica­ Controversies as to whether these tion, stated that "there never was a book fevers were of a "contagious" or "infec­ had a more mischievious tendency". tious" character were rife. "Contagious" Subsequent medical investigations, how­ diseases were those believed to be caught ever, proved that Burnett was right. by contact; "infectious" illnesses were those communicated by the atmosphere. Treatment Apart from the personal animosities with which they were conducted, these disputes Therapy consisted in bleeding, blis­ had practical implications of a social and tering, purgation, oral medication and economic kind. If these fevers were de­ "antiphlogistic" measures. clared "contagious", quarantine measures Bleeding was resorted to for lower­ were imposed with such attendant hard­ ing the temperature, relieving the head­ ships as isolation of patients and contacts, aches and promoting sleep. Great reliance the burning of their bedding and furniture was placed on early and liberal blood­ and the suspension of social and com­ letting. Sometimes as much as ninety mercial communications. If, on the other ounces of blood were removed over a pe­ hand, they were "non-contagious", qua­ riod of six hours with the recovery of the rantine restrictions with their irksome patient; occasionally up to two hundred consequences to the individual and the ounces were taken with "the most mark­ community were not enforced. ed advantage"; more commonly bleeding Among the opponents of Burnett's was repeated hourly with the removal of 11 thirty to forty ounces each time. The ope­ Rev. William Pargeter ration was sometimes followed by syn­ cope. The surgeon, therefore, kept a watch Another British physician flits across on the patient's pulse and 'when' this the medical stage in the very early years showed signs of sinking the bleeding was of the century in the guise of a clergy­ stopped. man. This elusive figure was Dr. WiIliam Burnett was enthusiastic about the Pargeter (1760-1810). He studied at St. beneficial results of bleeding which far Bartholomew's Hospital and graduated from "inducing extraordinary debility and M.D. from Marischal College, Aberdeen in a protracted convalescence" produced a 1786. In 1795 he abandoned medicine for "speedy restoration to perfect health". the church and entered the Royal Navy The patients themselves, far from resent­ as a chaplain. He was at the Battle of the ing it, asked for it! Burnett states that Nile on the Alexander (1798) and subse­ many of the patients felt its beneficial quently served in Malta as Chaplain of effects while the blood was flowing and the Garrison. In 1801, on the occasion of quotes one such patient as saying: "Sir, the burial in Malta of Sir Ralph Abercrom­ I am as strong as ever; I am quite well; I bie, Commander-in-Chief of the British feel the pain running out with the blood". Forces in the Mediterranean, Pargeter de­ Burnett continues: "So sensible were they livered the funeral oration at the Protes­ of this that on a recurrence of the head­ tant Chapel of Valletta. He extolled the ache they directly sent for the assistant military greatness and the "private vir­ surgeon to have more blood taken from tues" of Abercrombie and the "noble ex­ them". ploits" of the British Army in Egypt; re­ When less profuse bleeding was de­ minded his listeners of the uncertainty and sired, leeches were employed. From three transitoriness of human life and exhorted to twelve of them were applied to the them "to put on the whole armour of God" temples in severe headache or to the epi­ to ensure their triumph over death. Par­ gastric region when gastric symptoms geter retired from the navy in 1802 and were troublesome. To ensure a continuous died in Oxfordshire in 1810 (Hunter & flow of blood, a cupping glass was applied Macalpine, 1963 and 1965; Leigh, 1961). over the orifices made by the leeches by Pargeter is one of the early British which means up to twelve ounces of blood psychiatrists of the modern era and the could be procured. first British psychiatrist to come to Malta. Blistering was attended "with great We do not know, however, whether he success". Favourite plasters were empla­ took any interest in the medical affairs of strum epispasticum, emplastrum cantha­ the Island and particularly in the manage­ ridis and emplastra vesicatoria. They were ment of the insane. In his time the men­ applied to the region of the stomach, be­ tally sick were kept in the basement of tween the scapulae, on the temples, on the the Civil Hospital at Valletta where Par­ forehead and on the nape of the neck. geter must have gone pretty frequently to Great store was laid on brisk purgation, minister to sick troops. Did Pargeter ever sometimes aided by clysters for which visit this basement in the Civil Hospital Pu!v, Jalap cum submurias hydrarg, was where the more dangerous patients were prescribed. Hardly any faith was placed chained to the wall? If he did he would on drugs. Peruvian bark, antimonial pow­ not have been scandalised by this scene der, emetics and sudorifics were consi­ as the same conditions prevailed in Eng­ dered to be ineffective by some physicians land where not even very highly placed or decidedly harmful by others. The "anti­ personages were spared rough handling. phlogistic regimen" consisted in giving The case of King George Ill, the first Bri­ the patient tepid or cold baths; in spong­ tish monarch to rule over the Maltese ing his body; in the use of as few bed­ Islands, is notorious. He suffered from re­ clothes as possible to cover him; and in current attacks of mental disorder and prescribing pediluvium (footbath) to sooth was severely treated and even knocked the pains of the lower limbs. down during his long illness. 12

Pargeter was one of the early reform­ crombie (20th/21st December 1800). Dr. ers of management of the insane in Eng­ Marshall remained in the Island to enable land. In 1792 he published the Observa­ the inhabitants to avail themselves of the tions on Maniacal Disorders in which he occasion to vaccinate their children. An showed that the physical restraint of men­ Italian translation of Jenner's A Continua­ tal patients, then in common use, was un­ tion of Facts and Observations was pub­ necessary. He stressed the importance of lished in Malta, probably as a form of rapport between the physician and the health propaganda, and a number of child­ mentally sick as a salutary influence in ren were inoculated in the presence of tranquillizing patients and leading them Dr. Luigi Caruana, the protomedico or towards recovery. This was the emergent Chief Government Medical Officer, and Dr. idea that gave rise to the so-called "moral Lorenzo Cassar, the Palace Physician and treatment or management" of the insane Principal Physician of the Civil Hospital. which pervaded psychiatric therapy dur­ The experiment was a success and from ing the rest of the 19th century. then onwards vaccination against small­ Conditions in England began to im­ pox became standard public health prac­ prove in 1827 when two acts of parliament tice in the Maltese Islands (Bellet, 1801; provided "asylums" and regulated the care Cassar, 1965b and 1969). of "pauper and criminal" mental patients Dr. Walker was present at the battle (Hodgkinson, 1966). In Malta the humane in which Sir Ralph Abercrombie was fa­ treatment of the insane was ushered in tally wounded. He returned to England in ten years later when Dr. Thomas Chetcuti, 1802 and was made resident vaccinator the pioneer Maltese psychiatrist, set pa­ of the Royal Jenner,ian Society. A breach tients free from their chains and abolish­ between him and Jenner led to his resi­ ed the use of the stick to subdue excited gnation from the Society in 1806 but he patients (1838) (Cassar, 1949). continued to vaccinate until his death in 1830. Dr. Marshall was later appointed Vaccination Physician Extraordinary to George In (Fisk, 1959). Two other British physicians - Dr. Joseph Marshall and Dr. John Walker - Maltese Civilian Practice passed through Malta in the very early years of the century. It is very likely that Glimpses of the state of Maltese civi­ they met Pargeter but, in contrast to him, lian medical practice at this period may they have left an indelible mark on Mal­ be gleaned from Dr. William Domeier's tese medical history. Observation on the Climate, Manners and Not long after Edward Jenner dis­ Amusements of Malta published in London covered vaccination against smallpox in in 1810. Dr. Domeier (1763-1815) spent a 1798, the British Govemment took steps few years in the Island in the medical ser­ to introduce it to its naval and military vice of the British Army as Physician to forces and its possessions overseas. Malta Foreign Troops, probably from 1805 to was thus one of the first territories to be­ 1808 (Almanacco. 1807). He was a Ger­ nefit from this policy. man from Hanover who graduated doctor In the early days of July 1800 Dr. J. of Medicine in 1784 at the University of Marshall and Dr. J. Walker left England Gottingen. After his turn of duty in Malta for the Mediterranean. Both of them were he was admitted a Licentiate of the Col­ friends of Jenner and had obtained the lege of Physicians of London (1809) where vaccine lymph from him. When they he settled. He died in 1815 (Munk, 1878). reached Malta smallpox had broken out He was favourably struck by the mild in the fleet and Sir Alexander Ball order­ climate and the satisfactory state of the ed all men in the squadron based on Malta public health of the Island so much so that to be vaccinated. he considered it eminently suitable as a Dr. Walker eventually departed for resort for invalids and convalescents such Egypt with the fleet under Sir Ralph Aber- as those suffering from consumption, 13 dropsy, rheumatism and chronic dysente­ ophthalmology as well as "experiments in ry. He found the Island to be free of the philosophy" . "yellow fever of the West Indies and Naudi resigned the professorship in North America", of the "malignant inter­ 1834 and died three years later in his 57th mittent fever" of Italy and of the ophthal­ year "in consequence of the exertions mia and elephantiasis of Egypt. The only made by him in attending patients" dur­ epidemic that occurred during his resi­ ing the cholera epidemic of 1837 (Des­ dence here was one of smallpox which, patches 1836-37; Malta Government Ga­ however, was easily checked by a general zette 1837). inoculation with the vaccine. Another "man of talents" was Dr. Domeier was rather critical of local Luigi Caruana, Chief Government Medi­ professional standards. In his opinion the cal Officer, who was in charge of the Laz­ best Maltese physician was Dr. Cleardo zarett and the "Medical Police" but who Naudi from Axiaq (1780-1837). Naudi was spoke no English and only "very broken "acquainted with literature and a friend French". of natural history" and, what was rare in The practitioner with the widest those days, had a good command of the practice was Dr. Francesco Leone Grava­ English language. In fact he translated gna, one of the physicians on the staff of several religious and biblical writings for the Civil Hospital. He was a "reasonab18 the Wesleyan Missionary Society from good man". He later became Chief Gov­ English into Maltese (Cremona, 1940). ernment Medical Officer and a member of From 1801 he studied physics and mathe­ the Council of Health. He was carried off matics at the Malta University (Acta, by the plague of 1813 (Henner 1830d). 1800-32a). When the Chair of Experimen­ Domeier found that Maltese surgeons tal Chemistry and Natural History was were chary of performing serious opera­ instituted in June 1805, Naudi was chosen tions and only undertook to carry out to fill the post (1805-34). bleeding, cupping and blistering. Dr. Giu­ seppe Speranza, however, was "the best In October 1806 he delivered an ora­ of them". There were no dentists. tion in Italian at the Church of the Uni­ PharmaCists, too, received Domeier's versity on the occasion of the opening of strictures as they had "little knowledge the academic year. He reviewed the ori­ of chemistry, pharmacy, botany and mi­ gins and gradual growth of various neralogy". There was only one English branches of science including astronomy, chemist's shop but even this was "far navigation, physics, chemistry and medi­ from being perfect as it was run by two cine from the earliest times to the dawn army surgeons who, besides selling me­ of the nineteenth century; and records the dicines at a high price, generally under­ foundation of a "school of practical che­ stood little of pharmacy". There were mistry" and of a Botanic Garden with spe­ other army surgeons of whom some did cimens from "the four quarters of the midwifery such as Mr. Iliff, the hospital world" for the use of the medical students mate, who had the largest practice in this of the Malta University (Naudi, 1806). line. Some years after Domeier left the Island, Naudi was sent to London by the Public Medical Controversies Government (April 1812) "for the purpose of making himself better acquainted with A feature of the medical world of the regulations of the schools of medicine those days were the medical disputes in in that country and of the hospitals." He which members of the profession publicly stayed there for twenty-one months at­ engaged with one another in print - dis­ tending lectures in medicine, surgery and putes which were often spiced by person­ chemistry at St. Thomas's and Guy's Hos­ al rebukes and coloured with bitter words. pitals; a course of comparative anatomy An instance of such a controversy among and of botany at Brook's Museum; and Maltese physicians is furnished by the courses in midwifery, dentistry and polemiC on the Brunonian System between 14

Dr. Lorenzo Cassar and Dr. Gio Batta to be an admirer of William Cull en Saydon . (1710-90) and of Thomas Sydenham In 1780 John Brown (1735-1788) of (1624-89), "luminaries of the English Me­ Scotland propounded a medical theory in dical Faculty" (Guthrie, 1947). his Elementa Medicinae according to Dr. Gio Batta Saydon, born in 1773, which disease was the result of either too studied medicine at the University of Sa­ much stimulation or lack of it, especially lerno. During the insurrection of the Mal­ the latter. He, therefore, classified all dis­ tese against the French he attended the eases into sthenic or asthenic and the members of the Zurrieq battalion free of treatment consisted of giving stimulating charge. In 1801 he was medico dei poveri drugs in large doses. The theory caused at Bormla and during the plague of a stir in the United Kingdom, Germany, 1813-14 was made Principal Physician of France and Italy. It found adherents and the emergency hospital set up in Villa opponents also in Malta where a polemic Bichi for the plague stricken. dragged on for a number of years between It has been claimed that he was the the two physicians already mentioned. first doctor in Malta to recognise hydro­ After studying philosophy and the phobia. He wrote a Relazione dell'idrofo­ "medical institutions" (istituzioni medi­ bia accaduta in Malta l'anno 1809 (Report che) for two years in Malta, Dr. Cassar on Hydrophobia as it occurred in Malta continued his studies at Naples University. in the year 1809) which remained in ma­ He did his clinical practice at the Spedale nuscript form and has been lost. He treat­ degli incurabili and at the end of a course ed the sick during the smallpox epidemic of three years obtained the doctorate of of 1830 and the cholera outbreak of 1837. medicine of the University of Salerno in He died on the 1st October 1841. 1789. He specialised in teaching "the Saydon was a strenuous exponent of mutes to soeak" and after practising at Brown's theory which he defended against the Holy Infirmary of Valletta was grant­ the criticism of Cassar in a pamphlet en­ ed the warrant to practice in September titled Il sistema di Brown difeso da varie 1790 (Archives 1196.RML). On the 9th imputazioni e calunnie del Dr. Lorenzo September 1800 he was nominated Palace Cassar (Brown's System defended against Physician by Sir Alexander Ball and by the various accusations and calumnies of the beginning of 1802 he had become Dr. Lorenzo Cassar) published in Messi­ Princioal Physician of the Civil Hospital na in 1808. As in other such doctrinal dis­ of Valletta. putes of those days, Saydon's rejoinder In the same year he wrote a paper, does not go beyond abstract arguments in which he criticised and opposed the and persona! reproaches directed against Brunonian System as John Brown's medi­ Cassar who maintained that clinical ex­ cal ideas came to be called. He read it at perience coupled with the understanding a "solemn literary public meeting held in of the nature of disease constitute "the the Great Hall of the Maltese Hospital in true system, the most reliable guide and the presence of H.E. the Royal Commis­ the true mariner's compass of the prudent sioner.Sir Charles Cameron, on the 10th physician in traversing the stormy ocean June 1802". Among the audience were the of medical practice" (Il Globo 1841; Mif­ Presidents, professors and colleagues. It sud Bonnici, 1962). However, in spite of was later published in pamphlet form in Cassar's condemnation of Brown's theory, 1802 and again in 1808 (Cassar, 1802). Brunonian medicine had not yet disap­ He exposed the "errors and irration­ peared from Malta twenty years later ality" of the Brunonian concepts and pro­ (Hennen, 1830e). fessed himself a follower of the "vener­ able ancjent Hippocrates and his. succes­ Academic standards sors" whose teaching was the ",genuine result of experience and not of selfishness Domeier found that the teaching staff and bizarrerie" as happens with propoun­ of the Medical Faculty of the University ders of "systems". He declared himself consisted of only one lecturer - Dr. Lu- 15 dovico Abela - who taught all subjects The new garden was set up at Floria­ for two hours a day. To understand how na adjacent to Sarria Church on the site the University had been reduced to such of the present Government Elementary a state it must be borne in mind that Na­ School. In 1806 was published the first poleon had suppressed the University in catalogue of plants under the name of 1798 and tried to replace it by a Central Index Plantarum Horti Botanici Meliten­ School where medical subjects were not sis (Storia della societa medica d'incorag­ to be taught at all. He decreed, however, giamento, 1845; Cremona, 1967). that courses in anatomy, medicine and It is obvious from this short account midwifery were to be held at the Civil that Domeier's stay in our Island (1805-8) Hospital. When the Maltese rose against coincided with the initial phase of the re­ the French, all academic activities ceased vival of the study of botany in Malta. from September 1798 to September 1800 With regard to the study of anatomy when the French capitulated and left the and surgery, there is undoubted evidence Island. that these subjects were being taught at One of the first acts of Sir Alexander the Civil Hospital of Valletta, after the Ball, who was then President of the Mal­ revival of the University in 1802. This tese Provisional Government, was to re­ was. in a way, a continuation of the policy open the University on the 6th November laid down by Napoleon two years pre­ 1800 with Faculties in Law, Theology and viously. Medicine. The regulations of the Civil Hospital The students of medicine entered issued on the 20th March 1802 make re­ upon the academical course proper after ferences to (a) four students of Physic a preliminary study of the humanities, (allievi di fisica) who bled patients, did philosophy, mathematics and physics cupping, applied vesicants, fomentations, (Cassar PuUicino, 1958). The study of bo­ cataplasms and inunctions under the di­ tany, and of anatomy and surgery did not rection of the Master of Physic (Maestro figure in the medical curriculum and di Fisica); they accompanied the Senior Domeier remarked upon the neglect of Physician on his rounds; (b) five Licensed botanical studies and the absence of a Students of Surgery (allievi patentati di Professorship in Anatomy and Surgery. chirurgia) and (c) an unspecified number At a time when pharmaceutical reme­ of Supernumerary Surgical Students dies were mainly of a vegetable kind, a (allievi supranumerari di chirurgia). All knowledge of plants was rightly consi­ these categories of students received a dered essential both for pharmacist and salary of 15 to 20 scudi a month (one physician. In fact botany was being taught scudo = Is. 8d.) in Malta as early as the close of the 17th The following extracts from the hos­ century and a Botanical Garden was pital regulations give an indication of the planted in 1690 in the ditch of Fort St. nature of the students' training and Elmo near the Holy Infirmary for the use duties:- of medical students. It was entrusted to (a) The Senior Surgeon was allow­ Dr. Joseph Zammit, Teacher of Anatomy ed to entrust a few of the dressings to the and Surgery. The garden fell into disuse cure of some "good students to train in 1798 during the turmoil that followed them in the practice of surgery". the advent of the French to Malta. Napo­ (b) The Junior Surgeons were en­ leon, however, mindful of the necessity joined "to supervise the surgical stu­ of a Botanical Garden had decreed that dents so that they do not absent them­ such a garden was to be established in selves from the ward round or leave hos­ the viCinity of Valletta. This project was pital when on duty"; to make sure that carried into effect during the succeeding they carried out all their work and to re­ British domination when the Rev. Fr., Carlo port defaulters to the hospital authorities; Giacinto was appointed to the Chair of and finally to instruct the students in the Botany in our University by Sir Alexan­ medication and bandaging of patients. der Ball in 1805. (c) The Junior Surgeons on duty 16 was to perform "anatomical dissection for educational standards of the profession study purposes with the help of the sur­ by laying down requisites in age, train­ gical students". ing and qualifications for the different (d) The students had to "attend the categories of the medical profession. The daily ward rounds, morning and afternoon, aims of the College were only partially to carry out the orders given them by the achieved at this period with the passage Principal Surgeon. They were also to fol­ ef the Apothecaries' Act in 1815 (Hollo­ low the directions of the Junior Surgeon way, 1966). and medicate the patientts suffering from In Malta the gaps in the academical r:ngworm (tigna). teaching of the University were filled to­ (e) All the Students of Physic and wards the end of the decade by Dr. Agosti­ of Surgery had to. attend the daily lesson no Naudi, the brother of Dr. Cleardo Nau­ in anatomy and surgery. The lecturer had di already alluded to. to draw up a list of absentees every week Born in 1783 Agostino Naudi at first and submit it to one of the Presidents meant to study civil and military archi­ (two of whom formed a sort of lay hospital tecture but at twenty years of age he management committee). The Presid(;nts turned to medicine. He pursued his m8- decided upon the punishment to be dical education at the Medical Academy awa::,ded to the offender including dismis­ of Naples qualifying as physician and sur­ sal from employment. geon at the University of Salerno, being (f) The surgical students adminis­ the first among three hundred students. tered internal medicines in conformity On his return to Malta he taught with the prescriptions of the Senior Sur­ anatomy and dissection in the cemetery geon. of the Civil Hospital of Valletta in substi­ (g) They were taught the "obstetric tution to Dr. Aurelio Badat who had given art" by a Master of Obstetvics (Maestro up teaching because of senile mental decay di Ostetricia) both "orally and in writing". (1810). Naudi had to suspend his lectures (h) They were on call during the and demonstrations during the plague nlght according to a roster (Piano per il epidemic of 1813-14. regolamento dell'ospedale di Malta, 1802 Following the death of Dr. Ludovico b). Abela, Professor of Medicine (1800-15), The first men to qualify from the Naudi taught medicine privately, his newly restored Medical Faculty were students receiving the doctorate of the Aloysius Gravagna and Alexander Vella. University of Malta in 1819. From 1820 After undergoing a private examination onwards he substituted Dr. Stefano Gril­ by three examiners and sustaining a thesis let, Professor of Medicine (1815-31) who in public in the Church of the University, had become chronically ill. He also taught they had the degree of Medical Doctor botany, physiology, pathology and sur­ conferred upon them in August 1804. A gery. total of eleven medical men qualified bet­ He is alleged to have been the first ween August 1804 and July 1812. The to discover and describe the middle me­ studies were subsequently interrupted tem­ ningeal nerve for which he was com­ porarily by the plague outbreak from May mended by the Academicians of Paris and 1813 to October 1814 (Acta 1800-1832 b). granted the diploma of Insigne maestro di Shortcomings in medical studies and anatomia umana (Outstanding master of practice were not limited to Malta at this human ana tomy) by the Academy of Rome. period. They coincided, to a certain He wrote an account of the plague of extent, with what was happenning in 1813-14 in Latin. He submitted it to the England. In fact the practice of physi­ Medical Academy of Montpellier by which oians, surgeons and apothecaries was still "he was judged worthy of special and unorganised except in London; so much honorific mention". Dr. L. Barthelemy so that in 1806 the College of Physicians declared it to be "a masterpiece of patho­ tried to tackle this problem by formulat­ logy, the~apy and preventive hygiene". ing a scheme which aimed at raising the The manuscript was still extant in 1864 17 but cannot now be traced. From sketchy 1907; Naudi 1827 & 1828). references to it in contemporary medical A Professorship in Anatomy and Sur­ literature we know that it dealt with the gery was set up in 1822 with the appoint­ atmospheric phenomena and the state of ment of Dr. Gavino Patrizio Portelli (1795- public health prevailing immediately be­ 1865) to the Chair (Malta Government fore the outbreak such as the mildness of Gazette 1822). In the first decade of the the weather, the increased incidence of 19th century, Gavino Patrizio Portelli, sudden deaths which excited "public ob­ though still a youngster, was already serv­ servation and alarm", the remarkable fre­ ing in the Military General Hosp!tal at quency of hydrophobia and of intestinal Valletta under Sir William Franklm, the infestation with ascarides and earthworms Inspector of Military Hospitals, who took which were "never so general and so the boy under his patronage and encour­ numerous in the memory of man" (Hen­ aged the boy's parents to send. him to nen, 1830 f). study medicine in London - WhICh they In 1827 Naudi pub!ished a treatise on did. In London he studied under Con­ the cultivation of the silkworm to en­ stantine Carpue and then joined the 10th courage the Maltese farmer to undertake Infantry Regiment as Assistant Surgeon. this form of industry. In December 1813 he took part in the ex­ In the following year he wrote a brief pedition under Sir Thomas Graham against review, which remains in manuscript, of the French in Holland and was in the front the history of yellow fever. This disease line during the attack on the fortress of had been causing considerable anxiety to Bergen-op-zoom when he was slightly the health authorities of Malta since Oc­ wounded. In 1816 he was made a member tober 1804 when it occurred on an epide­ of the Royal College of Surgeons. He re­ mic scale at Gibraltar. Mortality was mained with his regiment until 1818 when high. Two-thirds of the inhabitants left he was called from Corfu by Sir Thomas the Rock to escape the disease and some Maitland to occupy the post of Principal of them, mostly Jews, came to Malta in Surgeon at the Civil Hospital of ValIetta the early days of the outbreak. The qua­ (Corriere mercantile, 1865). rantine regulations of Malta were tight­ By the time PorteIli became Professor ened against ships coming from infected places. Samuel Taylor Coleridge, who of Anatomy and Surgery in 1822, the aca­ was then in Malta, states that a ship from demic standards of Maltese medical men Ragusa with its crew dying of yellow had risen considerably. Pharmacists, also, fever was forced to sea from the Island had become "expert in the various phar­ (Sultana, 1969; Coburn, 1962 b). maceutical operations". In fact a British physician serving in Malta, Dr. John Hen­ Gibraltar was declared free from the nen, Inspector of Military Hospitals, de­ disease on the 1st January 1805 but the clared that "physic and surgery are not on dread of the importation of the infection a lower footing in point of respectability into Malta persisted for many years after­ in Malta than among the continental na­ wards. tions in the neighbourhood". It is true In his account of the history of yellow that surgeons were still somewhat con­ fever, Naudi traced its outbreak in Pen­ servative in treatment compared with their nsylvania in 1740 and its subsequent ap­ British counterparts but part of this fault pearance in Gibraltar with which Malt.a lay with the patients who were "so wedded was then in close and frequent commUnI­ to old practices and established usage that cation by sea. He quoted the observations the physician who should attempt any in­ of Robert Lind on the disease and ex­ novation in this respect would assuredly pounded his own ideas about its spread be left without any subjects to practise from an "infected" place to a healthy one upon". However, "modern medical and by means of atmospheric air. surgical practice" was ably taught and de­ Dr. Agostino Naudi died on the 11 th monstrated in the Civil Hospital (Hennen, November 1830 (CamilIeri 1831; Malta 1830 g). 18

Epilogue against smallpox was being widely recog­ nised; Corvisart was propagating the use The medical highlights of the decade of percussion in the diagnosis of diseases r' 1800-10 are Burnett's clinical description of the chest and heart (1808); lames Carrie of Undulant Fever; the introduction of (1756-1805) introduced the clinical ther­ vacc:nation against smallpox; the revival mometer; Laennec invented the stetho­ of the University with its Medical Faculty; scope in 1816; and a new more rational the initiation of the Government's policy approach to the management of the men­ of sending Maltese medical men for post­ tally sick was being adopted. graduate studies to the United Kingdom All these advances lay in the future and the beginning of the first contacts path of our professional ancestors - between British and Maltese medicine. British and Maltese - at the close of the On the debit side we find that acade­ first decade of the 19th century but before mical training in medicine was modest; they were to taste these benefits they were surgical practice was limited in scope; the called upon to bear the full weight of the running of hospitals was inspired by the most dreaded medical calamity of all times med;eval concept of "charity" towards - the plague that descended upon them the indigent and not by the idea of service and sorely tried them in the Malta epide­ to all members of the community; "fever mic of 1813-14; but that is another story cases" taxed the physician's time and that has already been told. efforts but their causation still eluded him; treatment, consisting mainly in bleeding and purging of the patient, was ineffectual; APPENDIX I time and energy were dissipated in abst­ ract theorising and sterile controversy. Doctoral College In assessing the men and ideas of the in the Faculty of Medicine period under review in Malta we must re­ (Collegio Dottorale member that we are judging them from nella Facolta della Medicina) the vantage point of the twentieth cen­ 1805 tury. To be fair to them we must bear in Dr. Luigi Caruana mind that the pattern of their lives mir­ Dr. Giovanni Agius rored the European intellectual and medi­ Dr. Francesco Dimech cal scene of their days and it is within this Dr. Francesco Leone Gravagna framework of time and state of knowledge Dr. Stefano Grillet that we must judge them to give them a Dr. Giuseppe Ciaja fair trial. Whatever their deficiences, Dr. Giuseppe Dingli those men did not live in an isolated cul­ Dr. Gabriele Pullicino tural backwater but were always in the Dr. Aurelio Badatt main stream of Western thought and events. Master of Anatomy and Surgery The world in which they were brought (Maestro di Anatomia e Chirurgia) up and trained was being swept away by 1806 a quarter-century of war sparked off by the French Revolution of 1789 and ending Dr. Aurelio Badatt at Waterloo in 1815. In 1810 they were un­ aware that they stood on the threshold of Master of Obstetrics a new era when budding scientific and (Maestro di Ostetricia) medical ideas would bear fruit in the fol­ 1806 lowing decades. The physiology of respi­ Dr. Francesco Buttigieg ration would be understood thanks to Lavoisier's contribution on the role of (Diario, lunario e calendario delle isole di Malta oxygen in the processes involved; the e Gozo per l'anno 1805, Malta, p. 17: Almanaeeo value of lenner's prophylactic vaccine delle isole di Malta e Gozo, Malta, 1806, p. 29). APPENDIX 11 Junior Surgeons Doctors graduating from the University (Chirurgi secondari): from 1804 to 1812 Antonio Casha Aloysius Gravagna - 1804 Giovanni Andreotti Alexander Vella - 1804 Carlo Grech Joannes Franciscus Falzon (Mosta) - 1806 Salvatore Saydon (Zurrieq) - 1807 Pharmacist Lucas Borg (Balzan) - 1809 (Aromatario~: Xaverius Micallef (Qormi) - 1809 Giuseppe Farrugia. Paolo Antonio Azzopardi (Siggiewi) (P:ano per il l'egolamento dell'ospedale di Malta. 1810 Ma!ta, 1802, pp. 1 & 2; Diario, lunaria e calendario Felix Brignone - 1812 dcl!e isole di Malta c Gozo per l'anno 1805, Malta, Joseph Galea - 1812 pp. 17.18; A!manacco delle isole di Malta e Gozo, Nh~ta, 1806, p. 29). Gregorius Gatt (Birkirkara) - 1812 Albinus Borg (Balzan) - 1812. (Acta Academ:ae Melitens:s 1800-1832, fols. 18 APPENDIX IV to 52). Naval Hospital Medical Staff 1803-4 APPENDIX III Surgeon in Charge:- Women's Hospital Medical Staff Mr. John Gray - appointed 25th No­ 1802 vember Dr. Gluseppe Ciaia (sic) Surgeon's Mate or Assistant Surgeon:­ Dr. Stefano Grillet Mr. John William Ellice - appointed Dr. Giuseppe Dingli (supranumerario) 22nd December Governor and Superintending Officer:­ Men's Hospital Medical Staff Lieut. William Pemberton - appointed 1802 21st December. Dr. Francesco Dimech Physician:- Dr. Francesco Leone Gravagna Dr. Leonard Gillespie (1758-1842) Dr. Leopoldo Bernard He was the first physician to be Dr. Lorenzo Cassar appointed to the Malta Naval Hos­ pital. He joined the Victory as 1805 Physician to the Fleet in January Senior Physicians 1805. (Medici primari): Francesco Dimech 1807 Dr. Francesco Leone Gravagna Surgeon:- Dr. Giuseppe Ciaja Mr. John Allen Dr. Stefano Grillet Assistant Surgeons:­ Dr. Lorenzo Cassar Mr. John Regnell Dr. Giuseppe Dingli Mr. Lorenzo Zammut (sic) (N:colas, N. H. The D:spatches and Letters of Junior Physicians Vice Admiral .Lo~d Viscount Nelson, Vo!. V" London, 1845, 111)' 294, 322 & 325: Gordon Pugh, P. D. Ne'- (Medici secondari 0 pratici): Dr. Emanuele Locano 5811 and H s Surgeons, Edinburgh, 1968, p. 26; A imanacco dl'lle isole di .v1alta e Gozo, Ma~ta, 1808, Dr. Salvatore Cutajar P·i I). Dr. Giuseppe Schembri References (Senior) Surgeons Acta AC:lde11liae lvleiitensis (1800-3za) fo;s. 6, 15 & (Chirurgi): 20. Arch:ves of Royal TTn:versity of Malta, De­ Dr. Aurelio Badatt partment of H·stury. Dr. Giuseppe Speranza Acta Academiae Melitensis (I800-32b) fo:s. 18, 23, Angel/) Ventura 27, 35, H cl:. .~2. 20

Almanacco delle isole di Malta e Gozo (1807), Ma:ta, HE:-.'NEN, J. (I 830g), p. 543 p. 33· HODGKINSON, R. G. (1966). Medical H'story la, Arch:ves. 1I96, fol. 41, Royal Ma:ta Ubrary. p. r3S. BELLET, D. S. (r80r). Continuaz'one di fatti e d'os­ HOLLOW AY, S. W. F. (1966). Medic:!.l History, la, servaz:oni intorno al vajuolo de'la vacca fatte da 107- 2 9. Odoardo fenner, Malta. HUNTER, R. &: MACALPINE, 1. (1963). Three Hundred BUR~ETT, V/. (I8r6a) A Pracfcal Account of the Years of Psych:atry, London, pp. 53S, 376 & 468. Med;terranean Fever as it appeared in the Sh'ps HU:-ITER, R. & MAcALPrNE, 1. (1965) Medical History, and Hosp'.ta!s of Hes Majesty's Fleet in that 9, p. IB1. Stat'on dur:ng the Years r808, ISll and rSr3 and l! Globo ([84r), 7th October, p. 220. of the G bra~tar and Carthagena Fever, London. LE:GH, D. (1951). The H:,tor'cal Development of BURNETT, W. (ISI6b), pp. 4-II, 44 & 70. Br:t:sh Psych'atry, Oxford, pp. 62 & 72. CAMILLERI, D. C. (JSr3). Elogio funebre del chiaris­ Malta (1907). 26th Apr:!, p. 2 . S;1110 Dr. AgosLno Naudi, Malta. iVIalta Government Gazette (IS22), 29th November, CASSAR, L. (1802). Od'erno, ietterario, academico p. 3 2 99. ragionamento, Malta. Malta Government Gazette (1837), 2nd August, CASSAR, P. (1949). The Institutional Treatment of p. 277· the Insane in Ma~ta, Malta, pp. 3-5 & rS. Malta T.nzes (1849), 23rd Janua:-y, p. 2. CASSAR, P. (1965a). Med:cal H.story of Malta, Lon- MIFSUD BO:-l:-lICI, R. (1962). Iz·Zurrieq, September I don, pp. 95-97. October. CASSAR, P. (1965b), pp. 251-256. MUNK, W. (I87S). The Ro!: of the Royal Co]ege of CASSAR, P. Medical H:story, 13, p. 68. Phys·c:ar.s of Lor.don, Vo:. 3, London, p. 8S. CASSAR PULLICI~O, J. (1958). Journal of the Faculty NAUDI, A. (1827). Sull'industria d'allevare i bachi of Arts, (Ma:ta), I, pp. 142 &146. da seta, Mess:na. COBUR~, K. (I962a). The Notebooks of Samuel Tay- NAum, A. (1828). Notizie sopra i:l febbre g:alla, lor Coler:dge, Text, Vol. 2, London, note 2420. JV1'...s. 807, Royal Malta L·brary. COBUHN, K. (1962b), note 2312. NAUDI, C. (r806). Orazione detta per l'apertura Corr'ere mercantile (1865), 9th January. degli studi nel mese di ottobre, Ma:ta. CREMONA, A. (1940). Vassalli and His Tmes, Malta, NICCJLAS, N. H. (IS4S). The Despatches and Let­ p. 103· ters of Vce Adm:ral Lord V:scount Ne:son, Vol. S, CREMO)lA, A. (1<)07). Ir-Review, 28th October, London, pp. r89, 190, 28S, 317 & 431. p. 106. NIC::JLAS, N. H. (rS46), Vo'. 6. pp. 8 & 19. Des;Jatches of Gove,nor to Secretary of State 26th Ord:n; e decreli dalli 3 lug/io alii 24 lugLo (rS05a), February 1836, fol. 425; 3rd January IS37 fol. 13; fol. 33S. lVJ.::. in the posses::;:cn of Chev. Jos. 14th Augw:t lS37, fo·s. 510 & 512, Governor's Galea, Mdina. Palace, Valletta. Ordini e dccreti, etc. (lSoSb), fol. 339. D:ct:onary of National B'ography (1896), vol. xlvii, Ordini e decret:, etc. (IBoSC), fo·s. 26r, 364, 409 London, P.S5. & 4r I. DOMEIER, W. (1810). Observat:ons on the Climate, Ordini e decreti, etc. (ISoSd), fo·s. 120, 440 et seq. Manners and Amusements of Malta, London, Hano per il regolamento dell' ospedale c ·vi.·e di p. 109. ]1!Jalta (IS02a), Malta. FISK, D. (1959). Doctor Jenner of Berkeley, Lon­ P:ano per it rego!amento, etc. (rSozb), pp. 7-9, 14 don, pp. 164, IS7 & 227-9. & 17· GUTHRIE, D. (1947). A History of Medicine, Edin­ Repo:-: of the Committee appointed by H.E. the burgh, pp. 67, 218 & 223. Governor to Cons:der :the Steps to be Taken for HENNE)I, J. (IS30a). Sketches of the Medical Topo- the SupprE'ss:on of Med:terranean Fever Among graphy of the Mediterranean, London, p. 579. the Popula.t·.on of th's Island. La:d on the Tab'e HENNEN, J. (IS30b). pp. 492 & 584-6. of t:1C Counc'l on 23rd June 1909. HENNEN, J. (1830c), pp. 95-98 & 517. Storia della Soc:eta' Medica d'Incoragg'amento HEN:-IE:-I, J. (1830d), p. 554. (1845), Malta pp. v-vi & r5-I6. HENNE:-I, J. (1830e), p. 54'1· SULTANA, D. (1959). Samuel Tay:or CO'er:dge ir. HEN:-IE:-I, J. (r830f), p 327. Malta and S;C :y, Oxford, pp. 215 & 2S6. 21

MAN'S ERECT POSTURE J. L. PACE, B.Pharm., M.D., Ph.D. Lond.,

Departm~nt of Anatomy, Royal University of Malta.

This is an abridged version of a Public limbs beoome .the only support of the body. Lecture giv,en under the auspices of the These characteristic stages in the develop~ Royal University of Malta Biological So­ ment of the upright or orthograde posture ciety in November 1969. culminate in the evolution of plantigrade Man when fore-limbs and hind-limbs ao­ This leoture is an attempt to desoribe quire human oharacteristics and the typi­ briefly how, when and where Man oame cal poise of the head is attained. by his ereot attitude. Though the upright posture is one of Man's posture has evolved through 3 the great and most oonspiouous of human stages. In the Hylobatian stage the pro­ oharaoteristios, several animals, as the nograde monkey differentiated into the squirrel, bear, kangaroo and some of the gibbon, a small anthropoid which is ortho­ monkeys and apes, oan maintain their grade in its gait, holding the body upright trunk upright; even some of the extinot in the phase of progression, but which dinosaurs are known to have walked up­ rests and even sleeps in the sitting posi­ right. In this oonneotion it is interesting tion. In the Troglodyte stage the small that surveys have oonstantly shown that anthropoids differentiated into the great the animals most favourite with ohildren anthropoids (e.g. ohimpanzee, gorilla and are those whose postures are in some orangutan), animals which, being heavier, ways or at some times rather vertical, as have a more marked orthograde posture the ohimpanzee, the monkey, as well as and gait, and which rest only when the the penguin, the most vertical of all birds. body is laid prone. In the final Planti­ In primitive aquatic animals, the limbs grade stage, characterised by Man, struc­ are propelling non-supporting organs being tural changes took place which were al­ mobile but with little stability. With the most entirely confined to the lower limbs. ohange from the aquatic to the terrestrial The evolution of the erect posture habitat, the limbs have to temporarily lift entailed structural as well as physiological and support the body weight during the alterations in all parts and systems of the act of propulsion while at the same time body. Most of these changes occurred in maintaining their propelling function, so the adaptation to arboreal life but some that some more stability is added to their were more recent, resulting from the mobility. In the terrestrial four-footed achievement of Man to walk upright. pronograde animals, all 4 limbs become The basic change in the evolution of permanently supporting though ambula­ posture was the shift in the body's centre tory organs. Some of these animals, how­ of gravity. As we move up the evolu­ ever, move forwards by a hopping type of tionary scale, the centre of gravity tends movement during which the hind limbs to move backwards from the head and take an increasing share of supporting the shoulder to the hind-limb and tail region. body weight; this becomes even more so In leaping animals, the hind-limbs increase with the adoption of arboreal life where in size and the tail en~arges, the centre of the animal advanoes along the branohes gravity coming closer to the organ of pro­ of a tree by reaching ahead for new holds pulsion (the hind-limbs). Higher up in with its front limbs. Finally the fore­ evolution, the centre of gravity tends to limbs lose their function of support and, move well back over the hind-limbs, so while the animal is in motion, the hind allowing the sitting position and freeing 22

the fore-limbs for manipulation and, later of the vertebral column as the result of on, enabling Man to stand. changes in the centre of gravity, there are Four-footed animals use their mouth also changes in its type of movement. In as a food-getting organ so that this is four-footed monkeys which leap from the situated as far as possible from the face, hind-limbs, the lumbar spine acts as a especially from the eyes; these animals, flexible lever which moves the upper part therefore have a long snout. With the of the body on a fixed pelvic base, the development of the erect posture and the centre of gravity being the anticlinal ver­ consequent use of the fore-limbs for grasp­ tebra, i.e. that vertebra with a straight ing, the animal now seizes the food with spine which separates the retroverted its hand and so conveys it to the mouth, thoracic from the anteverted lumbar with a consequent gradual recession of spines. In the bipedal anthropoid and in the snout region. The snout is, however, Man, this springing in the middle of the still quite large in the Great Anthropoids backbone is absent and the vertebral and its final recession is only reached in column, whose spines are uniformly slop­ Man. ing, acts as a whole - as a pillar rather With the recession of the snout, the than a spring. Associated with this change cranial becomes larger than the facial part in the type of movement, structural modi­ fications occur in the spinal muscles, of the skull, the reverse of the situation in the lower primates. The occipital con­ especially those of the lumbar region; dyles, which articulate with the vertebral these gain an ever-increasing attachment column, move forwards on the base of to the pelvis so rendering this a fixed base the skull so leading to an increasing dimi­ from which the erector spinae may act. nution in the angle between the axes of In four-footed animals the pelvic out­ the head and that of the trunk and this let looks backwards and forms the highest ultimately becomes almost a right angle. part of the abdominal cavity, the symphy­ There is a consequent reduction in the sis is at the lowest part of the pelvis, and strength and attachment of the muscles a tail is still present. With the assump­ at the back of the neck and the develop­ tion of the upright posture, the pelvic ment in Man of counterbalancing muscles outlet becomes the lowest part of the on the front, such as the sternomastoid. abdominal cavity, the symphysis moves Ultimately, the characteristic head-poise up in the direction of the umbi'licus, there of Man is attained, the whole skull be­ is a widening of the subpubis arch, and coming practieaIly balanced on the verteb­ early coccygealisation and disappearance ral column; this poise not only permits an of the tail. The increase in the pelvic increased range of movement, but also outlet anteriorly, the added weight of the allows the head to be placed to best ad­ abdominal contents, the increase in the vantage to catch sounds coming from any intra-abdominal pressure bearing on the direction( so that the movements of the pelvic floor, which now lies horizontally, pinna of the ear remain no longer neces­ and the disappearance of the tail (which sary). normally aots as a perineal shutter) all Simultaneously, changes occur in the lead to a weakening of the pelvic outlet vertebral column. With the evolution of in the bipedal posture. This could pos­ the orthograde· from the pronograde pos­ sibly account for conditions like uterine ture there is shortening of the lumbar and rectal prolapse occurring in ortho­ spine by sacralisation in a headward direc­ grade but not in pronograde animals. tion, but with the change later on into the Anthropoids appear t y p i call y plantigrade posture of Man, there is re­ "slouched forward". Struoturally there is lengthening of the lumbar spine by sacra­ no difference between the anthropoid and lisation in a tailward direction as well as the human shoulder and Man only keeps by an increase at the upper end of the his shoulders braced back because the lumbar vertebral series. Apart from al­ supporting reflex postural mechanism has terations which occur in the curvatures in him been perfected. The bones of the 23 arm are longer in the brachiators and roots via the heart, thus increasing the thicker in the heavier anthropoids. The aeration of the lung apices. hands in orthograde animals and in Man The shape of the abdominal cavity assume functions which they do not have seems to vary with posture. Four-footed in the pronogrades. Four-footed animals monkeys have elongated loins and, as rely mostly on their teeth for their offence their chest is situated lower than their and defence reactions but Man uses his flanks, the abdominal organs tend to sag hands for these purposes; Man is in fact against the diaphragm. In bipedal forms, said to be the only fisted creature on earth. the loins shorten .and the abdominal cavity Man also utilises his hands for the tasks widens from side to side becoming flat­ of scratching and cleaning: four-footed tened antero-posteriorly; this affects the animals only scratch with their back-foot, shape of the contained organs so that, for monkeys and apes can use -either front or example, there is partial disappearance of back limbs, whereas Man of c')urse uses the caudate lobe of the liver. In quadru­ only the fore-limb for this purpose. The peds there is no compression of the abdo­ human hand also takes on the function of minal organs because these animals are a tactile organ from the whiskers on the enclosed in a cylinder of spinal postural snout associated with lower animals. muscle from which fore- and hind-limbs act. In orthograde animals and even more The upright stance involves changes so in Man, however, the arms no longer in the chest and in the mechanisms of support the body and the thighs become respiration, changes which are necessary entended so that the abdominal wal'! to meet the more active use which Man muscles now exert continuous and marked makes of his body. In four-footed animals compression with a tendency to displace­ muscular slings extend from the shoulder ment of the abdominal organs; this is girdles; they help to support and ,transmit remedied by improved visceral support, the body weight to the upper limbs and namely more extensive peritoneal fixation in so doing compress and flatten th8 and the suspension of viscera from the lateral walls of the chest. In the ortho­ diaphragm as well as from the backbone. grades, however, the body weight has often to be supported by the arms during The groin is a distinctive feature of brachiation so that the chest now becomes Man's anatomy. Only in one animal, the flattened from front to back through com­ gorilla, do we find a tendency towards its pression by the anterior and posterior appearance. Its formation results from thomcic muscle layers. The sternum be­ the extension of the iliac crests and the comes fused into a single plate to shortening of the anterior border of the strengthen the anterior chest wall against ileum. In the male especially, its defence these greater stresses, the ribs and the mechanism may occasionally be weakened muscles acting on them become modified, giving rise to the formation of an inguinal the contours of the diaphragm altered, hernia. while the anterior abdominal muscles, The erect posture also presents which in pronogrades extend over the problems in the sphere of sex. Man and whole of the front of the chest, become other orthograde animals walk erect so drawn downwards, losing their attach­ that their genital regions are more evident ment to the upper 4 ribs. These changes than they are in quadrupeds. Primates lead to an alteration in the mechanism of use the rear approach in mating during respiration, - jo an upQeJ; type of breath- which the ·t~Jll~le' genitals are visible to ,~pg -yvith jn(m:!a~€d, resp~rfl.t.ory 'importance . th~: mal~; -.;he',,'ilSS!1mption of the erect .p£ the ;a;piea~ region' cif the lungs. Conco­ " posture and the ,.consequent swinging of mitantly the' heart, which in quadrupeds the vagina' to the, front has led Man to comes in contact with the diaphragm only adopt the frontal approach. This could at its apex, becomes in bipedal animals possibly explain the appearance of the firmly bound to the diaphragm; the dia­ secondary sexual characters, such as the phragm thus becomes attached to the lung beard, breasts, pubic hair, etc., on ~p.e 24 front of the body, Pronograde animals anthropo:d foot attains a prehensile stage walking on all fours have their vaginal while that of the human foot retains its passage almost horizontal, but the erect primitive adducted position, In the new­ human female walking bipedally has her born the human foot, like the anthropoid vagina almost vertical; male seminal one, is inverted and shows the same fluid deposited in it would therefore tend flexion lines on its sole: the human baby to gravitate out and be lost were it not at first walks on the outer side of its feet for human orgasm which often leaves the and only later wth eversion of the foot female exhausted so that she has to lie does the inner margin come to bear the horizontally for some time after inter- weight of the body, course. The prehensile foot has a 3 functional Associated with the verticp.l posture, elements - tarsal, metatarsal and digital. changes also occur in the nervous system. The increase in weight of the body asso­ The centres of the mid-brain and cerebel- ciated with the change from the small to lum which regulate postural tone become the great anthropoid stage leads to an in­ more elaborated and the reflex centres in crease in length and strength of the SdP­ the. spinal cord more coordinated. The porting tarsal element while the metatar­ vasomotor pos'tural mechanism, which sal elements remain the same and the controls the distribution of blood, becomes grasping digital elements shorten. In Man, specialised to allow blood to be propelled the foot becomes modified as a "stepping­ upwards against gravity, so ensuring a off" lever in progression so that the great continuous supply to the brain. The toe element becomes even more predo­ stretch reflex also' becomes more deve- minant and the small toes even more re­ loped. duced. There is no doubt that the best We finally come to the changes in the foot adapted for terrestrial progression is lower limbs, especially those in the foot: a foot of few digits, as evidenced by the it is indeed the structure of the foot which horse which stands only on its third digit, mostly severs Man from all other exist- and Man has come to rely mostly on his ing primates. first digit, the great toe for this purpose. The adoption of an erect posture In four-footed monkeys, the mid-tar- brings the femur in line with the vertebral sal joint is flexible to allow the heel to be axis so that there is a more complete rota- raised while the great toe and digits re­ tion of the hip joint (hence the permanent tain their gmsp. In the bipedal small twist in the fibres of its capsule) as well anthropoids this joint becomes somewhat as an increase in the size of the gluteal less flexible, while in the great anthro­ muscles. As the leg becomes more sup- poids the joint allows of eversion and in­ porting in function it loses its power of version though there is still no longitudi­ pronation and supination, the rotator nal plantar arch. This arch, which first muscles of the tibia and fibula shifting appears in the gorilla, is due to the weight their origin and becoming flexors and the of the body being applied on the outer fibula becoming markedly reduced. margin of the inverted foot so that the But above all, changes occur in the inner margin of the tarsus assumes a pos­ foot. The anthropoid and the human foot tura! function. Continued inversion raises are similar in structural composition and the inner margin of the tarsus and the differ only in the arrangement and form of metatarsal element of the great toe which their components. The basic difference is soon becomes incorpo'fated with those of that whereas the anthropoid f00t, has a the others so leading' to the formation of free mobile great toe·-used- as a'--grasping a true Ibngitudinalplari.lar'arch: the grasp­ thumb, in Man the .great ..J:'0e -becomes -iYng'anthropoicrfoot is'thtis ctmverted into merged with t:he- metata'fsal·-se'Fies forming 'the' 'si:q:ip'brfing human foot. The longitu­ the part of a rigid supp'ot1fiil'lg' plantar arch. 'clina1"'plantar arch has great functional In the initial'·_devel~prrieRt:aI: stages the - 'irhpbrtance and its collapse, by a break­ human and anlhropo'iClfoot are alike and clown of the mid-tarsal joint, leads to the it is only laterithat the great toe of the common condition of flat foot. 25

Muscular changes are associated with of the pelvic floor with the possibility of these skeletal ones. There is a change in prolapse, the breakdown in the defence the size and attachment of the muscles of mechanism of the groin with the forma­ the great toe but there is only one new tion of herni,a, and the disruptions of the muscle formed ,namely a second belly to longitudinal plantar arch and the forma­ the flexor hallucis brevis. There are also tion of flat-foot. I may also mention the modifioations in the insertion of the foot poss~bility of disloca1tion of the base of invertors, the appearance of a new ever­ the vertebral spine (spondylolisthesis), tor (Peroneus tertius), while the plantaris lateral curv'ature of the spine (scoliosis), become cut off from the plantar aponeu­ drooping of the shoulders with pressure rosis by the heel. on the· brachial plexus, and hallux valgus The human child attains its fuBy (the so-called "bunion" disease). To these erect posture 14 to 15 months after birth must be added herniations of the inter­ - it usually stands unsupported by the verl~C'bral discs of the spine ("s'lipped age of 14 months and walks unaided d'sc") which often accounts for cases of at 15 months. Subsequent maintenance of so-called sciatica, lumbago and backpain. a good erect posture is influenced by cul­ The erect posture of Man marks him tural aspects of training, background a.nd off from other animals, lifting him physi­ environment. Posture is also to a large cally above the ground. It affords him im­ degree influenced by the inner emotions proved and new forms of vision, the pos­ and it has been said that "we stand and sibility of speech and gesture, above aU move as we feel." manual dexterity. Man's upright posture brings with it Man's erect posture is in fact the certain serious mechanical drawbacks. I symbol of his biological superiority. have alreadY referred to the weakening A CASE OF ANO-RECTAL AGENESIS: POSTOPERATIVE COMPLICATIONS CAROL J. JACCARINI, M.D., M.R.C.P., D.C.R., PAUL VASSALLO AGIUS, M.D., M.R.C.P., D.C.R., RAPHAEL ATTARD, M.D., B.Sc., F.R.C.S.

Summary: When 1 year o~d (28/11/70) and weighing 7.2 Kg. (16 Ibs.) the Rehbein pull-through An analysis of the postoperative com­ ab domino-perineal operation (Rehbein, plications of a case of ano-rectal agenesis 1959) was performed (R.A.) (see fig.). The is here presented. The multiplicity of recto-urethral fistula was tied and the factors involved, with special emphasis on colon, after dissection, was passed through protein-calorie malnutrition, together with the rectal tube (denuded of its mucosa) the importance of team-work in the ma­ and tethered to the perirectal tissues with nagement of this case, is emphasised. the end sutured in eversion to the anal margin. The colostomy was not touched Case Report: at this stage. During and after operation, The child was born at St, Luke's the child was given 400 mls. of blood and Hospital on 6.11.69 of a para-3 mother, intravenous fluids were continued as 5% after a normal pregnancy and delivery at dextrose N/4 saline at the rate of 800 term. The birth weight was 3.6 Kg. (8 mls. per 24 hours. The next day, since lbs.), At birth he was found to have 'im­ he was pyrexial and rales were heard over perforate anus' of the ano-rectal agenesis both lung fields he was started on i.m type and meconium was seen coming out Ampicillin and Cloxacillin and the drip of the urethra indicating the presence of a rate was reduced to 640 mls. per 24 hours. fistula. The next day a transverse colo­ At this time, the urine output was very stomy was performed (R.A.). The follow­ poor and a few hours later the infusion ing day he developed generalised twitch­ rate was increased to 1200 mls. per 24 ings which were easily controlled with hours and the antibiotics were continued paraldehyde and he was put on 'prophy­ intravenously. His urine output improved lactic' antibiotics. His subsequent pro­ and by the second postoperative day he gress was uneventful and he was dis­ was afebrile and progressing well. The charged home at the age of 7 weeks colostomy worked on the third day, but weighing 4.9 Kg. (10 lb. 10 oz.). the abdomen was still distended and the He was admitted to the children's child vomited several times. At this time ward on several occasions under the care he was given intravenous potassium sup­ of Dr. T. Agius Ferrante: at 16 weeks with plements (14 mEq./lit of K+) and the gastro-enteritis; at 5t months with severe gastric aspirate was replaced with equi­ anaemia (Hb 7.9 G%) and vomiting; at 9 valent amounts of normal soline via the months with severe anaemia (Hb 8.4 G%) drip. Serum electrolytes and blood urea and diarrhoea; and at lOt months with were monitored as necessary. anaemia (Hb 8.8 G%) and chest infection. On the sixth postoperative day, the At 11 months of age (28/10/70) he was patient's condition deteriorated: he be­ admitted to the surgical ward for further came pyrexial (Temp 102.5° F) and had a surgery on his ano-rectal agenesis, but sinus tachycardia of up to 200/min; his operation was postponed because of re­ abdomen was very distended, bowel current upper respiratory tract infections. sounds became infrequent and pus could V.M: () lyf..ANO-RECTAL AGENESIS

97 8·3 6'0 (66) (56) (41)

BLEEDING l OPERATION DIATHESIS p. U.O. GU WOUND ~RIA SEPSIS OE'DEMA PROSTIGMINE I.M. __------______~V z ILEUS> < NON- FUNCTIONING COLOSTOMY> .VlO --­ ~ 'z z-O -l-wO jjJl-l'- t;: Vl2 r:- cn~ ..:. 0:: 0::0 (\! :r: w "'" w::JCl -; .. IJJ CL coN a.. cnd) IJ') ..J..J OF a::O 0' « 22 103 t t ~8 «..,j «Cl Cl sE ., Cl.J 2::S Cl..J 102 0 2 ~O • §~ «0 ~~ 38 -l-l 1011 ~§ col'- a. co(\! a..cn .,. /." ./. '. . IOOLLit"'O'2. 0 0 0 ". .".. \ /'3 9<) \/ . 98 •

97

96 o '~~~~~~----~------~ TEMP. ~--ORAL FEEDS------

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 I I I I I I I I I I I I I I I I POSTOPERATIVE DAY

N -..) 28 be seen exuding from the operation colostomy started functioning. The ami­ wound. He was digitalised and the fever noacid solution was discontinued after 3 and tachycardia settled over the next 24 days. Afterwards, while the child was hours. An erect X-Ray of the abdomen being given more plasma, he was reported showed fluid levels and on 5/12/70 (i.e. to have collapsed, becoming pale and limp, 8 days after the first operation) laparo­ with rapi~ resp~rations. The plasma was tomy was performed. When the skin stopped add blood, hydrocortisone and sutures were removed it was obvious that oxygen were given. His general condi­ the abdomen had "burst" and the small tion slowly 'improved and by the next intestine was distended throughout. This day (17/12/70) he was well enough to be was decompressed by a tube passed via started on 10% dextrose by mouth and the colostomy and the abdomen was the IV fluids were reduced in amount. closed by through and through tension The oedema had by now greatly improved sutures. Postoperatively following blood and was limited to the lower limbs and transfusion he was continued on intrave­ the bleeding diathesis had resolved. On nous fluids. By the 8/12/70 the colos­ 18/12/70 he was started on milk feeds tomy had still not functioned and the child and solids together with a multivitamin was noted to be developing generalised preparation. He then became febrile and oedema, though there was no clinical had loose stools and was treated with a evidence of circulatory overloading and short course of oral Sulphaguanidine and no albuminuria. Serum electrolytes and Streptomycin suspension (Guanimycin). blood urea were normal but the total se­ The diarrhoea settled, but the pyre xi a rum proteins (4 G%) and, in particular the pers:sted for 2 weeks before it resolved albumin (2.1G%), were low. spontaneously without chemotherapy. By the 23/12/70 the oedema had virtually He was given 200 mls. Plasma and disappeared and the main problem was Frusemide (Lasix) 10 mg. (1 mg./Kg.) IM. then one of severe anaemia (Hb 6.0 G%). He was also tried on oral feeds in an at­ He was treated with intramuscular, and tempt to provide calories but he vomited later oral, iron and on the 8/1/71 a repeat these immediately. By this time, his general state had grossly deteriorated. He Hb was 13 G%. On 18/12/70 it was noticed that the was very pale and listless with general­ child could not bear weight on his right i3ed pitting oedema, distended abdomen, leg, keeping it flexed at the hip. X-Ray an infected. operation wound, poor urine showed changes suggestive of metaphy­ output and a still non-functioning colos­ sitis of the right femur. This however tomy. He also had numerous ecchymoses settled within a few days with simple and bled easily from venepuncture sites passive movements of the hip jOint. and from the tension sutures. On 12/12/70. he was given more blood, daily Lm. injec­ Following this, progress was unevent­ tions of Vitamin K were started and IV ful and the child underwent two further fluids were recommended as 10% dex­ operations under general anaesthesia. On trose. On 14/12/70 because of shortage 18/2/71 the anal orifice was dilated and of suitable peripheral veins, a 'cut-down' on 8/3/71 the colostomy was closed. The was performed on the left long saphenous postoperative periods were both smooth vein in the groin and a 12 inch nylon IV and the child was discharged home well cannula was inserted via the femoral vein on the 6/4/71 with a Haemoglobin of 13.7 up into the inferior vena cava. Through G%. He is to be re-admitted in a few this he was given a high-calorie solution months' time for trimming of the rectal of Aminosol-Fructose-Ethanol (Aminosol­ stump. Vitrum). Comments: Meanwhile, the colostomy had still not functioned .lO days after the second (1) Postoperativ.e oliguria operat:on and'Prostigmine 0.2 mg. 1M. This was, in part due to the fact that was given. About 4 hours after this the the child initially received less than the 29 basal daily fluid requirements for his (3) Oedema: weight, i.e. 640 to 800 mls. rather than 1200 mls. The blood urea was however This was not an unexpected compli­ never elevated, showing that good renal cation as the child had been on a grossly function was maintained throughout the inadequate protein-calorie intake during intra- and post-operative periods. The his first 12 postoperative days. A 7.2 Kg. oliguria was probably largely a manifes­ (16 lb.) child in good health would require tation of the normal postoperative res­ a basal intake of about 800 calories (100 ponse to surgical stress which causes in- cals/Kg.) and 24G protein (3G/Kg.) per . creased antidiuretic hormone and corti­ day. The patient had 5% dextrose N/4 costeroid release with water and salt re­ saline as basic intravenous fluids supply­ tention. Marked oliguria is nevertheless ing him with 240 to 360 calories per day often a worrying feature in an ill child depending on the amount of fluid intake. and a useful test is to increase the rate of The only source of protein was two blood infusion over half an hour and to observe transfusions (given on two separate days) its effect on the urine output. This was which supplied about 14G protein in all. done in our patient with a brisk diuretic The oedema was therefore due to protein­ response. calorie malnutrition causing hypoprotei­ naemia. Moreover, the possibility that It must also be remembered that in the child may have been hypoproteinae­ these patients additional fluid and solute mic before operation is unlikely because are lost via the skin and the respiratory he had a normal haemoglobin. Plasma tract, (especially in the presence of pyre­ was given, but this is only of limited be­ xia) and via the gastro-intestinal tract nefit to maintain the intravascular osmo­ through gastric aspiration, vomiting and tic pressure, thereby slowing the progress colostomy secretions. In the presence of of the oedema. Moreover, the calorific ileus one must also make allowances for value of plasma is only 20 calories per water and solute sequestered' in loops of 100 ml. which is clearly inadequate. For dilated bowel. All this requires careful these reasons it became obvious that the collection and measurement of all losses child needed urgent parenteral nutrition and meticulous input-output charting on and until the Aminosol-Fructose-Ethanol a fluid-balance sheet. solution was made available to us we gave 10% dextrose (supplying about 320 calo­ (2) Non-functioning Colostomy: ries per day) via a small peripheral vein. Aminosol contains in the physiologi- The colostomy failed to function at . cal L-form, all the 8 essential and 10 no­ all for about 10 days after the second essential aminoacids. An absolutely vital operation, though bowel sounds could be factor in the metabolic utilisation of nitro­ heard on and off on several occasions. gen is that adequate non-protein calories This was probably due to a multiplicity must be given simultaneously (Michener of factors among them hypokalaemia, and Law 1970). These are provided by oedema of the bowel wall, wound infec­ fructose and ethanol, making up the high­ tion and the poor nutritional status of the calorie solution (about 875 calories per child. Serum potassium level was nor­ litre). As this is hypertonic and irritant mal but as this is a poor index of the state to vessel walls, a venous catheter was of the intracellular potassium, the child threaded up the inferior vena cava and the was nonetheless given K supplements solution was given at the rate of 800 mls. intravenously. Cholinergic drugs to sti­ per day (lOO ml/Kg/day) for three days. mulate intestinal paristalsis are rarely Further plasma, blood and 10% dextrose indicated because other measures espe­ were then given and over the next few cially gastro-intestinal suction and proper days the oedema became less obvious and hydration usually suffice. In this patient, after a week it virtually disappeared. the colostomy started working about 4 Once oral feeds are re-established in such hours after administration of Prostigmine. cases, rapid improvement usually follows. 30

(4) Bleeding Diathesis: (6) Pyrexia of unknown origin: This was probably due to several fac­ The cause of this fever remained ob­ tors. Non-availability of protein for scure. There was always the great risk synthesis of the various coagulation fac­ that the operation wound might become tors and impaired liver function with 'septic' because of difficulty in separating failure of synthesis of the Vitamin-K-de­ it from the colostomy area. Repeated pendent factor (II, VII, IX, X) were per­ swabs from the wound site grew mixed haps the two most important mechanisms. flora including Proteus and Pseudomonas It is also likely, that Vitamin K itself may organisms. Blood culture (17/12/70) and not have been readily available for absorp­ urine culture (22/12/70) grew similar or­ tion from the large bowel because the ganisms, but the significance of these patient had been on broad spectrum anti­ results was doubtful because of the close b:otics (Ampicillin and Cloxacillin) for proximity of the colostomy to the opera­ some time before. On 14/12/70 the plate­ tion wound, to the LV. cut-down at the let count was 112,000/cu.mm., so that groin and to the genital region, in a small thrombocytopenia may have been an ad­ child. Although urinary tract infection, ditional factor. Coagulation studies were or even 'low-grade' septicaemia via the not performed. The patient was treated venous catheter seemed likely possibili­ with plasma, blood transfusions and Lm. ties at the time, it was decided to with­ Vitamin Kl injections and the bleeding hold antibiotic therapy as apart from his tendency settled after abqut 5 days. fever the patient was progressing very satisfactorily. The fever finally settled (5) Anaemia: after 14 days. The child had previously been ad­ Conclusion: mitted to hospital with moderately severe anaemia but his haemoglobin levels on the The postoperative care of a seriously second and fourth postoperative days were ill child who has undergone major surgery normal. The Hb dropped to 11.1 G% and may be suffering from multiple com­ around the time when.it was obvious that plications, necessitates close liason bet­ the operation wound had gone septic. The ween the surgeon, the paediatrician and film later on showed microcytosis and the laboratory and nursing staff. It is hypochromia and the anaemia was most clear from the comments about this case likely due to a combination of infection, that the utmost attention to detail is cru­ iron deficiency and protein-malnutrition. cial in the management of such cases. Also, repeated blood sampling by vene­ puncture can, in a child of this age, Acknowledgements: amount to quite a considerable degree of We thank the resident house-officers blood loss. Using microtechniques, need­ and the ward sister and her staff in W.S.2. ing as little as 0.1 ml. capillary blood (ob­ for their care and attention in looking after tained by the heel-prick method) would this patient. We are also grateful to the avoid this complication. David Bruce Military Hospital, Mtarfa, for By the 27/12/70 the child's haemo­ the supply of Aminosol (Vitrum) and to globin had fallen to 6.0 G% and therapy Miss R. Jones of the Medical School for was started with intramuscular and later secretarial help. oral iron. The poor initial response to this was probably due to the concomitant References: presence of infection which is known to MrCHENER, W.M., and LAW, D. (1970) Ped;at. eLu. interfere with incorporation of iron into N. Amer. 17: 373· the haemoglc~~in molecule. REHBEI:-1, F., (1059) Ch'rurg 30: 4 1 7. r 31 HOSPITAL MORTALITY IN MYOCARDIAL INFARCTION FREDERICK F. FENECH, M.D., F.R.C.P.E., M.R.C.P., D.C.H., Physician, St. Luke's Hospital, Malta and Lecturer in Medicine and Clinical Pharmacology Royal University of Malta Medical School

The World Health Organisation Material (1969) reported that ischaemic heart disease has reached enormous proportions, One hundred and thirtyfour patients striking more and more at younger sub­ with myocardial infarction were admitted into the unit. The diagnosis was con­ jects. It was claimed that in the coming years, it will result in the greatest epide­ sidered established if (1) pathological Q waves appeared on the electrocardio­ mic mankind has faced unless this trend gram, accompanied by an elevation in the is reversed by concentrated research into S-T segment and a subsequent inversion its cause and prevention. A Mayo Clinic in the T wave, or (2) there were changes study of the Rochester population of in the S-T segment and T wave suggestive 30,000 in which there is a 73% necropsy rate, showed that coronary heart disease of infarction or there was bundle branch block &ccompanied by a significant and was the cause of death in 4 out of 10 men transient rise in the serum aspartate and in 2 out of 10 women (Spiekerman et aminotransferase. aI., 1962). In Malta deaths from ischae­ Most of the patients receivedox:ygen mic heart disease in the years 1968 and for the first 48 hours. Pain was relieved 1969 accounted for 19% of all deaths. It by intramuscular injection of 100 mgm. is moreover the general impression pethidine or 15 mgm. morphine );ulphate. amongst Maltese physicians that the inci­ dence of ischaemic heart disease is in­ In patients with very severe pain, intra­ venous morphine sulphate was sometimes creasing. resorted to. Anticoagulants were not Acute myocardial infarction is an routinely given. They were used in male extremely common emergency in general patients under the age of 50 and in those hospitals with a high incidence of acute patients with associated atrial fibrillation, medical admissions. It is now genenilly congestive heart failure or evidence of agreed that the introduction of coronary venous thrombosis; intravenous heparin care units, by providing facilities for early was used in the first 48 hours, whilst oral detection of arrythmias and emergency phenindione in 1968 and warfarin in 1969 resuscitation, has contributed substan­ were g;ven on admission and continued tially to lower the hospital mortality from for 6 weeks, the dose being adjusted to myocardial infarction. In the absence of give a prothrombin ratio of 2-2.5/l. such a unit, the usual hospital mortality Thirtysix per cent of the patients had in is in the region of 30%. The purpose of fact received anticoagulants. Left ventri­ this paper is to review the cases of myo­ cular failure was treated with digoxin cardial infarction admitted into a medical and diuretic therapy; and in the absence unit of St. Luke's Hospital in the years of pacing facilities, steroids in doses of 1968 and 1969 as well as to assess the 60 mgm. daily were started on the deve­ factors affecting the hospital mortality in lopment of 2nd degree heart block or this group of patients. complete heart block. 32

Results TABLE III Mode of Onset The age and sex distribution of the patients are shown in Table I. The age 1. Chest Pain 115 cases of the patients ranged from 28 years to 2. Syncope 4 cases 82 years. There were 103 men with an 3. Heart Failure 15 cases average age of 58 years, whilst the mean age for the 31 women was 65 years. TABLE IV TABLE I Incidence 01 previous infarction Age & Sex of Patients First 114 I I Men Women Second 19 I I Third 1 Age: (Yrs.) 1968 1969 1968 1969

JI to 60 years for the whole group. There - " - - I 20 - 30 1 was a history of previous myocardial in­ + 31 - 40 3 3 - farction in 19 patients; in one instance, I the episode which necessitated hospital I 41 - 5~ 9 14 1 1 admission was the third myocardial in­ 51 - 60 10 16 2 7 farct (Table IV). Thirtyeight patients j gave a history of hypertension. There I ~61 - '/0 13 16 5 4 were on the other hand 28 diabetic pa­ tients. In 2 patients, diabetes was first 71 - 80 3 7 5 5 recognised at the time of the myocardial BO - - 2 1 - infarct (Table V). Total: 44 59 14 17 TABLE V I I Associated Diseases Average age: 58 yrs. I 65 yrs. As determined by the electrocardio­ I Hypertension gram, there were 67 cases of anterior in­ 30 out of 103 male patients farction, two of these combined with 8 out of 31 female patients posterior infarction. Fortythree myocar­ II Diabetes Mellitus dial infarcts were posterior and 24 intra­ 16 male patients mural and subendocardial (Table Il). In 14 female patients the whole group, there were 2 cases of One of each sex diagnosed at time of acute complete heart block associated in infarction. one case with anterior infarction and in the other with posterior infarction. The time of admission into hospital after the onset of chest pain was worked TABLE 11 out in III patients. Thirtyone per cent Site of Infarction of the patients were in hospital within 6 hours of the onset of pain whilst 74% Anterior 67 were admitted within 24 hours (Table VI). Posterior 43 Two patients developed myocardial in­ Intramural &. Subendocardial 24 farction in hospital whilst receiving treat­ ment for other conditions. Chest pain with or without shock was The monthly distribution of cases the presenting feature in 115 cases (85%). admitted to the unit as shown in Fig. I. Heart failure was the presenting symptom The highest admission rate occurred from in 15 cases arid syncope in 4 (Table Ill). May to July. The mortality rate for the The patients presenting with heart failure period or admission to hospital was had a mean age of 67 years as compared 19.4%. The time of death in the 26 pa- 33

TABLE VI as shock, heart failure, arrythmias, pre­ Time of admission after onset of pain vious infarction, diabetes mellitus and hypertension as well as the age and sex Time (hrs.) No. of the patients influence the prognosis. 0- 6 hrs. 34 (Honey and Truelove, 1957). It has been 7 - 12 hrs. 25 established that diabetes mellitus is pre­ 13 - 24 hrs. 24 valent in Malta and that it is of the obese 25 - 48 hrs. 14 middle-age onset type (Zammit Maempel, 48 hrs. + 14 1965). A recognised feature of ischaemic heart disease is the unusually high pro­ tients is shown in Fig. n. Nine of the 26 portion of women affected. This is re­ deaths occurred within the first 24 hours flected in the fact that 45% of the female and by 48 hours 15 deaths had taken place patients as compared to 15.5% of the with an additional 6 deaths during the males were diabetic. It has moreover remainder of the first week. The average been suggested that among diabetics with age of the 18 fatal male cases (mortality long-standing disease, a higher prevalence 17.5%) was 61 years compared to 68 years of ischaemic heart disease exists in late for the 8 female patients (mortality 26%). onset mild diabetics than in early onset insulin dependent subjects who had at­ Discussion tained the same age group (Weaver et aI., 1970). A number of factors influence the Hospital mortality from myocardial prognosis in myocardial infarction. It infarction, irrespective of the presence or has long been realised that such factors absence of coronary care facilities, is in-

24 MONTHLY Il;!CIDf;NCE 23 22 21 20 19 18 17 16 15 14 /3 12 If 10 9 8 7 6 5 4 '3 2 I

FEB. MAR. APR. MAY. JUN. JUL. AUG. SEP. OCT. 1'0101. DEC. 34

tv10Rl~1,1TY AFTER MVROCARDIAL INFARCTION 9

8 AVER.A.C;E MEAN AGE OF MORTALITY

7 ~ 61 Years (IB Cases) ,,- , 6 Female 68 Years ( B Cases) U') I-z 5 l.JJ Yoon~est Patient: 4B Years ( Male) ~ 0... 4 LL 0 3 z0 2

-- .

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 DAYS AFTER ADMISSION

fluenced by such factors as the average Indeed 40% ot deaths from acute myo­ age of the hospital coronary patient popu­ cardial infarction occur within 1 hour of lation and the speed of admission. The the onset of symptoms (McNally and Pem­ effect of age grouping in mortality has berton, 1963); whilst in men of middle-age been recognised (Honey and Truelove, and younger, 63% of deaths occur within 1957). As a matter of fact, the mortality 1 hour (Bainton and Peterson, 1963). In of some American county hospitals (Grif­ Edinburgh, the mortality of cases admitted fith et al., 1962) with a relatively older after 12 hours was 11% as compared to group of patients was higher than that in 19% in those admitted within 4 hours the Veteran hospitals (Beard et al., 1960) (Lawrie et aI., 1967). This is reasonable where the patients are younger. This rise for cardjac arrythmias, which are most in mortality with increasing age is de­ frequent soon after the infarct, and are a monstrable in this study. common cause of death within a few hours Another important factor is the time of the myocardial infarct. In fact Stock of admission after onset of symptoms. A et al., (1967) found an overall incidence of high proportion of patients admitted dur­ arrythmias in 76% of patients. Indeed it ing the first few hours of the illness, when was the appreciation of the high incidence the risk of death is greatest, will increase of arrythmias during the first 48 hours of the overall mortality, whereas admitting myocardial infarction and the improved patients several hours after infarction techniques of resuscitation that led to the produces a lower mortality during the creation of coronary care units. There is period of admission (Lown et al., 1967). no doubt that the main contribution of 35 these units to the lowering of the hospital mortality has fallen to 11 % (Pantridge, mortality from myocardial infarction from 1970). 30% to an average of 15-18%', has been Studies from different parts of the the prevention of the arrythmic deaths. world have demonstrated the value of co­ The mortality from myocardial in­ ronary care units for acute myocardial farction in various hospitals prior to the infarction in hospital patients; and there establishment of coronary care units has is no doubt that our mortality would have varied from 26% to 52% (Honey and True­ been lower had such facilities been avail­ love, 1957; Beard et al., 1960; Griffith et able. However an interesting develop­ al., 1962; Brown et al., 1963; Restieaux ment has been the suggestion by Mather et al., 1967; Norris et al., 1968; Herndorn, (1970) that mortality from myocardial 1969; Hofvendahl et al., 1969; Bloomfield infarction in patients treated at home may et al., 1970). The mortality in the present not be higher than in those treated in series was 19.4%. This wide range of hospital. In fact, his mortality for pa­ difference in mortality must surely reflect tients treated at home was 11%. He went differences in the age of patients and on to suggest that home care was suitable speed of admission into hospital rather for many patients. However hospital care than differences in the standard treat­ would always be needed for those patients ment. In Hofvendahl's series, where the with arrythmias and those where home hospital mortality was 35%, the average care is not possible. In view of the cost age of male and female patients was 67 involved in treating all patients with years and 71 years respectively as com­ myocardial infarction in coronary care pared to 58 years for Maltese male pa­ units, it is very important that the Bristol tients and 65 years for Maltese female findings be confirmed by further studies. patients. Moreover 55% of the Swedish Malta with its small size and stable popu­ patients were in hospital within 6 hours lation, is an ideal setting not only for of onset of symptoms as compared to 31% establishing an ischaemic heart disease of the Maltese patients. register but also for a comparative study All studies on myocardial infarction of the value of home and hospital care in have confirmed the fact that most of the acute myocardial infarction. hospital deaths occur in the first 48 hours. In the present series, 34.6% of all deaths Ref.erences occurred in the first 24 hours; this is very similar to the figure of 31% found by BA1XTOX, C.R., PETERSON, D.R. (1963). New Eng Norris et al., (1968) in New Zealand. Re­ J. Med., 268, 569. suIts of attempted resuscitation in cases BEARD, 0.\\'., HIPP, H.R., ROBIXS, M., TAYLoR. of cardiac arrest after myocardial infarc­ J.S., EBERT, R.V. and BERAN, L.G. (1960). Am. J. Med., 28, S7!. tion in general medical wards are poor BLOOMFIELD, D.l{., SLIOKA, J., VOSSLER. S. and when compared to ones obtained in coro­ EDELSTE1N, J. (1970). Chest, 57, 224· nary care units. Survival rates in general BROWN, l{.\I','.G., MAcMII.LAN, R.L., FORBATH, N., medical wards have varied from 5% to MELGRANO, F. and SCOTT, J.\\'. (1963). Lancet, 10% (Nachlas and Miller, 1965; Stennler, 2, 349. 1965; McNicol, 1966); in the present study DAY, H.\\'. (1965). Amer. J. Card: 01. , IS, 51. it was 5,%. However in coronary care GRIFFITH, G.C., LEAK, D., and HEDGE, B. (1962). units, there is a 40% to 54% survival rate , Ann. Int. Med., 57, 254· (Julian et al., 1964; Day, 1965). Wherever HERXDORX, R.F. and SMALLEY, P. (1969). Illino:s coronary care units have been introduced, Medical Journal, 136, 60. the mortality from acute myocardial in­ HOFVENDAHL, S., LOBENIUS, P., LUNDMAx, T., and WESTER, P.O. (1969). Lakaetigningen, 66, 2602. farction has been halved. Moreover in HOXEY, G.E. and TRUELOVE, S.c. (1957). Lancet. Belfast since mobile coronary care units I, 1155. have been introduced in order to put myo­ JULIA:-1, D.G., V ALE:-1TINE , P.A., MILLER, G.G. cardial infarction patients as quickly as (1964) Amer. J. Med., 37, 915. possible under coronary unit facilities, the LAWRIE, D.M., GREENWOOD, T.\V., GODDARD, M., 36

HARVEY, M.B., DO:-lALD, K.W., ] ULIA:-I , D.G., M., ROB1XSO:-l, ]., BRIGDE:-I, \\'. and McDo:-;ALD, and OL1VER, M.F. (1967) Lancet., 2, 109· L. (1967). Lancet, I, 1285. Low:-I, B., FAKHRO, A.M., HOOD, \Y.B., and THoRx, STOCK, E., GOBLE, A. and SLOMA:-I, G. (J967). Bd. G.\\'. (1967). ] .A.M.A., 199, 188. med. ]. 2, 719. MATHER, M.G. (1970). Brit. med. ]., 2, 231. SPIEKERMA:-;, R.E., BRA:-;DENBURG, ] .T., ARCHER, NcNE1LLY, R.H. and PEMBERTOX, ]. (1963). Brit. R.W.P. and EDwARDs, ].E. (1962). Circulation, med. ]., 2, 139. 25, 57· McN1COL, M.\\'. (1966). Pracbt:oner, 196, 209. STEMMLER, E.]. (1965). Ann. intern. Med., 63, 613. NACHLAS, M.M. and MILLER, D.L (I965). Am. Heart WEAVER, ].A., BHATIA, S.K., BOYLE, D., HADDEN, ]., 69, 448. D.R., and MO:-;TGOMERY, D.A.D. (1970). Lancet, NORR1S, R.M., BE:-ISLEY, K.E., CAUGHEY, D.E. and I, 783. SCOTT, P.]. (1968). Brit. med. ]., 2, 143. W.H.O. (1969). Executive Board, Bulletin Interna­ PA:-;TRlDGE, ].F. (1970). Chest, 58, 229. t:onal Society of Cardiology, No. II9, p. 1. RESTIEAUX, N., BRAY, C.,BuLLARD, H., MURRAY, ZAMMIT MAEMPEL, ].V. (1965). Lancet, 2, II57.

ISOLATED RIGHT VENTRICULAR HYPOPLASIA WITH ATRIAL SEPTAL DEFECT

P. VASSALLO AGIUS * M.D., D.C.H., M.R.C.P. Registrar to the Pediatric Unit, Brompton Hospital.

Isolated Hypoplasia of the right ven­ receding brow, and long thin limbs with tricle is a rare congenital cardiac ano­ long fingers and toes. There were no heart maly whioh has been infrequently report­ murmurs and the peripheral pulses were ed in the literature. Less than fifteen cases normal. X-ray of the chest was normal have so far been recorded. We describe and the ECG showed left vent-ricular here the clinical, haemodynamic and an­ hypefltrophy. After the first day she had giogmphic findings in two cases, and no further cyanotic attacks. briefly review the literature. She subsequentLy thrived, but show­ ed slight cyanosis at rest and a heart mur­ Case Reports mur was first noted at 10 months of age. She was referred to the Brompton Case 1 Hospital and at 2 years of age was admit­ ted for further investigation. Her general J.F. was the second child of healthy condition was good. There was probable parents; she was a fuB term normal hos­ cyanosis at rest, which became obvious pital de'livery, following a normal preg­ on crying; there was no differential cya­ nancy. There was no difficulty in onset nosis. The peripheral pulses were normal. of respiration. B.W. 5 lb. 13 oz. She had The blood pressure was 80 mm Hg by two cyanotic attacks on the first day and palpation in upper limbs. The fingers and was noted to be cyanosed on crying dur­ toes were clubbed. There was no chest ing the firSlt week of Hfe. On generalexa­ bulge and no thri1!l. The hea.rt was quiet mination she was a peculiar looking baby with a grade of 1-2/6 ejection murmur with a small head (circumference 12t"), best heard at the second left intercostal space. The second sound was single. The * At present Lecturer, The Medical lungs were clear on auscultation and the School, Royal University of Malta. liver was not palpable. Table 1. Haemodynamic data of Case 1 and Case 2

CASE 1 CASE 2

Pressure 02 S.tn. Pressure 02 Satn. _.Kg. ~ _.Kg. ~

~ixed Venous - 58 49

Right Atriu. a=3 v=5 58 a=7 x=:4 v=5 y=4 47 Jilel1n=5 Right Ventricle 11/0-5 56 13/2-6 45 presystolic wavec6 pre.ystollc .ave=7 Pulmonary Artery 11/5 56 - - rwedge Jlllellln=7 - - Pulmonary Vein - 96 - 98 !Left Atrium .lMiU1=2 87 a=4 x=2 .,,=3 -75-84 lill0an=3 !Left Ventricle 70/0-3 81~90 65/6-7 73-80

~x1l1ary Artery 75/55 81 63/46 gO

QP 2.4 L./ain./Sq.M. 1. 4!1 L. /min ./Sq .1L

QS 3.3 L./e!n./Sq.M. 2.2 L./~in./8~.H.

QP/QS 0.73 0.64

CJ,> ~---.. -~--- -...1. 38

Investigation: Hb 14.6 g%, P.C.V. brother are an normal. His parents are 53%. Chest X-ray showed slight to mode­ healthy. rate cardiomegaly with some probable re­ He was admitted to the Brompton duction in lung vascularity. E.C.G. Axis Hospital for further assessment when + 100° and an adult R/S pattern, indica­ aged 6 months. On examination he dooked tive of mild left ventricular hypertrophy. well with height (64 cm) and weight 6.300 A clinical diagnosis of tricuspid atresia kg) both around the 10th percentile. He was made. was mildly cyanosed at rest but there was Cardiac catheterization: (right axil­ no clubbing. His periphe:ral pulses were lary approach) was carried out under ge­ normal. There was no heart murmur and neral anaesthesia, breathing 25% oxygen. the second sound was single and of nor­ Both right and left pulmonary arteries mal intensity. The lungs were clear to we,re entered. There was a presystolic auscu'ltation and the liver was not en­ wave in the R.V. pressure tracing equal larged. There was no other abnormality to the right atrial 'a' wave and a narrow on routine examination. Relevant investi­ ejection peak of the right ventricular pres­ gations showed Hb 16.5g%, P.C.V. 54 %. sure curve. (Table 1) The presystolic wave Chest X-ray showed normal size heart was also seen in the pulmonary artery with diminished pulmonary vasculature. pressure curve. The left atrium was en­ E.C.G. showed an indeterminate axis with tered from the right atrium, and the left normal P waves; adult R/S pattern indi­ ventricle from the left atrium. Oxygen cative of left ventricular hypertrophy. A saturation data revealed systemic arterial clinical diagnosis of tricuspid 'atresia was desaturation (81%) and a right to left made. shunt at atrial level. A!t cardiac catheterization (Dr. G. A. Selective angiocardiography, with in­ B. Miller) the systemic saturation was jection of 75% Triosil into ther'ight atrium 80%. The atrial septum was crossed by showed opacification of both the left catheter and there was a :right to left atrium and an anteriorly placed right ven­ shunt at atrial level. There was again a tricle from which arose a normally situ­ presystolic wave transmitted to the R.V. ated pulmonary artery. The pulmonary The pulmonary artery was not entered. valve was not well seen. (Fig. 1) Injection (Table 1). of contrast medium into the left ventricle Selective angiocardiography with in­ showed no abnormality of this chamber jection of 75% Triosil into R.A. showed or of the aorta, and no ventricular septal passage of contrast medium into a smooth­ defect (Fig. 2). walled small anterior right ventricle, and thence into the pulmonary artery. The Case 2 right outflow tract was not well seen. There was also some opacification of the P.M. The mother had taken Nit~aze­ left atrium. Injection of contrast medium pam in the last 4 months of pregnancy, into the left ventricle demonstrated no which had been otherwise normal. He was abnormality. the second of diss'tmilar twins, deNvered by breech with forceps application to the Discussion after-coming head, at 39 weeks' gestation (pitocin drip for prolapse of cord). Birth Taussig (1936) drew attention to the weight 7 lb. His condition was poor at association between defective develop­ birth and he was placed in an incubator ment of the right ventride and anoma,lous for three days. Cyanosis and a heart mur­ tricuspid and pulmonary valves. However, mur were noted during the first few days. isolated hypoplasia of the right ventricle However, he subsequently thrived and de­ in the absence of valve atresia is very velopment was normal. rare. The condition may be associated A brother aged 6 years, a sister aged with hypoplasia or stenosis of the tri:cus­ 8 years, and another brother and sister pid valve, and an atrial septal defect or both aged 9 years (twins), besides his twin a patent foramen ovale is often present. 39

Fig. 1 Case 1 Angiogram with injection of contrast medium in the right atrium. There is opacification of right and I,eft atrium, right ventricle, pulmonary artery and aorta. 40

Fig. 2 Case 1 Angiogram with injection of contrast medium in left ventricle. Nor­ mal appearances. 41

Cooley et al. (1950) diagnosed isolated suggested that deviation of blood from hypoplasia of the right ventricle on angio­ SVC which normally flows to the RV in graphic appearances, which was confirm­ foetal life (as in their case of anomalous ed at necropsy. Gasul et al. (1959) dia­ systemic venous drainage to left atrium) gnosed a similar case at thoracotomy for might result in underdevelopment of the a Glenn procedure on a child with sus­ right ventricular myocardium. This is simi­ pected tricuspid stenosis. Medd et al. lar to LV hypoplasia which occurs when (1961) gave the detailed anatomical find­ premature narrowing or closure of the ings at necropsy in two siblings with iso­ fora men ovale results in reduction of flow lated hypoplasia of the right ventricle and into the left ventricle (Lev et aI., 1963). tricuspid valve. Sachner et al. (1961) des­ The case reported by Cooley et al. (1950) cribed the clinical and haemodynamic fea­ was attributed to absence of the right tures in three adults with this condition, coronary artery, though this was found to all in the same pedigree,' and presenting be normal in others. In UhI's case (Uhl, with progressive right heart failure. They 1952) there was almost total absence of also gave the necropsy findings in a two the mY0c:l.rdium from the right ventricu­ month old 'infant. Fay and Lynn (1963) lar wall, with marked dilation of the cham­ reported a six year old with hypoplastic ber, wh:ch contained a large ,laminated right ventricle associated with atrial sep­ mural thrombus; microscopic examination tal defect and supravalvar pulmonary ar­ of the right ventricular wall showed epi­ tery stenosis; there was marked clinical cardium and endocardium adjacent to each improvement following anastomosis of other with no intervening cardiac muscle; the right pulmonary artery to the superior the coronary arteries were normal. It is vena cava (Glenn procedure). Stoerner here suggested that the determing factor and Apitz (1965) gave the clinical, haemo­ for deve!opment of the myocardium is the dynamic and angiographic findings in a 4 blood flow into the chamber during foetal year old boy with this anomaly, a Blalock­ life rather than the coronary artery Taussig anastomosis was performed but supply. he died a few hours after operation. Raghib et al. (1965) reported a male infant Clinical Features with hypoplasia of the right ventricle and tricuspid valve, and Davachi et al. (1967) The clinical features resemble those described this patient's sister who died of tricuspid atresia. Cyanosis is a constant with an identical malformation. Overy feature and is often recorded as being pre­ et al. (1966) recorded a case of anomalous sent from birth. Heart murmurs are usual­ systemic venous drainage with hypoplasia ly absent in the straightforward case of of the right ventricular myocardium and hypoplasia of the right ventricle with a right to left shunt at atrial level. patent foramen ovale or ASD, and when present an associated anomaly such as Aetiology pulmonary stenosis or frank tricuspid in­ competence should be suspected. The The aetiology is obscure. A familial E.c.G. typically shows left axis deviation factor has been prominent in some report­ but the axis was + 110° in one case of ed cases (Sachner et aI., 1961; Medd et aI., Medd et al. (1961). The praecotdiaI lead 1961; Davachi et aI., 1967). Wood (1958) pattern is that of left ventricular domin­ noted that congenital heart disease recur­ ance, and there is usually ,less positive ring in more than one member of a family deflection of the QRS complex over the is usually of the same type. The stblings right chest leads than one would expect. and parents of the cases reported here Indeed ,if in the presence of signs of pul­ have no clinical} evidence of congenital monary stenosis there is little or no evi­ heart disease. A primary failure of deve­ dence of RV activity in the ECG the dia­ lopment of the muscle of the free wall of gnosis of hypoplasia of the right ventricle the right ventricle has been postulated should be borne in mind. Bi-atrial or right (Medd et al., 1961). Overy et al. (1966) atrial hypertrophy is a feature, and the 42

PR interval is usually prolonged due to the total aplasia first described by UhI. right atrial dilatation. The chest X-ray Gasul et al. (1959) carried out suc­ shows a normal sized heart with under­ cessful palliative sur~ery in one case, who filling of the lung fields. The presence of survived, anastomosing the superior vena cardiomegaly, without other evidence of cava to the right main pulmonary artery heart failure, would be in favour of a di'a­ (Glenn operation). If there is a concomi­ gnosis of Uhl's anomaly (Aplasia of the tant atrial septal defect, this should be myocardium of the right ventricle) (Uhl, closed at the same time (Gasul et al., 1966; 1952). Overy et al., 1966) but heart failure may supervene. On the whole, treatment of this Catheterization and Angiocardiography anomaly has been disappointing.

At cardiac catheterization the passage Ack.nowledgements of the catheter from RA to RV excludes tricuspid atresia. The tricuspid valve is I am grateful to Dr. T. P. Mann, who normally situated. The pressure trace may referred these cases for investigation; Dr. be similar in pulmonary artery, right ven­ M. C. J oseph for encouragement and per­ tricle and right atrium, with a presystolic mission to publish and helpful criticism; wave, possibly transmitted as fa·r as the and Dr. G. A. H. Miller for help with the pulmonary artery, and a narrow right ven­ haemodynamic data. tricular ejection peak. A right to left shunt is demonstrable at atrial level. On angio­ References cardiography, injection of the contrast medium in the right ventricle shows this COOLEY, R.N. SLOAN, R.D., NANLON, C.R. and BANNSON, H.T. (1950) Radiology, 54, 848. chamber to be normally situated but DAVACHI, F., McLEAN, R.H., MOLLER, T.H., and usually "Small and the pulmonary artery EDWARDS, J.E. Journal of Ped·at. 7I: 869, 1967. may be normal or hypoplastic. Injection FAY, J.E. and LYNN, R.B Canada. M~d. Ass. J., of the contrast medium in the right atrium (1963) 88; 812. will demonstrate the right to left shunt at GASUL, B.M., ARCILLA, R.A. and LEv, M. Heart this level. The left ventricle is normal and D'sease in ChEdren. D:agnos's and Tl'eatment. the ventricular "Septum is intact. In Uhl's (1966) p. 7°4· anomaly the right ventricular cavity is GASUL, B.M., \YEINBERG, M. Jr., LUAN, L.L., FELL, usually enormous, but it may be difficult E.H., BrCOFF, J. and STInGER, Z. (1959) J.A.M.A. to distinguish from hypoplasia of the right 17 I , 1797· ventricle if a clot has formed in the right LIlV, M., ARCILLA, R., RIMOLDI, H.J.A., LICATA, ventricle thus diminishing the size of this R.H. and GASUL, B.M. Am. Heart J. 65: 638, 1963. cavity. In Ebstein's malformation the MrmD, \Y.E., NEUFIELD, H.N., \\'EIDMAN, \Y.H. ap.d RV wall is normal or thin but the ventri­ EDWARDS, J.E. Br:t. Heart J. 23: 25. 1961. cular cavity is diminished by a down­ OVERY, H.R., STEINBICKER, P.G. and BLOUNT, S.G. ward displacement of the tricuspid valve. Circu:ation. 33: 613, 1966. Both the cases reported here present­ PERRIN, E.V. and MEHRIZI, A. Am. J. Dis. Childr., ed with a clinical picture of tricuspid 109: 558, 1965. atresia. In both cases the correct diagno­ RAGHIll, G., AMPLATZ, K., MOLLER, J.H., Jur" K.L. sis was suspected during cardiac cathete­ and EDWARDS, J .E. Am. Heart J. 70: 806, 1965. -rization from the characteristics of the SACKNER, M.A., ROB1NSON, M.J., JAMISON, \\'.L. and pressure tracings. LEWIS, D.H. C:rculation, 2';': 1388, 1961. STOERMER, J. and ApITz, J. Med. Kl'n. 60: 1777. The angiocardiographical appe~ran­ 1965. ces in both cases excluded malposition of TAUSSIG, lLB. Bu'!. Johns Hopkins Hosp., 59: the tricuspid valve; the size of the cavity 435, 1936. of the right ventricle was compatible with UHL, H.S.M. Bull. Johns Hopkins Hosp. 91: 197, hypoplasia of the muscle wall rather than 1952. 43 MEGALOBLASTIC ANAEMIA DUE TO ANTICONVULSANT THERAPY

PlO MANGION, M.D., M.R.C.P. (U.K.), Medical Registrar, St. Peter's Hospital, Chertsey, Surrey.

Megaloblastic anaemia occurring insidiously. For two years she had noted during prolonged anticonvulsant therapy increasing pallor and tiredness, but only was ·first described by Mannheimer et al. over the last three months had she con­ in 1952. Subsequent studies (Reynolds, sidered the possibility of physical illness. 1968; Klipstein, 1964; Malpas et al., 1966) One month before admission she was have established that such anaemia is due given iron tablets without symptomatic to a Idisturbance of folic acid metabolism improvement. Instead, she developed and may be associated with a variety of shortness of breath on exert:on, extreme anticonvulsants. Large-scale surveys have fatigue, dizziness, palpitations and ankle revealed that serum and red cell folate swelling. She also noted frequent head­ levels are commonly low in patients on aches, and had increasing difficulty in anticonvulsant therapy, but a significant thinking and remembering both recent degree of anaemia is rare. According to and remote events, but did not complain Wintrobe (1967), less than 100 such pa­ of soreness of the tongue, paraesthesiae, tients have been reported. A case of unsteadiness in walking, gastro-intestinal severe megaloblastic anaemia complicat­ disturbances, or loss of weight. Three ing therapy with phenobarbitone and days before admission, a doctor had given diphenylhydantoin sodium (phenytoin) is her cyanocobalamin lOOO p.g. intramuscu­ here described. larly, though no haematological investi­ gations had been performed. Case Report On examination she was a moderately obese dyspnoeic woman with striking A 41-year old married woman was pallor of the mucosae and skin, and there admitted to St. Peter's Hospital, Chertsey, were several bruises on the extensor sur­ Surrey, in November 1970, complaining faces of the arms and shins. The tongue of increasing tiredness, shortness of was normal. She had a regular full­ breath and ankle oedema. Since the age volume pulse of 96 per minute, with a of 10 she had been suffering from grand blood presure of 120/60. The apex beat mal epilepsy which had been treated with was 8 cm. to the left of the midline, and phenobarbitone 60 mg. t.d.s. and pheny­ the impulse was hyperdynamic; there was toin 100 mg. t.d.s. On this regime she an apical triple rhythm with a soft mid­ had approximately one fit every two systolic murmur; the jugular venous pres­ months. She was one of a pair of identi­ sure was raised to 5 cm., and bilateral cal twins, and her sister had also deve­ basal crepitations, a tender enlarged liver loped epilepsy at the same age. The and sacral and ankle oedema were also patient had undergone a cholecystectomy observed. A firm enlarged spleen was for gall stones in 1963, and had been felt 6 cm. below the left costal margin. successfully treated for iron deficiency Numerous round and flame-shaped hae­ anaemia in 1964. Menstruation had ceased morrhages and soft exudates were seen in 1968. There had been no children from in the optic fundi. The remainder of the her 16-year marriage. neurological examination was normal and Her present symptoms had developed in particular there was no evidence of pe- 44 ripheral neuropathy or cerebellar distur­ haemoglobin level rose from 6.3 g/100 bances. m!. to 10.5 g/100 ml., at which stage she Immediate investigations gave the was discharged from hospital. Treatment following results: by folic acid 5 mg. t.d.s., phenobarbitone Haemoglobin 4.5 G/100 m!. (32%) 6c) mg. t.d.s., sulthiame 200 mg. q.d.s. and PCV 14%, MCHC 33%, MCV 115 cU.mm. diazepam 10 mg. nocte was continued. Reticulocytes 25% Initially, treatment was also given for White cell count 3000/cu.mm. (neutrophils congest:ve cardiac failure with satisfac­ 74%, eosinophils 2%) tory results. As regards anticonvulsant Platelet count 65,000/cu.mm. therapy, . phenytoin was discontinued on The blood smear showed marked aniso­ admission to hospital and sulthiame (Os­ cytosis, poikilocytosis, a few macrocy­ polot) in increasing doses substituted. tes, occasional erythroblasts, and some There was a deterioration in epileptic polysegmented neutrophil leucocytes. control, three nocturnal fits occurring in Serum iron 75 p,g/100 ml. Total iron bind­ the first two weeks. When folic acid ing capacity 430 p,g/100 ml. treatment was started at the end of the Serum folate assay (Lactobacillus casei second week, fits became even more fre­ method) 2.3 ng/ml. (normal range 6-20 qeent and on one occasion status epilepti­ ng/ml.) cus supervened but was controlled by Occult blood in faeces negative x 3. intramuscular paraldehyde. Eventually Serum vitamin B12 assay (Lactobacillus geod control was re-established using leichmanii method) more than 1000 phenobarbitone 60 mg. t.d.s. and sulthiame pg/ml. (normal range 180 - 900 pg/ml.) 200 mg q.d.s. together with diazepam 10 Vitamin B12 absorption normal by the mg. at night. Schilling method. When last seen at the outpatient cli­ Chest x-ray - slight enlargement of the nic on 24th April 1971 she was well with heart with evidence of pulmonary con­ a haemoglobin level of g/100 ml. gestion. Blood urea and serum electrolyte levels, Discussion liver function tests, electrocardiogram and urine analysis were all normal. Circumstantial evidence leaves little Later investigations showed a mildly doubt that this patient initially had a diminished red cell survival time using megaloblastic type of anaemia, although the 51 Cr-Iabelled red cell method. The it is unfortunate that a diagnostic marrow 3-day stool fat content and xylose absorp­ examination was .not performed. The pe­ tion test were normal. ripheral blood picture which showed A provisional diagnosis of megalo­ severe anaemia, macrocytosis, leucopenia, blastic anaemia following long-term anti­ polysegmented neutrophil leucocytes and convulsant therapy was made. Marrow thrombocytopenia was characteristic, and examination was not performed because the response to cyanocobalamin and later of recent vitamin BI2 medication. It was to folic acid therapy, in the presence of a decided to observe the response to this low serum folate level, was confirmatory. and to continue with oral iron therapy but The red cell survival studies excluded not to add folic acid to the treatment im­ serious haemolytic disease as a cause of mediately. The marked reticulocytosis splenomegaly, and in any case consider­ and rising haemoglobin level which oc­ able splenomegaly may occur in uncom­ curred during the first week following plicated megaloblastic anaemia. At out­ admission is shown in fig. 1. It will be patient follow-up some weeks later there seen that during the second week there had been a marked decrease in the size of was no further rise in the haemoglobin the spleen. Retinal haemorrhages may level. Treatment with folic acid 5 mg. occur with severe anaemia of any type t.d.s. was now added. This was followed but are particularly associated with the by a well-marked reticulocytosis. In the megaloblastic anaemias and the leukae­ first three weeks of folic acid therapy, the mias, and may be related to the associated 45

A.:!-.;5:s.; 0 ., 11, t

B:1. IMIG,., SJ...;U;., 11'1 r...... sl: I1 .r~() L.,y .I.!;C.ID t ~ » Itb

~ 10

].5 , 'J \ \ \ \ \ \, \ ~o 9 •\ \ 1\ \ I \ \ I \ I \ \ \ I \ \ \ \ IS' I \ \ \ ...... - .... ,-...... "- ... 10 t. .,.. ~,c.c..Io"'fk6

Zl 46 thrombocytopoenia. The partial response usually considered to be due to a com­ to vitamin Bl2 therapy in the presence of petitive interaction between the anticon­ a normal vitamin Bl2 absorption was con­ vulsant drug or drugs and folic acid (Klip­ sistent with folate deficiency. There was stein, 1964; Hawkins and Meynell, 1958; no evidence of other causes of folate defi­ Reynolds, 1970). It has also been sug­ ciency such as poor nutrition, malabsorp­ gested that the drugs may interfere with tion, liver disease or severe haemolytic folate absorption (Hoffbrand and Neche­ disease. She had never been exposed to les, 1968). There is no evidence that the drugs of the cytotoxic folate-antagonist mechanism involves liver enzyme induc­ group. There can be little doubt that anti­ tion, which is known to occur with some convulsant drugs, in the combination of drugs, particularly phenobarbitone (Con­ phenobarbitone and phenytoin, were res­ ney, 1967). ponsible for this patient's haematological Anticonvulsant-induced anaemia in­ picture. variably responds to treatment with folic Megaloblastic anaemia is a well­ acid in pharmacological doses (Wintrobe, recognised but rare complication of long­ 1967). There may also be a partial or term treatment with phenobarbitone, complete response to treatment with vita­ phenytoin and primidone. Evidence of min Bl2 • This is understandable in view megaloblastic haemopoiesis is commonly of the close association of folic acid and seen in patients undergoing anticonvul­ vitamin Bl2 in basic biochemical processes. sant therapy. A macrocytic blood picture In our patient vitamin B12 therapy led to has been recorded in 11 - 33% of patients a dramatic reticulocytosis but a small rise on anticonvulsant treatment (Malpas et only in the haemoglobin level. A further al., 1966; Ibbitson et al., 1967; Hawkins marked and persistent rise followed the and Meynell, 1958) and megaloblastic exhibition of folic acid therapy. changes on bone marrow examination in The institution of folic acid therapy 38% (Reynolds et al., 1966). Serum vita­ in patients with anticonvulsant-induced min Bl2 levels are almost always in the folate deficiency may in turn cause certain normal range in these patients, though the problems. An increase in the frequency levels are often lower than in control or severity of epileptic attacks may be in­ subject (Malpas et al., 1966). On the duced, and status epilepticus has been other hand, evidence of a disturbance of observed (Chanarin et al., 1960; Wells, folate metabolism is commonly found. 1968). It has been suggested that the Serum folate levels of less than 5 p.gjl00 anticonvulsant action of phenobarbitone m!. in up to 80% of patients on anticon­ and phenytoin may be at least in part due vulsant therapy have been reported (Ibbit­ to their effect on folic acid metabolism son et al., 1967; Reynolds et al., 1966). (Reynolds et al., 1966), the low serum FIGLU tests are of no value in detecting folate level contributing to adequate con­ this type of folate deficiency (Reynolds et trol of the epilepsy. It is possible that al., 1966). On this evidence it has become the temporary deterioration which oc­ generally accepted that disturbed folic curred in our patient may have been re­ acid metabolism is commonly associated lated to the initiation of folic acid therapy with prolonged anticonvulsive treatment. as well as the discontinuation of pheny­ This induced folate deficiency rarely leads toin. It is uncertain whether in patients to megaloblastic anaemia, and rather more with anticonvulsant-induced anaemia, the commonly according to some (Reynolds offending anticonvulsants should be dis­ et al., 1966), to such other manifestations continued and others substituted in addi­ as mental, emotional and behavioural de­ tion to folic acid administration. It is terioration, florid psychiatric disturbances, usually recommended that the dose of peripheral neuropathy, intestinal malab­ these drugs should be reduced to the low­ sorption and secondary infertility (Hughes est compatible with adequate epileptic J ones, 1968). control, as there is some evidence that The mechanism of the disturbance of folate deficiency is related to the dose folic acid metabolism is obscure. It is (Hawkins and Meynell, 1958) and dura- 47 tion (Klipstein, 1964) of anticonvulsant Acknowledgement therapy. In our patient sulthiame, which does not appear to interfere with folic My thanks are due to Dr. K. F. R. acid metabolism, was substituted for phe­ Schiller of St. Peter's Hospital, Chertsey, nytoin but phenobartitone had to be con­ Surrey, for permission to publish this case tinued to control her epileptic attacks. and for help in the preparation of this It is self evident that folate deficiency paper. resulting from anticonvulsant therapy, when it causes such serious sequelae as References megaloblastic anaemia or peripheral neu­ ropathy, must be treated, but does folate CHANARIN 1.. LAIDLow J .• LOUGHBRIDGE L.\\'. and deficiency per se require treatment? Is M-::lLLD! D.L. (1960) Br. med. J .. I. 1099. there a case for the routine administration CONNEY A.H. (1967) Pharmac. Rev. I9, 317. of folic acid supplements in all patients on HAWKIXS C.F. and MEYNELL M.J. (1958) Q.J1. Med. 27, 45· long-term anticonvulsant treatment? The HOFFBRAND A.V. and NECHELES T.F. (1968) Lancet. answer must depend on how far the anti­ 2~ 528. convulsant action is indeed dependent on HUGHES JONES N.C. (1968) Cl:n:cal physiology 3rd. disturbed folate metabolism. It would EdiEon p. 239. seem that, in the present state of our IIlBlTSOX R.N., DILENA B.A.. and HORWOOD J .M. knowledge, supplementary treatment with ([967) Australasian Ann. Med. r6, 144. folic acid should be restricted to those KLIPSTETN F.A. (1964) Blood. 23, 68. patients in whom psychiatric or neurolo­ MALPAs J.S .• SPRAY G.H .• and WITTS L.T. (1966) gical disturbances are present, or who Br. med. J. I, 955· have developed megaloblastic anaemia. MANNHE1MER E., PAKESCH F., REIMER E.F .• anc! All epileptic patients on anticonvulsant VETTTER H. (I952) Med. K1:n. 47. 1397· therapy must therefore be monitored for REYNOLDS E.H. (I968) Brain. 9I, I97. REYNOLDS E.H. (II970) Modern Trends in Neu;:o~ogy, neurological, psychiatric and haematologi­ 5th. Vol.. p. 281. cal deterioration, so that folic acid supple­ REYSOLDS E.H .• MILNER G .• MATTHEWS D.M .• and ments may immediately be given if the CHANARlN 1. (I966) Q. J1. Med. 35, 521. deterioration, which often develops insi­ 'VELLS D.G. (I968) Lancet. I, I46. diously, can be traced to folate deficiency. WINTROBE M.M. (I967) Haemato~ogy. 6th. Edit:on, p. 552. 48 RECU RRENT TETAN US

JOHN B. PACE, M.D., B.PHARM., F.R.C.S, Department of Surgery, Royal University of Malta and ANTHONY BUSUTTIL, M.D. * Department of Pathology, Royal University of Malta

Summary A recent survey of cases of tetanus encountered in Malta during the period Tetanus may recur in 0.5 - 1.0% of 1954-1968 uncovered three instances of cases, months or years after the initial recurrence. The purpose of this paper is infection. A review of the literature un­ to report these three cases and to discuss covered 98 cases of recurrent tetanus re­ the possible underlying aetiological fac­ ported to date. Three cases of recurrent tors and therapeutic problems of recurrent tetanus encountered in Malta between tetanus. The details are taken from the 1954 and 1965 are presented. The recur­ records of St. Luke's Ho.spital, Malta. rent illness has a lower mortality rate than that of tetanus in general, but its Case Reports treatment presents some difficulties and hazards, mainly of an immunological na­ Case I. ture. The possible reasons for recurrence (1) The patient was V.M., a 56-year­ of this disease are reviewed and prophy­ old field labourer. Some twelve days lactic measures are suggested. after sustaining a punctured wound in the right foot through the spines of a sea It has been known for over half a urchin, he developed lock-jaw, dysphagia century that a clinical attack of tetanus and neck stiffness. He was admitted to can occur in the same individual more hospital on 21st May, 1954, three days than once. A review of the world litera­ after the onset of symptoms. ture showed that ninety-eight cases of re­ On examination, he was apyrexial and current tetanus have been recorded. Vener had a pulse-rate of 82 per minute. Marked and Bower (1940) found five documented trismus and neck rigidity were evident. cases and described an additional case. The punctured wound in his right foot was By 1950, fifty-four cases had been reported hardly detectable. in the German and French literature (Mo­ Treatment for tetanus was instituted. bus, 1950). In an analysis of 202 cases of The patient was placed in a darkened, tetanus, Garcia Palmieri and Ramirez quiet room and sedated by means of Para­ (1957) included five instances of recur­ ldehyde retention enemata. After the rence of the disease. Thirty-three other uneventful injection of a test-dose of anti­ cases were added to the literature by va­ tetanic serum, 100,000 I.U. of tetanus anti­ rious authors between 1954 and 1968 toxin were administered intravenously. (Martin and McDowell, 1954; Gunaratna, Fluid balance and adequate nutrition were 1958; Alhady, 1961; Wickramasinghe and maintained by means of intravenous dext­ Malinie Fernando, 1967; and Sahadevan, rose-saline infusion and nasa-gastric tube 1968). feeding. Steady improvement occurred on this * Present address: Pathology De­ treatment. The trismus and dysphagia partment, Western Infirmary, University receded in a few days, allowing the dis­ of Glasgow. continuance of intravenous and tube feed- 49 ing; and all the signs of tetanus disap­ rigidity was marked and the tendon re­ peared within a fortnight. The patient flexes were exaggerated. was discharged from hospital on 5th June, Initial treatment consisted in Chlor­ 1954. promazine, 25 mg. every 8 hours; crystal­ (2) Sometime in November, 1956, line Penicillin, 1 million units twice daily; V.M. sustained a punctured wound in the and Streptomycin, 0.5 Gm. twice daily. left sole and, a few weeks later, he noticed No improvement was recorded on this a septic fissure in the first interdigital treatment. Five days after admission the cleft of the right foot; he ignored both patient developed painful generalised mus­ lesions. On the 7th January, 1957, he cular spasms. At this stage, 200,000 LU. developed increasing stiffness in the lower of tetanus antitoxin were administered limbs followed by inability to open his intravenously at the rate of 15,000 LU. mouth, difficulty in swallowing and pain­ every half-hour. Following this, the ful neck stiffness. When admitted to hos­ symptoms and signs of tetanus gradually pital, on 10th January, 1957, he was run­ subsided over a period of two weeks. The ning a temperature of 100° F. (37.7° C.) patient's discharge from hospital was de­ and his face was flushed and exhibited a layed until August 10, 1959 because in­ typical 'risus sardonicus'. Marked rigidity vestigations and treatment had to be car­ was present in the muscles of the neck, ried out for coincidental urogenital and abdomen and lower limbs. The tendon arterial disease. reflexes were very brisk. Generalised (2) M.G. was re-admitted to hospital muscular spasms occurred periodically. on April 1, 1960 complaining of epigastric Treatment followed the previous discomfort of a few days' duration, as­ lines. After intra-dermal, subcutaneous sociated with ingravescent stiffness of the and intramuscular test-doses of A.T.S. had abdominal muscles, followed later by pro­ been given without producing any hyper­ gressive spasticity of both lower limbs sensitivity reaction, 195,000 LU. of tetanus and rigidity of the back muscles. Twenty­ antitoxin were given very slowly by intra­ four hours before admission he developed venous drip. One million units of crystal­ dysphagia and intermittent generalised line Penicillin intramuscularly twice daily muscular spasms. He could not recall and 5ml. of Paraldehyde intramuscularly having received any wounds within the 6-hourly were also administered. preceding few days or weeks. The intermittent spasms ceased with­ On examination, the patient was afeb­ in days and the patient made a full re­ rile and had no obvious wounds; he had covery within two weeks. He was dis­ trismus and muscular rigidity of the abdo­ charged from hospital on 25th January, men and back. 'Flare-up' of tetanus was 1957. diagnosed and treatment commenced. In view of the patient's previous experience Case 11. of horse serum, three test-doses (intra­ dermal, subcutaneous and intramuscular) (1) M.G., a farmer aged 70 years, of A.T.S.: were given at half-hourly inter­ was admitted to hospital on May 4, 1959. vals: although there was no hypersensi­ He gave a two-day history of lumbo-dorsal tivity reaction, the therapeutic dose of te­ backache and increasing stiffness, the tanus antitoX'in was restricted to 10,000 latter commencing in the back and spread­ LU. and administered intramuscularly un­ ing to become generalised. He also expe­ der antihistaminic cover (Diphenhydra­ rienced difficulty in articulation and swal­ mine hydrachloride 50mg. t.d.s.). Intra­ lowing. There was no history of wound­ muscular injections of Penicillin (l million ing but a healed punctured wound was units every 6 hours) were also given. discovered on the plantar aspect of the During the first two days of treatment right big toe. the muscular rigidity became more severe, The patient was pale and sweating, but no further spasms were recorded. The and presented the typical facies of tetanus. symptoms then slowly regressed and re­ Trismus was present, abdominal and back covery was complete in 26 days. The pa- 50 tient was discharged from hospital on Initial treatment consisted in 105,000 April 27, 1960. LU. of tetanus antitoxin by intravenous (3) The same man (M.G.) was re­ infusion; Penicillin 0.5 Megaunit 6 hourly; ferred to hospital for the third time on Streptomycin, 0.5 Gm a day; and Paral­ October 28, 1960, with a 6-day history of dehyde, 5 ml six hourly. increasing difficulty in masticating and During the first few days generalised swallowing so1:d food. Again, there was convulsions took place frequently and, on no history of recent injury. the fourth day, a further intravenous dose On examination, there was obvious (50,000 LU.)· of antitoxin was given. trismus and general muscular rigidity; the Thereafter, the muscular spasms became tendon reflexes were brisk and sustained. milder and less frequent, until they ceased The temperature was within normal limits. by the ninth day of treatment. The tris­ Tetanus was suspected with some reserve mus and general rigidity took longer to in view of the two previous attacks, and clear up. By August 27, 1964 there were treatment was witheld during the first no residual signs of tetanus and the pa­ twenty-four hours of observation. By the tient was discharged. second day of admission, however, the (2) On July 1965, the same boy progression of the rigidity had made the (M.A.) was referred to hospital with a diagnosis of tetanus obvious. two-day history of jaw stiffnes, inability Treatment consisted in the intramus­ to swallow and VOice-change to the nasal cular injection of 10,000 LU. of tetanus type. This time there was no history of antitoxin, with the usual precautions, Pe­ recent injury. nicillin (1 million units twice daily), Strep­ On examination, he had a tempera­ tomycin (0.5 Gm twice daily) and Paral­ ture of 100° F (37.7° C) and a pulse-rate dehyde (5 ml 6 hourly). of 96 per minute. Trismus was consider­ The symptoms and signs gradually able and the tendon reflexes were brisk subsided over a period of two weeks and and sustained. No local cause in the head the patient was finally discharged home and neck was found to account for the on November 19, 1960, twenty two days presenting symptoms; no enlarged cervi­ after admission. cal lymph nodes were present; and no wounds were detected. Case Ill. In view of the patient's previous ex­ perience of A.T.S. and the mildness of the (1) M.A., a nine-year-old schoolboy, symptoms, only a fractionated dose of was referred to hosp'ital as a case of teta­ 1,500 LU. of tetanus antitoxin was given nus on July 17, 1964. Nine days pre­ initially, but Penicillin, Streptomycin and viously he had sustained a cut in his left Paraldehyde were administered as usual. big toe while unpacking cases in a ware­ During the first two days, the trismus house. He gave a four-day history of increased and a progressive painful rigi­ increasing limitation of jaw movement, dity developed in the muscles of the neck, pain on swallowing, stiffness of the neck abdomen and lower limbs. On July 21, and pain in the back. the third day after admission, the full On admission, the patient ran a tem­ treatment regime for tetanus was insti­ perature of 99° F (37.2° C) and had a pulse tuted: an intravenous infusion of dextrose­ rate of 100 per minute. He had a typical saline was set up, a naso-gastric tube was 'risus sardonicus', trismus and rigidity of inserted for feeding purposes; Paraldehyde the neck and abdominal muscles. Gene­ was administered more frequently and the ralised muscular spasms occurred from Penicillin dosage was increased; tetanus time to time. A healing incised wound antitoxin (200,000 LU.) was infused very was present on the plantar aspect of his slowly intravenously, with the usual pre­ left big toe; in addition he had bilateral cautions against anaphylaxis. In spite of otitis with purulent discharge. An aural this, the signs of tetanus increased in se­ swab gave a mixed growth of non-speci­ verity during the next few days. Further fic organisms. intravenous doses of antitoxin were given 51 on July 22 (100,000 LU.), on July 25 exception of the first, it is very difficult (50,000 LU.) and on July 29 (50,000 LU.). in practice to distinguish between these Following the last dose of antitoxin, various types of recurrence. In the first the patient's recovery from tetanus was instance, the apparent wound may not be rapid, but his discharge from hospital was the portal of entry of Cl. tetani; while delayed until August 17, 1965 because of several cases of tetanus have no demonst­ infection at onc of the sites used for intra­ rable wound. The possibility of asympto­ muscular injections. matic residual clostridial contamination of wounds is well known, and the longevity Discussion of Cl. tetani spores in such lesions is noto­ rious. Moreover, clostridial spores may It is, perhaps, not widely known that be present in trivial, healed, long-forget­ tetanus may recur in the same individual. ten or unknown wounds, where they are In one of our cases (n) the illness recurred very often undetectable, and their rever­ twice. A recent survey (Pace, Busuttil sal to the pathogenic vegetative form is and Muscat, 1968) has shown that the in­ unpredictable. On the other hand, of cidence of tetanus in the Maltese Islands course, fresh infection through new overt averages 19.4 cases a year; on the basis or occult wounds is an ever-present pos­ of this figure, the three cases of recurrent sibility and may occur at any time after tetanus reported above represent an ap­ recovery from tetanus. Therefore, any proximate incidence of 1% of all cases of attempt to differentiate relapse from re­ tetanus. In their series of 2,007 cases of infection on the basis of the length of the tetanus, Patel et al. (1961) recorded a re­ sympton-free period between attacks of currence rate of 0.84% while Vakil et al. tetanus, as suggested by the above-men­ (1964) estimated an incidence of 0.5%. tioned authors, would have no scientific The interval between consecutive at­ foundation. In clinical practice, the allo­ tacks of tetanus ranged, in our cases, cation of given cases of recurrent tetanus from 6 to 32 months. A distinction has into one or other of the three theoretical been made in the past between 'relapse' types proves impossible in the majority. and 're-infection', on the basis of this time In our view, such a classification is only interval. Vener and Bower (1940) defined of academic interest and serves no prac­ 'relapse' as recurrence of the manifesta­ tical purpose, since it has no bearing on tions of tetanus within one month of re­ diagnosis, course, treatment or prognosis. covery from the previous attack through There is now ample evidence that one persistence of the original infection; while or more attacks of tetanus do not guaran­ Patel et al. (1961) considered as relapse tee immunity from recurrence, nor do they any recurrence within six months. In our necessarily render any subsequent at­ view, the distinction between relapse and tack(s) less severe. Turner et al. (1957) re-infection cannot be made on the and Vakil et al. (1964) have shown that grounds of an arbitrary time factor. In there is little or no active immunity, as fact, there may be three kinds of recur­ measured by the amount of circulating rence, namely: endogenous antitoxin just after the initial (1) recrudescence of symptoms and attack and during the recurrent bout of signs within a few days of apparent re­ tetanus. It is possible that the surviving covery, due to incomplete control of the cases of tetanus have been exposed to initial infection; (2) relapse of the illness only a small dose of toxin, insufficient to as a result of reactivation of persisting be lethal and inadequate to elicit a signifi­ dormant infection in the original causative cant immune response (Turner et al., lesion, weeks or months after control of 1957). It is also possible that the large the previous attack; or (3) re-infection of therapeutic doses of antitoxin adminis­ the recovered patient with Cl. tetani tered during the survived attack depress through the primary unhealed lesion or the patient's active immune response by through a fresh wound, followed by the neutralising toxin before it can exert its reappearance of clinical tetanus. With the antigenic effect (Cook & Jones, 1943; 52

Oakley, 1963). A very small minority of lactic reactions looms large (vide Cox, individuals may be subject to recurrent 1963). Although, fortunately, none of our infection because they possess an incom­ patients developed untoward reaction to petent immune system (Soothill and Squi­ A.T.S., Vakil et al. recorded hypersen­ re, 1963). The ten antigenic strains of Cl. sitivity reactions in 6 out of 11 patients. tetani all produce an immunologically In view of this, if A.T.S. has to be used, identical exotoxin (A. Trevor Willis, 1964); the routine employment of repeated test but, in spite of this qualitative similarity, doses followed by fractionation of the some strains may provide a quantitatively therapeutic dose should be the rule; con­ weaker antigenic stimulus than others and, commitant cover with antihistaminics or therefore, are less likely to produce a corticosteroids may also have to be con­ significant degree of active immunity. sidered. Ideally, Human Tetanus Hyper­ Finally, Patel et al. (1961) consider that, immune Globulin should be used as this even if some immunity is acquired as a would be safe and effective, but it is still result of the first attack of tetanus, it is rare and expensive. likely that a highly virulent infection In the light of the foregoing, prophy­ would swamp the defences and result in laxis emerges, as always, the ideal to be a second attack of the disease. aimed at. Active immunisation by means The mortality from recurrent tetanus of adsorbed toxoid should be offered to seems to be lower than that from tetanus all recovered cases of tetanus. It would in general: none of the cases reported in seem particularly advisable in 'high-risk' this paper ended fatally. Vakil et al. individuals, such as children, field labour­ (1964) ascribed this to a tendency for ers and patients suffering from chronic earlier admission to hospital of those pa­ ulceration or undergoing self-administered tients with recurrence. We feel, however, parenteral therapy, particularly diabetic that the first infection confers a certain degree of active immunity which, al­ Acknowledgements though inadequate to prevent the reap­ pearance of the clinical manifestations of We wish to thank Professor V. G. tetanus, is sufficient to afford some pro­ Griffiths, Head of the Department of Sur­ tection. gery, Professor A. P. Camilleri, Dean Recurrent tetanus presents important Faculty of Medicine, and Dr. A. Cuschie­ clinical problems. It is uncommon and is ri, Chief Go"ernment Medical Officer, for relegated to further obscurity by the fai­ kind permission to publish. lure of many textbooks to include a few words acknowledging its existence. This References fact, coupled with the occasional absence

of an obvious portal of entry of infection ALHADY, S.M.A. (1961). Med. J. A

Paper read i\.SS. Surg. and Phys., Malta. VAKIL, B.J., MEHTA, A.J. and TULPuLE, T.H. PATEL, J.c., MEHTA, B.C., DHIRAWAKI, M.K. and (1964). Post. Grad. Med. J., 40, 60I. MEHTA, V.R. (1961) J. Ass. Physcns. Ind.a, 9, T. VENER, H.I. and BOWER, A.G. (1940). J. Amer. PAYLI:-iG WRIGHT, G. (I958). Proe. R. Soc. Mei., Med. i\ssoe., II4, 2198. 51, 999· \VICKRAMASIKGHE, S.Y.D.C. and MALINIE FERNANDO SAHADEVAK, M.G. (1968). Br:t. Med. J., 2, 492. (1967). Br:t. Med. J., 4, 53 0 . SCClTHIL, J.F. a:d SQUIRE, J.P. (1963). Clinical WILLIS, A. TREVDR (1964). "Anaerob:c Baetel":ology As;:>eels of Immuno:ogy. (B:ackwell Scientific in CLn.:eal Mclj c ne". (Butterworth) 2nd Ed. Pub::caf ons, Oxford), p. 307. p. 179· TUR:-iER, T.B., VELASC.:J-JOVEN, E.A. and PRU­ \\'ILSON, G.S. and MILES, A.A. (1964). "Princ:p:tS DDVSKY, S. (1957). Bull. Johns Hopk:ns Hosp., of Bacter:ology and Immunity". (Edw. Arnold), [02, 71. 2, 1096.

SOME ASPECTS OF BRUCELLOSIS

EMANUEL AGIUS, B.Sc., M.D., D.P.H., DIP. BACT., F.R.C.PATH., F.B.M.A. ROSEMARY PEPPER, B.Sc. DAIRYING (READING), M.Sc. (CANTAB.) Dept. of Bacteriology, St. Luke's Hospital.

The occurrence of human brucellosis study of the disease in the animal popu­ in Malta is of long standing and has pre­ lation in Malta and of the possible means sented various problems ever since it be­ of preventing it was carried out by an ex­ came accurately diagnosable and clearly pert working for F.A.O./W.H.O. and the distinguishable from other prolonged Government of Ma'lta, in conjunction with fevers. Between 1896 and 1964 incidence Government veterinary officials and has ranged from a maximum of 81.6 per others. A vaccine was tested, found to be 10000 inhabitants· in 1946 (2410 cases) to effective and safe and put to limited use. 1.7 in 1964 (56 cases). In 1939 centralised Various measures were taken to control pasteurization of milk was introduced but caprine and bovine brucellosis and a only in a small area (Valletta and Floriana), decrease was noted both in the animal with a population of about 24000, was the and in the human incidence of the illness. introduction and use of unpasteurized milk (Alton G. G. 1968). The reported inci­ then forbidden by law. Gradually this dence in man since 1964 has been as fol­ prohibition was extended until it became lows: 70 cases in 1965, 24 in 1966, 29 in complete in 1964, the last area in which 1967, 14 in 1968, 57 in 1969, and 51 in the ban was made effective being the is­ 1970. Throughout this period the popu­ land of Gozo which, with a population of lation can be considered to have remained about a tenth of that of the two islands, stable at about 320,000. The fact stands had an incidence of brucellosis ranging out that by 1968 a record lowering of in­ from a sixth to as much as half of the cidence had been obtained and one could total number of cases over the period 1953 reasonably have begun to hope for eradi­ to 1969. (Agius, 1965) cation of the illness. This could only be Between 1956 and 1969 an intensive attained by the eradication of the disease 54 in the animal reservoir such as has in fact being of an automatic, self-registering been attained in some countries. character. Surveillance is exercised over The incidence since 1968, however, is milk as it reaches the consumer both by disturbing for instead of the expected the laboratory attached to the Milk Mar­ further decreases or, at least, stabilisation keting Undertaking and, quite indepen­ of the position, there have been notable dently, by the laboratory at the Head Of­ rises. The writers, working in the Bacte­ fice of the Health Department, a large riology Department of the main and by far number of samples being regularly exa­ the largest general hospital in the island, mined every week. (Report, Hea'lth Dept. have an opportunity of learning about the Malta). No test has ever shown any fault occurrence of cases and they believe that in pasteurization or anything to suggest the real number of cases is certainly the possibility of pathogenic micro-orga­ greater though not very markedly so than nisms having survived the heat treatment. the number of cases reported. There is It is also probable that if unpasteurized often some doubt about the point at which milk had ever gone out to consumption a positive agglutinin titre can be consi­ there would have been a noticeable out­ dered as diagnostic of an active and pre­ break comparable in character to that of a sent infection but the incidence would be water-borne epidemic; this has not been stilt higher, judging by laboratory findings, the case. than the reported incidence even if only In every reported case the Health a titre of 1/320 or higher is taken as signi­ authorities carry out a close investigation, ficant. In 1970, for example, there were which generally, but by no means always, 12 such cases including two with a posi­ leads to suspicion being cast on some tive blood culture. Failure to notify does definite way of infection. Between the not generally arise from a reluctance to 7th and the 22nd March 1969 a milk sup­ accept the agglutination reaction( at least pliers' strike led to a suspension of the at 1/320 or higher) as a positive finding pasteurized milk service. It was still ille­ but through other causes often purely gal to sell unpasteurized milk throughout fortuitous. In fact it is probable that that period but obviously the temptation some cases with a titre below 1/320 may for the milk producers to sell milk ille­ be ones of active brucellosis; one such case gally was very great. At St. Luke's during with a titre of 1/80 had a positive blood the first 3 months of that year there had culture. In view of this it is likely that been only 5 cases of brucellosis whilst the real number of cases markedly ex­ there were 57 cases by the end of Decem­ ceeds the reported incidence. This is not ber. In 1970 there was a similar strike surprising since this occurs everywhere from the 14th to the 28th April; there had to a varying extent and can be allowed been 22 cases up to April and there were for. However in our environment and 60 cases in the remaining 8 months. It under the prevailing circumstances this was not possible to explain every case on has a particular importance. When era­ this basis; in fact this would apply only dication is being aimed at completeness in a few cases. of notification becomes vital, since the origin of every case must be accounted Frequently, questioning rules out the for. In brucellosis fortunately the human possibility of the infection having arisen patient is not very important as a cause from the consumption of milk; a surpris­ of other cases but even this aspect should ingly large number of persons insist they be considered. never use milk as such, the majority main­ How can the cases which have arisen taining they use either pasteurized or since 1968 be accounted for? The ques­ tinned milk. In such cases the alterna­ tion is not easily answered. Obviously tives are: the first point to consider is whether a) contraction of infection through pasteurised milk could have led to infec­ occupational exposure. Locally there tion. In fact a close surveillance of the have been cases amongst workers in labo­ whole process is maintained, most of it ratories, in a veterinarian and in a doctor 55 where one could almost establish the in­ Brucellosis (Report, 1971) states that cident which led to infection. Brucella melitensis can survive in cheese b) through ingestion of accidentally for 100 days. One is reluctant to attribute contaminated food. This is often a sur­ the illness to the consumption of cheese misal but cannot be ruled out. One prac­ since most people eat cheese at some time tical possibility is through consumption of or other and the explanation may appear meat from animals which could have been too facile, but it very often seems to be harbouring Brucella organisms. (Agius the only one discoverable. Ferrante 1970). Meat from various ani­ Complete eradication of the disease mals is used in sausages, which could be will not occur unless brucellosis is era­ eaten uncooked. In Malta sausages con­ dicated in the animal reservoirs and this sist wholly of meat and are fairly widely still needs the complete putting into effect consumed. of the measures now available. For this c) through inhalation of dust pol­ a sustained effort fully backed by the lo­ luted by urine of diseased animals. This, cal .Government and FAO/WHO is essen­ is only a legitimate surmisal. tial. At the moment things are not quite right from this point of view but there is d) through the consumption of a glimmer of hope that they may be cheese made from infected milk. Patients righted in the not too distant future. frequently admit to the consumption of Notification must be more accurate and fresh cheese and this then appears as the complete. The consumption of cheese is most likely source. For the information one source of infection which could and of non-Maltese readers we may say that should be dealt with at once. The Milk there are special cheeses made in Malta Marketing Undertaking does produce and which are marketed either "fresh", a few sell excellent cheese made from pasteur­ days after they are made and still soft, or ized milk, but it does so intermittently and "dried" for a longer and variable period the supply does not keep pace with the after manufa.cture, when they are harder. demand. It is time the sale of cheese ("gbejniet moxxi"). These latter are some­ made from unpasteurized milk was for­ times consumed after they have been bidden: only so can this loophole be liberally sprinkled with pepper and steeped plugged. It would be an excellent idea for days in vinegar ("gbe;niet tal-bzar"). if the making of cheese locally was Traditionally cheeses are made from changed from a cottage industry to a sheep's milk and sheep in Malta have been properly organised one selling a safe and repeatedly Droven to suffer much less guaranteed product. It also appears rea­ frequently than goats and cows from bru­ sonable to suggest that a warning notice cellosis (Alton 1968). However, even a should be displayed when cheese made small proDortion of animals could be a from unpasteurized milk is being offered source of danger and it is probably true for sale. Apart from every scientific con­ that tradition is occasionally departed sideration one should note that the three from and goats milk is used in cheese types of local cheese are really delectable making. Moreover, one of the great and could grace a gourmet's table. We centres of cheese making is Gozo, where have the makings of an excellent indust­ brucellosis is frequent. Brucella orga­ rial enterprise and even export would be nisms do survive the cheese making pro­ a great possibility when the day comes cess consisting in coagulation with rennet. when one can recommend Malta cheese One of us cultivated Brucella from cheese without any fear. made by the method adopted locally and using artificially infected milk 3 days after Acknowledgements it had been manufactured (Report 1940); Gilli (1943) states it can survive in fresh We thank other members of the labo­ cheese for UD to 44 days. Gargani (1952) ratory staff whose work supplied some of found Brucella to survive for 90 days. The the results quoted, Mr. A. Serge, O. i/c Joint FAO/WHO Expert Committee on Statistics, Health Department and Mr. C. 56

Montebello, Manager of the Milk Market­ AL',·);, G.G., (1958), S:. Luke'~ Ho~:->. Gn. Ma:ta. ing Undertaking. G.\RG\NI, G. (1952), C:n. vet. M lan, 75, 257. References Report. (1<;40) Med. & r-:L,a::h De?t. M'da; (1964- AGIUS, E. (1965) Arch. lust. Pasteur Tun's, 42, 31. 1959) Hea:'th Dept., M:da; (1971) Jo 'lt FAO/ AGIus-FERRANTE, T.J. (1970) Pe:sonal Commun'ca "'HO EXp8rt Comm:::tee en B~uc~'lcGs, F:fth tion. Ropo:·t.

DR. C. DE LUCCA ANO HIS WORK AS A BIOLOGIST MARIO GAUCI

Dr. Carmelo De Lucca who died on ture and Tourism decided to set up a Na­ the 6th March, 1971, was born at Msida, tional Sciences and Folklore Museum at Malta, on the 24th November, 1916. He Vilhena Palace at Notabile, Malta, Dr. De studied at the Lyceum and later at the Lucca was appointed, on the 1st July 1967, Royal University of Malta, where he ob­ Assistant Curator of the Natural History tained the Bachelorship in Science and Section. On the 'death on the 3rd October qualified as a Pharmaceutical Chemist in 1970 of the Curator of the Section, the 1939. He graduated in Medicine in 1943. late Professor H. Micallef, Dr. De Lucca He served as Resident Medical Officer acted as Curator. in the various Hospitals of the island from In 1969, Dr. De Lucca published "A 1943 to 1946. He was appointed District revised check list of the Birds of the Mal­ Medical Officer on the 24th August, 1946 tese Islands". This check-list was the re­ with residence in the village of Gharghur, sult of about forty years of watching, re­ Malta, where he lived until his death and cording and collecting as many specimens in whose neighbourhood he carried out as could be reasonably found in the Mal­ many of his observations on the entomo­ tese Island. Particular attention was given logical and ornithological life of Malta. to re-assessing and determining the sub­ Dr. De Lucca was at the University species of birds found in both islands and of Malta as Demonstrator in Biology for to arranging the Families, Genera, etc., in the periods 1947-50, 1953-56 and from accordance with modern views on Bird January to May 1959 and from 1962 up Systematics. The Publishers (E. W. Clas­ to the time of his death as Lecturer i,n sey Ltd. of Hampton, Middlesex) in the Pharmacognosy. Introduction wrote: ". . . Self -advertise­ In 1964 Dr. De Lucca was invited to " ment would sit strangely on the should­ attend a congress of Mediterranean Bio­ "ers of the author of the present work logists, held at the Institut Oceanogra­ " and in fact, the reader will find that the phique of Monaco by the Commission "work itself is all that is necessary, or Internationale pour l'etude scientifique de "indeed could be said, in praise of his la Mer Mediterranee. At this Congress he " scholarship." read a paper entitled "The place of Lepi­ Through the good offices of Dr. De doptera in the Zoogeography of the Mal­ Lucca, his father, Mr. Vincenzo De Lucca, tese Islands" which was published in the donated in 1969 to the Museum Depart­ Rapports et Proces-verbaux des Reunions ment, Malta, a fine collection of birds con­ de la C.I.E.S.M.M. (volume xviii (2) 1965). sisting of over 600 mounted specimens and When the Ministry of Education, Cul- including a number of rare items. 57

In 1970 Dr. 1. R. F. Brown and Pro­ 1950 fessor W. H. Bannister of the Deparment Contributo all'Ornitologia delle lsole of Physiology and Biochemistry of the Maltesi - "Rivista Italiana di Ornitolo­ Royal University of Malta and Dr. De gia", anno xx, serie II, 1950. Lucca published "A comparison of Mal­ Systemic list of rare or accidental tese and Sicilian Sparrow Haemoglobins" birds caught in Malta since about 1936. in the Journal of Comparative Biochemis­ Casual immigrant Rhopalocera in try and Physiology, vol. 34 published by Malta - "The Entomologist", vol. lxxxiii, the Pergamon Press of Great Britain. February, 1950. Dr. De Lucca was a Member of the An account of species of Rhopalocera British Ornithologists' Union, the British occurring in Malta and recorded by va­ Ornithologists' Club, the British Trust for rious authors. Ornithology and the Societa Italiana di A contribution to the list of Maltese Scienze Naturali, a Fellow of the Royal Lepidoptera "The Entomologist's Entomological Society of London and the Monthly Magazine", vol. lxxxvi, 8th Sep­ local representative of the Royal Naval tember, 1950. Bird Watching Society. Twenty-five species of Lepidoptera A list of publications by Dr. De Luc­ Heterocera caught by the Author during ca is given below: the years 1948-49 and not previously re­ 1948 corded for Malta. Notes on some moths observed at Additional records of Micro-Lepidop­ Malta. "The Entomologist's Monthly tera from Malta - "The Entomologist", Magazine", vol. lxxxiv, 30th July, 1948, vol. lxxxiii, November, 1950. listing seven moths occurring in but not Fourteen species of Crambidae, Ptero­ previously recorded for Malta. phoridae, Phaloriidae, Cosmopterygidae, Some species of Crambidae (Lepi­ Oecophoridae, Ethmiidae and Tireidae doptera, Heteroneura, Pyralinae) observed caught by the Author and not previously in Malta - "The Entomologist", vol. lxxxi, recorded for Malta. October, 1948. 1951 Six species of Lepidopterous fauna Notes on the biology of Cnephasia not previously recorded for Malta. Gueneanae Duponchel (Lepidoptera: Fort­ Some aspects of the Biology of the ricidae) "The Entomologist", vol. Lepidoptera - "Scientia", vol. xiv, No. 2 lxxxiv, September, 1951. April-June, 1948. A description of the life The larval form of this species was stages of Lepidoptera. first discovered by the Author and des­ 1949 cribed in these "Notes". Further moth captures from Malta - New additions to the Lepidoptera of "The Entomologist's Monthly Magazine", Malta - "The Entomologist", vol. lxxxiv, vol. lxxxv, 25th April, 1949. Nine species November, 1951. of Lepidoptera not previously recorded Twenty-five species of Heterocera and for Malta. Microlepidoptera caught by the Author Further notes on Lepidoptera Hetero­ and not previously recorded for Malta. cerna from Malta - "The Entomologist's Monthly Magazine", vol. lxxxv, 22nd Juliy, 1953 1949. Additions to the list of Maltese Micro­ Eleven species of Lepidoptera caught lepidoptera "The Entomologist's between 1940-48 and not previously re­ Monthly Magazine", vol. lxxxix, 28th May, corded for Malta. 1953. Microlepidptera new to the Maltese Twenty species of Crambidae, Phyci­ Islands - "The Entomologist", vol. lxxxii, tinae, Pyralinae, Pterophoridae, Eucosmi­ July, 1949. dae, Glyphipterigidae; Gelechiidae, Plutel­ Twelve species of microlepidoptera lidae, Oecophonidae, Depressariinae, Gra­ not previously recorded for Malta. cilariidae and Tineidae caught by the 58

Author and not previously recorded for 1969 Malta. Emitteri Eterotteri Maltesi - 'Bollet­ 1956 tino della Societa Entomologica Italiana', New additions to the Lepidoptera of vol. xcix - ci, no. 5-6, 20 June 1969. the Maltese Islands - "The Entomolo­ Systematic list of twelve species of gist", vo!. lxxxix, October, 1956. Miridae, Lygacidae, Pyrrhocoridae, Roho­ Thirty-twe species of Nocteridae, Ca­ palidae, Pentatomi'dae, Cydnidae caught radrinae, Phytonetrinae, Catoculinae, Geo­ by the Author and not previously recorded metridae, Sterrhinae, Geometrinae, Phyci­ for Malta. tinae, Pyraustinae, Pteroforidae, Pholonii­ Lepidoptera of the Maltese Islands - dae, Eucomidae, Gelechiidae, Cosmopty­ 'Entomologist's Record' vol. 81, 15th May ridae, Oecophoridae, Coleophoridae, Ti­ 1969. Systematic list of twenty-six species neide caught by the Author and not pre­ Heterocera and Microlepidoptera caught viously recorded for Malta. by the Author or by Mr. P. Sammut and not previously recorded for Malta. The 1959 Author also refers to the capture of six­ Note sull'Ornitologia delle Isole Mal­ teen rare species during the period 1951- tesi - "Rivista Italiana di Ornitologia", 66. XXIX year, series 11, Milan 1959. Bird migration over the Maltese Is­ The correct status of many subspe­ lands 'Ibis' Ill, July 1969. cies of birds new to Malta assessed by the A broad survey of bird migration. Author and his father, Mr. Vincenzo De A revised check-list of the Birds of Lucca - co-authors of these "Note". the Maltese islands - E. W. Classey Ltd. 1965 Hampton, Middlesex, Fefruary 1969. The place of Lepidoptera in the Zoo­ Besides giving a true picture of the geography of the Maltese Islands - Ex­ past and present status of the various traits des Rapport et Proces-verbaux des species of birds found in the Maltese Is­ Reunions de la Commission Internationale lands, the Author gives the subspecies or pour l'etude scientifique de la Mer Medi­ races of all the birds known to occur or terranee, volume xviii (2) 1965. to have occurred in the Maltese Islands as A paper on the faunal and vegetation migrants, resident, rare visitors or vagrant aspects and the characters of Maltese Le­ and records those species or subspecies pidoptera prepared and read by the Auth­ that have been identified since 1917 includ­ or at a congress of Mediterranean biolo­ ing new occurrences. gists held at Monaco in 1964. Besides the abovementioned publica­ tions, Dr. De Lucca supplied the necessary 1967 material on which the following publica­ The migration of birds - "Journal of tions were prepared - Une nouvelle va­ the Royal University of Malta Biological riete d'Aciptilia: A. spicidactyla insularis Society", - January, 1967. nova by L. Bigot in 'Lambillionca', vo!. Notes on the Migratory movements lxi, nos. 7-8 of the 25th August 1961. of birds. A description of a moth, based on Cisticola juncidis in Malta" - "Ibis", specimens caught and supplied by Dr. De 109, no. 4, October 1967. Lucca and which, on account of the Recording the occurrence of four smaller wingspan, M. Bigot considered to birds of this species at Salini, Malta, in be a species different from the typical one. June, 1967. Two new: Micro-Lepidoptera from Appunti sull'Ornitologia delle Isole Malta - by Dr. H. G. Amsel of Baden, Maltesi - 'Rivista Italiana di Ornitologia', 'The Entomologist', vol. lxxxv, no. 1071, XXXVII year, series 11, Milan 1967. - August 1952. Systematic list of rare or accidental birds Description of a new species which occurring for the first time in the Maltese the Authur dedicated to Dr. De Lucca Islands between 1955 and 1966. (Oegoconia deluccai sp.n.) and of a new 59 species (Apatema fasciata melitensis ssp. Amsel after Dr. De Lucca (Praeacedes n.) which were both caught in Malta by deluccae sp.n.). These lepidoptera were Dr. De Lucca in October 1950. caught by Dr. De Lucca in Malta. Newe Pterophoriden, Gelechilden und Uber Mediterrane Micro-Lepidopte .. Tineiden aus Paliistina und Malta by Dr. ren und einige Transcaspische arten von H. G. Amsel of Buchenburg/Baden in Bull. Hans Georg Amsel (Karlsruhe) in the Soc. Fouad ler Entom.' xxxviii, 1954 (51). 'Bulletin' of the Institut Royal des Sciences Description of four new species of Naturelles de Belgique, tome xxxi, no. 83, Pterophoridae, Gelechiidae and Tineidae. Bruxelles, December 1955. Of these species, one was named by Dr.

RETROPERITONEAL TUMOURS A Study of Five Cases

J. A. MUSCAT, M.D., F.R.C.S. Senior Surgeon MARIE THERESE PODESTA', M.D. House Surgeon St. Luke's Hospital

Retroperitoneal tumours and cysts weeks prev:ous to admission he had had are often regarded as a nebulous group of a bout of melaena, and four days before lesions with a sinister reputation, prob­ admission he had haematuria with passage ably through their uncommon incidence of clots per urethram. There was no coupled with the fact that their potential haematemesis, no haemoptysis and no site of origin, is anatomically extensive chest pain or cough. and may be remote. The many and varied On examination he looked pale. There pathological classifications put forward in was no cervical node enlargement. Pulse the literature add 'little to help one form 80, regular; B.P. 140/80. a sharper mental picture of the clinical There was good chest expansion, problem they pose. The present commu­ good air entry throughout and normal nication is a study of five cases which breath sounds. The heart sounds were have all come under our care in the space normal. of a few months. Abdominal examination revealed a tender mass in the left loin. Special in­ Case 1. P.B. Male aged 29. vestigaNons were as follows: First admitted to hospital in Mel­ Ba. Meal: No free oesophageal reflux bourne, Australia in February 1970 with or hiatus hernia. Stomach was reason­ a history of progressive loss of appetite ably well filled and outlined. No obvious coming on ,in December 1969 followed, organic lesion could be seen. Unable to within a month, by continous pain in the fill the duodenal cap sufficiently to exclude back felt on both sides but worse on the pathological states. left. He also complained of epigastric Chest X-Ray - Pleural fluid left base. pain felt immediately on eating. Three No obvious pulmonary changes. 60

Hgb. 9 G., Prothrombin 80% Serum Bilirub:n 0.3 mgm %. At operation, preliminary cystoscopy, reVealed blood and clots coming from left ureteric or,ifice. Laparotomy showed a large hard craggy retroperitoneal mass extending from the level of L.l beneath the spleen, acoss the pancreas to beneath the liver. The mass was invo~ving the left ureter and lymph nodes in the greater omentum. The small bowel was clear of tumour. Biop3y material was reported up­ on thus: A large firm lymph node measur­ ing 1.5 by 2 cms. M'croscopically almost all the lymphoid tissue is replaced by diffuse proliferation of cells with large rcund to oval vesicular nuclei with pro­ minent nucleoli. Mitotic figures are nu­ merous. There is a fair amount of ret:­ cular formation. The tumour is also in­ filtrating the surrounding adipose tissue. Diagnosis: Ret~culum cell sarcoma. Following operation the patient de­ veloped melaena, the Hgb falling to 3.6 G. Be was transfused with 8 pints of blood. He was later transferred to Peter MacCal­ C:Jse 1: Lymphogram lum Clinic for Mega Voltage Therapy. He was at this Clinic for a month have resulted from previous infection. from 25.2.70 to 24.3.70 Amongst the On 14.3.70 he returned from week­ special investigations he had there was a end leave complaining of severe left chest lymphogram, reported upon as follows: A pain. X-Ray chest showed further eleva­ bilateral injection of contrast was made. t:nn of :eft hemi-diaphragm and partial The nodes and vessels in inguinal, iliac collapse of the left lower lobe togethe~' and para-aortic regions were outlined. The with a small left pleural effusion. The upper one third of the thoracic duct ap­ appearances were considered to be clue peared moderately dilated but the signi­ to a pulmonary infarct or consolidation, ficance of this finding was not evident. collapse resulting from bronchial occlu­ The iliac nodes on either side appeared sion. IVP showed kidneys normal in out­ within normal limits. Two groups of line and function. The left pelvicalyceal para-aortic nodes were demonstrated one system appeared attenuated and the up­ on the right side opposite L2-L3 and one per one third of the left ureter appeared on the left opposite L3-L4. The nodal somewhat irregular. These appearances tissue appeared abnormal and involvement would suggest that early infiltration of the by the malignant lymphoma has almost kidney and ureter by the lymphoma may certainly occurred. The absence of nodal have occurred but these findings are not tissue above the level of L3 on the left diagnostic. side would suggest surgical removal above On 21.4.70 he was admitted to St. this level. The appearance of the inguinal Luke's Hospital, Malta. He was then nodes on either side remains equivocal. complaining of severe pain in low back Lymphatic stasis is demonstrated adjacent and occasional vomiting. His general con­ to these nodes and patchy filling is seen dition was poor. He showed wasting. within them. These changes may be re­ No enlarged lymph nodes were present lated to the malignant process or they may in the neck, axillae or groins. His abdo- 61 men was tensely distended, shifting dull­ tions were audible over both bases. The ness and a flu:d thrm being present. There apex beat was in the 6th interspace out­ was bilateral ankle oedema. Hgb 81%, side the mid-clavicular line. There was a PCV 40%, WBC 16,400, ESR 40 mm. soft systolic murmur localised to the apex Chest X-Ray L. pleural effusion. On and the left para-sternal region. 22.4.70 nine pints of straw coloured tur­ The abdomen was grossly distended. bid fluid were removed from his abdomen. Its entire cavity seemed to be filled by a He was started on a course of i.v. large, well defined, bilobular, rubbery, cyclophosphamide and given opiates for hard, non-tender mass which showed a the persistent pain. His subsequent course fair degree of lateral mobility. Normal was relentlessly downhill. At no time did bowel sounds were audible. There was he show any response to the cytostatic a left inguinal scar, no enlargement of drugs afforded to him and these included inguinal lymph nodes. A right inguinal chlorambucil, vinblastine and prednisone. hernia was present. Rectal examination There was re accumulation of fluid in showed slight enlargement of the prostate. his abdomen and left chest necessitating repeated tappings. His pain never left him and he com­ plained bitterly of it as it affected the left lower chest wall which was often tender on palpation. On l.8.70 he developed paraplegia. On 25.8.70 he died. Permission for post mortem examina­ tion was not given.

Cas.j;l 2. S.T. Man aged 74.

This patient presented on 22.7.70 complaining of a gradual increase in ab­ dominal girth which he had noticed over the previous three months with "harden­ ing" of his abdomen. There was no ab­ dominal pain of any note but occasional mild dragging pain was present. His bowel habit was not disturbed though he did tend to being occasionally costive. His appetite had fallen off and he thought Case 2: Showing displacement of left he had lost some weight. There was no ureter nausea and no vomiting. He had never The following investigations were noticed passing any blood with his stools carried out: Hgb. 72% PCV 39% No pro­ or his urine. He had no difficulty with teinuria, no glycosuria, Blood Urea 14 urination but was experiencing a slight mgm%. (3 to 5) nocturnal frequency in the last Serum electrolytes Na-126 m.Eq., few months. K-4.4 m.Eq., Plasma chloride 93 m.Eq./ He was admitted to St. Luke's Hos­ Litre. Modified Glucose Tolerance Test: pital on 23.7.70. On examination he Fasting blood glucose 78 mg./l00ml. 2 looked slightly pale and drawn; T. 99° F Hour Blood Glucose Level: 155 mg./lOO Pulse 100/min, regular and good volume. ml. Urine glucose absent. B.P. 195/100 There was no cervical node Faecal Occult Blood: Positive in 1 enlargement, and no jugular congestion instance in 3. LV.P.: Mass in mid-abdo­ Examination of the chest showed good men mainly to left side with irregular cal­ air entry on both sides; some fine crepita- cification anteriorly and to the right. Re- 62 troperitoneal, not connected to renal tract. outline of the colon is not much altered Both kidneys concentrate the dye well. and the condition is probably due to an Left Ureter displaced. No abnormality inflammatory process which has produced in kidneys. adhesions and perforation of the colon. Operation was performed on 5th August 1970. G.A. Dr. J. Psaila, and Dr. Case 3. P.B. Girl aged 12. Alex Galea. Through a left paramedian incision a This girl was first referred to the large solid and highly vascular retroperi­ Medical Division under the care of Dr. toneal tumour was removed. It was seen Luis Vassallo on 27.7.70 for abdominal to be arising from the anterior aspect of pa,in and splenic enlargement. She had the abdominal aorta seeming to have bur­ been quite well until about three weeks rowed into the sigmoidmesocolon. In the before admission when she first began to course of its dissection parts of the me­ have intermittent fairly severe pain in socolon and adjoining segment of colon left upper quadrant of abdomen. It was were inadvertently contused but the bowel severe enough to make the patient take was not opened. Haemorrhage was at to bed. Her appetite was not impaired times difficult to control. A tube caecos­ and there was no nausea or vomiting. Her tomy was performed prior to closure with bowels were regular. There was no loss drainage. Six pints of blood were given of weight. Mictupition was normal. over the operation and immediate post operative period. The tumour weighed 12t lbs. or 5750G. On the third day after operation he developed intractable hiccup, and on the sixth day post-operation a faecal dis­ charge was evident through the site of his tube drain. Meanwhile the caecos­ tomy had already begun to function. His further post-operative recovery was slow but unattended by other com­ plications and he was discharged home with wound healed and a dry abdominal wall on 7th September 1970. He was next seen at Follow Up Clinic on 26.9.70. His general condition had be­ gun to pick up, he was eating better and had no amdominal pain or discomfort. He was however troubled by having to go to stood 6 to 8 times a day to pass soft nor­ mal coloured faeces. He was put on an opiate mixture. On 10th October when he next re­ ported he complained of constipation, not having had a motion for four days. Case 3: Showing tooth rudiment He was now putting on weight and his abdomen was soft and not at all dis­ On examination she was a pale, tended. A barium enema was asked for. timid, apprehensive girl. No lymphade­ The barium Enema report dated nopathy was noted in neck, axillae or 17.10.70 ran as follows: No signs of ob­ groins. Pulse Rate 112/min., B.P. 120/90. struction in the colon. There is however A large mass was palpable on the a fistulous communication in sigmoid re­ left side of the abdomen extending back gion with formation of an irregular ca­ to the loin. It was firm and smooth and vity and a long narrowed sinus. The dull to percussion. Her blood picture 63 showed a Hgb of 96% or 14.2G, W.B.C. The abdomen was well covered and no 8,300, E.S.R. 5 mm. 1st hr., LV.P. showed masses or organs were palpable. Rectal a mass in the left hypochondrium sepa­ examination revealed a large smooth rated from the kidney and containing a hard mass occupying the sacral hollow toothlike structure, suggesting dermoid and abutting on the lower rectum. The cyst. rectal mucosa could be moved over it Laparotomy was performed on though the mass itself was completely 11.8.70 under general anaesthesia (Dr. C. fixed. The prostate was small and firm. Borg). A large retroperitoneal cyst aris­ Investigations gave the following re­ ing from an area situated below the tail sults: Hgb-100%, W.B.C. 9,900. Serum alk. of the spleen was removed through a left phosphatase 8.7 K-A units, acid phospha­ paramedian inclslOn. The abdominal tase 0.5 K.A. units. Blood urea 35 mgh%. wound was closed with drainage. She Barium enema showed a forward dis­ made a good post-operative recovery and placement of the rectum with a rounded was discharge with wound well healed indentation at the posterior aspect, sug­ on 30.8.70. gesting a presacral mass. Operation under general anaesthesia Case 4. Male F.G. aged 70. (Dr. F. X. Micallef) was performed on 13.10.70. 27.8.70 Referred to Surgical Out Pa­ The tumour was explored through a tient Clinic for "Haemorrhoids". This pa­ sacro-perineal approach with excision of tierrt stated that he had been troubled the coccyx and last piece of sacrum. It was w~th piles for some 11 years. His more found to be filling the true pelvis and to immediate concern however was that of extend upwards to beyond the promon­ constipation. There was no history of tory of the sacrum. It was quite fixed prolapse or anal bleeding. On examina­ to this latter bone and seemed to be tion he was a well preserved florid corpu­ arising from it. It was enveloped in a lent man. There was no cervical lympha­ pseudo capsule which, on opening, re­ denopathy. The chest was clinically clear. vealed the tumour to consist of a gelati­ nous chondro-osseous mass. Most of this material was scooped out in the face of fairly brisk bleeding, the resulting ca­ vity being packed. A lateral left iliac colostomy was performed. His post-operative course was punctuated by bouts of severe hypogast­ ric pain and retention. This was to some extent relieved by catheterization. He is now passing urine per urethram and re­ lieved af pain. The histological diagnosis was as follows "Several hemorrhagic portions of lipomatous tissue that measure 9 x 7 x 6 cms. Section shows a myxomatous sar­ coma infiltrating fat. Cellular pleomor­ ph~sm is a prominent feature and mito­ tic activity is considerable." He was referred to Dr. Sultana for radiotheraphy; but was however turned down because: "size of tumour, its histo­ logical nature, and the obesity of the pa­ Case 4: Showing forward displacement tient contraindicated even an attempt at of rectum palliative radiotherapy." 64

Case 5. J.A.B. aged 3! years. On 16.5.64, he was transferred to the Isolat:on Hospital because he had measles. He was referred to the Paediatric He also had gross ascites which was Wards under the care of Dr. T. Agius emcarassing his respiration. On 5.5.69, Ferrante on 29.1.69 with a 2 month history 500 C.c. of white chylous fluid were re­ of abdominal enlargement accompanied moved. He continued to leak for 3 days. by cyanosis. Clinical examination re­ On 25.5.69, he had recovered from his vealed ascites. There was no hepatos­ measles and was transferred back to the plenomegaly. paediatric ward. Paracentesis was performed on 5th The patient was transferred to the February, 1969 and some 500 C.c. of Hospital for Sick Children at Great Or­ chylous fluid was obtained. mond Street, London on 17.6.69 The pos­ Laboratory and X-Ray findings were s,ibility of a blockage of the lymphatic as follows: duct system was entertained. There it 1. Urinalysis repeatedly normal. was found that the chylous effusion was 2. Blood count and picture. not an ascites but a large cystic mass. The child was operated on by Mr. H. Hb: 13.4/100 ml: 91%. P.C.V.: 43%. Nixon on 2.7.69. A large unilocular cyst 64%. Easinophils 4%. Basophils, Lym­ about 8 x 6" was found situated in the phocytes 24% Monocytes: 8%. Stained transverse mesocolon and extending up films: No abnormal features. posteriorly behind the pancreas. The cyst 3. Bl. urea: 19 mg./100 ml. was between the leaves of the mesocolon. 4. Occult blood in stools: negative. Its own wall was delicate and thin like 5. Agglutinins titration - negaDive. the wall of a lymphatic vessel, so that it 7. The chylous fluid was examined was impracticable to excise the cyst wall a) bacteriologically: no pathogens comp:etely. The cyst was therefore mar­ were detected. supialised and two large tubes placed b) biochemically and histologically: within it. The drains were left in for 14 Total fluid cholesterol: 85 mg./ days post-operatively, using suction for 10 ml. the first 4 days. There was no evidence Total extractable fats: 2.4 g./100 of re-collection of fluid so the drains were ml. removed. Total fluid proteins: 4.3 gr./100 He returned to Malta on the 20.7.70. ml. Part of the operation wound was infected Fluid albumen: 3.2 gr./100 ml. and kept discharging pus for some time. Electrophoresis revealed practically He was discharged well on the 29.7.70. the same absorption of protein fractions The diagnosis was of, a large unilocu­ in the fluid as in normal serum with only lar lymphatic mesenteric cyst and there a marked lower concentration in the y was no evidence of any other abnormality fraction. of the lymphatic system. The cytological appearance was ho­ mogeneous with the presence only of mo­ Comment nonuclear cells belonging to the 'lympho­ cyte' series; scattered between the more The rarity of primary retroperitoneal numerous, larger and less mature lym­ tumours is generally accepted. The inci­ pho~d elements were many small mature dence may be gauged by the fact that over lymphocytes, with homogeneous deeply a 30 year period between 1930 and 1960, staining nuclei suggesting the possibility 101 cases were treated at the Lahey Clinic of giant follicular lymphoma. while at the Memorial Hospital in New The child was discharged to out pa­ York between the years 1926 and 1951 tients on 19.3.69 and readmitted on there were 120 verified cases. 30 cases 21.4.71 with recurrent abdominal distur­ were left unverified. This latter series bance. which is the largest reported from any 65 one institution represents an incidence of tion from extrinsic compression. It is 0.2% when one takes into account that rarely due to direct involvement of sto­ throughout this 26 year period 60,000 pa­ mach or intestine. Haematuria is a very tients with tumours were seen. Incidence rare early symptom; it was present in seemed equal in both sexes. profuse degree in our first case. The evil reputation which they have With regard to special investigations is on the whole well deserved. 85% of the all agree that the most useful radiological New York series were malignant, as were study is an intravenous pyelogram. AP 88 cases of the 101 from the Lahey Clinic. and lateral views often show displacement In Donnelly's series 91 % were malignant. of kidney and/or of the ureter. The lymphomas constitute the largest A gastro-intestinal series is also very group amongst the malignant neoplasms. useful to show displacements and thus af­ Fully a third of the tumours reported from ford evidence as to precise location of the the Lahney Centre were of lymphatic node tumour. Newman & Pindi reckoned they origin, while 24 of the 120 from the Me­ were "sufficient to establish a diagnosis". morial Centre were classified as lym­ In our cases, LV.P. did point to in­ phomas. volvement of the left ureter in the first However of these, the reticulsarco­ case and in the second the man had dis­ mas form the least common type, the lym­ placement of the left ureter and the dif­ phosarcomas being the most frequent. fuse spotty calcification afforded clues as Most workers agree that the diagno­ to the nature of the mass in question. sis is not easy. Enlargements of the kid­ Other X-Ray procedures which may ney, adrenal, pancreas, spleen and liver provide highly useful information are have to be excluded, as also such lesions aortography and lymphangiography. Peri­ as aortic aneurysms. The tumours may renal insufflation is not without its dan­ arise from anywhere from the diaphragm gers and pneumoperitoneum is not help­ to the pelvic floor, and from a wide ve­ ful. A preoperative diagnosis may be ar­ riety of tissue such as fat, areolar tissue, rived at in about 30 to 40% of cases. How­ connective tissue, fascia, muscle, vascular ever, there is no substitute for explora­ tissue, nerve tissue, somatic and autono­ tory laparatomy to reach a definitive his­ m'c, lymphatic vessels and lymphat:c tological diagnosis in order to determine nodes. Only a minority are hormonally resectability. active tumours. These include the extra­ Knowledge of the state of the renal may here be made of the hypoglycaemia tract, the previous lavage and sterilization and its associated symptoms occasionally of the intestinal tract and the availability seen with retroperitoneal sarcomas. This of considerable quantities of blood are use­ was not seen in the two large series ful prerequisites to successful surgical quoted above. (47 Fibro Sarcomas; 4 Neu­ treatment. rofihomas). Our second case required to be trans­ Up to 1966, 145 pat;ents were re­ fused with 6 pints of blood over the ope­ rorted showing this phenomenon. ration and also necessitated a caecostomy The most common clinical finding is as a safeguard following inadvertent con­ an abdominal mass. Pain is generally tusion of the mesocolon. present; it is ill localised, it may be felt in The mortality rates reported in the the back but is not often severe when the larger series in the literature is not incon­ pa tient presents. Gastro-intestinal symp­ siderable. A 10% mortality and a 22% toms may be remarkably inconspicuous morbidity rate was present in the Lahey even in the patient with a huge abdominal Clinic series, among the malignant group. mass as was seen in our second case. Radiotherapy plays a primary role in Anorexia, we'ght loss, and constipation the treatment of lymphomas. With other are commonly complained of, less fre­ tumours, it has a subsidiary role. Accord­ quently vomiting and haematemesis. This ing to Pack and Tabak, Myxosarcomas are latter may be the result of portal conges- only slightly radio-sentitive. However, it 66 is generally considered that radiotherapy them in the odd half page of the standard should be offered to all cases of tumours surgical text book. They pose a difficult not amenable to resection and to those and fascinating problem to the pathologist that are not for technical difficulties ex­ and to the physician. To the practising cised completely. surgeon they are a challenge that may tax To conclude: primary retro-peritoneal his resource. In dealing with them, tumours, though uncommon, are not great though he can often only bring to his pa­ rarities and should not be neglected. They tient temporary relief, he is occasionally merit more notice than is generally given rewarded with a gratifying outcome.

EMOTIONAL AND PSYCHOSOMATIC DISORDERS IN GENERAL PRACTICE

GODFREY T. FIORINI, M.D. Toronto, Ontario - Canada.

Summary: (b) of a study of the causes of such ill­ nesses. The incidence of psychosomatic and 950 cases were studied consecutively emotional disorders in general practice in the month of November, 1969 as they was recorded and found to corroborate attended the office. Each patient, on the findings of other authors. Psychotro­ coming to the office, for whatever reason, pic events were correlated to psychoso­ would have his name taken down and matic illnesses. listed on a special chart where he would be classified as to age, presenting symp­ Any practising physician will neces­ tom, diagnosis, race, education, civil sta­ sarily be confronted with a certain propor­ tus, religion and medication received tion of patients who seek medical advice whilst miscellaneous items relating to his for emotional reasons having no apparent medical and social history would be organic disease. Though it seems simple noted. These cases were gathered in to classify illnesses into organic and emo­ sixteen working days. These consulta­ tional or psychosomatic, it soon becomes tions would include some patients that apparent that at certain times it is very would come weekly for an allergy injec­ difficult to draw a dividing line. It is tion as well as those that woul'd come obvious that organic illnesses generate for a certificate for work. Some other emotional disturbances and emotional dis­ pat:ents would be included twice, being turbances generate organic illnesses. The cases of injuries sustained at work who knowledge of the genesis of emotional and would be seen once a week for follow up. phychosomatic illnesses is of paramount So inevitably some visits would be very importance in medicine. This paper is an cursory. Many of these patients would attempt to obtain a perspective of the have been known beforehand and their problem as it presents itself to the general previous histories would have been re­ practitioner. It consists of (a), a study of corded, thus making a quicker appraisal the incidence of emotional and phychoso­ possible. matic illnesses in general practice, and The main object of this first stage of 67 the study was to sift those adults that infancy onwards can suffer from symp­ were suffering from emotional disorders. toms qf stress and emotional disturban­ Very few patients would present with a ces, but these would require a different depression, anxiety state or just bad perspective and woul be better dealt with nerves. A larger percentage would pre­ as a separate series. sent with a somatic complaint. Those This group of patients consisted al­ patients that were suffering from an emo­ most entirely of new Canadians, whose tional disturbance as a result of an organic stay in Canada varied from a few months disability ,were excluded from the group. to twenty years. Many of these patients Amongst these would be included those had some English language difficulty. patients who had suffered a coronary The patients examined thrombosis or were suffering from cancer consisted of: or from other prolonged illness. It is Children (under 15) 230 natural that such patients should suf­ Males (oyer 15) 325 fer from emotional repercussions after Females (over 15) ... 395 such an event. What is not equally clear Incidence of nervous and psycosoma­ to many is the fact that such events gene­ tic disorders: rate emotional upheavals amongst close Males (over 15) 71 'kinsmen. These emotional upheavals re­ Females (over 15) ... 140 sult from grief, can occur in dependents Total 211 experiencing financial difficulties and in persons closely related to the event, ex­ Incidence % periencing other sqcial repercussions. Males 325 71 21.8'% For example when the father of a Females 395 140 35.4% family is hurt at work or elsewhere, this Total 720 211 29.3% M. 9.8% would cause emotional disturbances not F.19.4% to himself alone but also to his wife and chHdren with varying intensity, emotional Events and psychosomatic illnesses effects being felt also by his friends and by other assqciates to a varying emotional In this survey an attempt was made extent. These emotional upheavals in the to trace the relationship between life next of kin can generate a certain amount events and emotional illness. It is quite of organic illness. Many individuals clear that we are continuously influenced would overcome the crisis without seek­ by events. The fact that there is a war in ing medical advice, but others will present South Vietnam is an event. The psycho­ to the doctor as epigastric discomfort, or tropic effect that this war is causing or has spastic colitis, or tachycardia etc. caused on the Vietnamese people is ob­ viously different from its effect on the A case would be classified as psycho­ American people and again different from somatic on 3 conditions: its effect on the Canadian people. It is (1) The condition must belong to quite possible that some people around one of those listed as possibly the world are not even aware that a war psychosoma tic. is going on. In such a case there would be (2) The patient must admit to an no mental effect at all. So we may safely emotional disturbance. say in general terms that there are many (3) The emotional disturbance must events happening all around us, many of precede the somatic condition. which we are not even aware of, some of The first 950 patients, including in­ which do not concern us at all, other.s fants, seen in the ,first sixteen working still that strike home. It is with the latter days in November, 1969, were classified that we are mostly concerned in this as already described, but no diagnosis of paper. There are some events which occur psychosomatic illness was attempted on within the family group which are very children under 15 years of age. It is re­ momentous and generate emotional. con­ cognised that children of all ages, from flicts. These are events that may happen 68

Classification of certain conditions with reference to psyychosomatic status.

Excluded Included

Skin reactions: Urticaria Neuroderma titis Musculoskeletal Backache Tension Headache reactions

Respiratory reactions

Cardiovascular reactions

Gastro-intestinal reactions

Genitourinary reactions General physical conditions Neurasthenia Tremors Palpitations Mental reactions Insomnia Irritability Loss of interest Confusing thoughts Apprehensive dreams Endocrine reactions Thyrotoxicosis Hypothyroidism Obesity

to any family and there are many of them are concerned with here is not merely that must happen to all of us and yet a list of all the possible significant events though we are aware that such events that may influence an individual, but those should occur we find ourselves ill prepared occurrences which strike at a person's to meet them when they do happen. innermost constitution. These events we An event is defined as a "happening shall label as Psychotropic Events, and we or an occurrence". This implies a begin­ shall divide them into acute or chronic. ning. It also implies a duration, which is By definition psychotropic events can a variable. Some events last a very short never be neutral in effect. They may either time, others last longer and others still be traumatic, if noxious, or euphoric, if are chronic. The event may therefore have pleasant, or mixed. A pleasant life is an ending or it may be such that its end­ usually built from day to day by a balan­ ing may not be in sight. The seriousness cing of the traumatic with the euphoric of an event is also a variable. What we events. It is when some unusual and un- 69 expected traumatic event occurs, that the 19. Marriage. individual is thrown out of balance and 20. Birth. in some cases falls ill. 21. Began or ended school. A group of 134 patients were chosen 22. Menopause. and asked to answer a series of 60 ques­ 23. Inter-racial marriage. tions. The patients were divided into two groups. The first group consisting of 77 (B) - Chronic Psychotropic Events patients who were suffering from what 1. Chronic illness of a member of the was diagnosed as psychosomatic illnesses; family. the second group of 57 persons were pa­ 2. Chronic illness or disability of person tients who 'did not seem to have any emo­ concerned. tional disturbances and had come to the 3. Tight finances. office for some other reason, such as pre­ 4. Homosexual spouse. gnancy, a minor injury, a minor cold etc. 5. 'Involuntary lack 0,£ children to mar- In this survey all the patients were ques­ ried couples. tioned as to the incidence of recent or 6. Teenagers in the home. chronic events, as well as to their hob­ 7. Alcoholic spouse. bies or tension relief events. The score 8. Separation from parents or next of was recorded per patient. 'kin: The following is a list of the events, 9. Parents died over five years ago. divided into 3 groups, on which the pa­ 10. Parents do not get along. tients were questioned: 11. Husband' and wife do not get along. 12. Bachelorship or spinstership. (A) - Acute Psychotropic Events (Events that occurred w£thin 2 years) (C) - Hobbies or Tension Relief Events 1. Change of residence. 1. Fishing. Summer or Winter. 2. Change of health in a member of the 2. Sports. Games. Outdoor or Indoor. household. 3. Vis,iting friends or relatives. 3. Personal injury or illness. 4. Cinema. 4. Immigration to Canada. 5. Theatre. 5. Separation from parents and siblings. 6. Watching television at home. 6. Death of a close friend. 7. Reading. 7. Death of a parent or close relative. 8. Craftwork at home. 8. Taking on a major debt, such as a 9. Daily alcoholic drink with meals or motgage or loan. in the evening. 9. Promotion at work. 10. Playing a musical instrument. 10. Change to a 'different kind of work. 11. Card games. 11. Son or daughter leaving home. 12. Music - records or radio. 12. Demotion at work or loss of a job. 13. Dancing. 13. Retirement. 14. Membership in a club. 14. Separation or divorce. 15. Other hobbies. 15. Arrest and/or court conviction. 16. Social gatherings - weddings, par­ 16. Business and financial setbacks. ties. 17. Family and in-law squabbles. The following is the score obtained 18. Pregnancy. by the psychosomatic cases and the con­ trol group: Psychosomatic No. of Acute Chronic No. of Tension Cases Events Relief Events 77 362 204 158 303 Average 4.70 2.6 2.05 3.9 Control Group 57 187 127 60 256 Average 3.28 2.23 1.05 4.5 70

Analysis of the incidence per event.

(A) Acute Psychotrapic 1 Psy. Grp. Per cent Control Grp. Per cent ------:-:~--t------l--- 1. Change of residence 36 18 23 17.5 1 2. Change of health in a household I 17 8 5 4 3 I . member 3. Personal injury or illness I 7 3.5 14 13 4. Immigration to Canada I 18 9 12 9

5. Separation from parents and sib- I 20 10 11 9.5 I lings I I 6. Death of close friend 10 5 0.8 I 7. Death of a parent or close relative i 10 5 0.8 8. Taking on a major debt, mortgage i 20 10 12 9.5 or loan I 9. Promotion at work 1 0.5 0.8 10. Change to a different kind of work 6 3 7 5.6 11. Son or daughter leaving home 7 3.5 0.8 12. Demotion at work or loss of a job 10 5 o o 13. Retirement 0.5 o o 14. Separation or divorce 10 5 8 6.4 15. Arrest or court conviction 1 0.5 3 2.61 16. Business or financiaJ setbacks o o o o 17. Family and in-law squabbles 2 o o 18. Pregnancy 9 4.5 3 2.3 19. Marriage 8 4 7 5.6 20. Birth 12 6 4 3 21. Began or ended school o o 4 3 22. Menopause 7 3.5 o o 23. Inter-ra.cial marriage 2 1 o o

In analysing the figures the first im­ control group as far as the acute events pression seems ta be that there are more are concerned is about the same, while events happening to psychosomatic pa­ the average chronic events is higher in the tients than to the control group. In ana­ psychosomatic group than in the control lysing the figures further we find that the group. The reason that the acute events average for the psychosomatic and the are about equal in the two groups is ob- 71

(8) Chronic Psychotrapic Events I Psy. Grp. Per cent Control Grp. Per cent l. Chronic illness of a member ofl 12 7.5 4 6.7 family I 2. Chronic illness or disability of 3 2 8 13 person concerned 3. Tight finances I 55 35 25 41.5 4. Homosexual spouse 1 0.63 0 0 5. Involuntary lack of children to 0 0 2 32 married couples 6. Teenagers in the home 2 1.26 3 48 7. Alcoholic spouse 7 4.41 1 1.6 8. Separation from parents or next El 6.3 0 0 of kin 9. Parents died over 2 years ago 1 1.63 0 0 10. Parents do not get along 30 18.9 7 11.2 1l. Husband and wife do not get along 14 8.82 4 6.4 12. Bachelor or spinster 9 5.67 3 4.8

viously because the control group came to Kessel and Shepperd, 1962; Kessel, 1965; the office for a medical event such as a Mazer, 1967; Roessler, 1961; Rowen, 1960; pregnancy, an injury etc. If the control Silverman, 1968; Watts and Cawte, 1964), group were picked up from the general observations were found to be essentially population the score of the control group similar except for the fact that these ill­ would obviously be lower. nesses were labelled as neuroses by these The tension relief events hit about the authors. The term neurosis has been same ,average in both groups. Again this avoided in describing these patients as the is to be expected considering that both term seems to have a morbid personality groups come essentially from the same connotation which seems to imply a cer­ ethnic background, having the same cul­ tain degree of frustration on the part of tural and social status. There is how­ the doctor in handling these patients. It ever, a slightly higher occurrence of ten­ is felt that these patients are ordinary sion relief events in the control group. citizens in the grip of the currents of human civilization and facing the hard Discussion: facts of life. Their symptoms are only an expression of the uncontrollable reac­ An attempt was made to find the in­ tive processes that automatically occur cidence of emotional illness in general within the body as a result of psychotro­ practice. This was found to be in the pic events. What the physician sees in his region of 22% for men and 35.4% for wo­ office from behind his desk is only men. On comparing the results of other a snapshot of a phsiological reaction authors (Coats, a 1969; Coats, b 1969; in a process of resolution. Hence 72 the frustration of the physician when th:s survey the catastrophic events are: prescribing the usual antacid and anti­ Ill-health in a household member spasmodic for the symptomatic relief Bereavement of gastric symptom caused py the Son or daughter leaving home fact that the worker has been laid off Demotion or loss of a job from his work. These emotional problems Menopause should not be considered as merely func­ Alcoholic spouse tional and therefore not requiring treat­ Separation from parents or next of ment, as they would otherwise lead into kin. actual organic illness, which would natu­ These are events that actually happen rally satisfy the organic oriented doctors. to most people at some time or other. Yet It is true that many events correct them­ we seem to be so unprepared for them selves in time. The worker who loses his when they do happen. It would appear job may find a better one. It is therefore that mental provisions should be laid out important to enumerate the events in his in preparation for such events. The ten­ history when assessing the medical status sion relief events, one notes the lace of of a patient. Medication and advice should ly poor in both groups. Considering ten­ be given accordingly. The human biolo­ sion relief events one notes the lack of gical reaction may be presented in this physical exercise especially in the female manner. population. The mental stimulation and Event > Emotional disturbance > the physical well being engendered by Somatic disturbance > Actual organ pa­ physical exercise or sporting activities thology. seem to have been missed by this group A list of psychosomatic illnesses has of persons. been given. Many conditions that are ques­ tionably psychosomatic such as bronchial References asthma, thyrotoxicosis etc., have been deliberately omitted; other conditions that COATES. D. (1969) Yorklea s.tudy. June. Primary are still possibly psychosomatic have not relationships in the city: some preliminary ob­ been even mentioned, such as repeated servat:ons. respiratory infections. COATES. D. b. (I969) Yorklea study. Dec. Symp- The score on events among the two toms. problems and life events. groups was fourtd to be moderately higher KESSEL. N. (I965) Pract .• I94. 636. KESSEL. N. and SHEPPERD. M. (1962) J. Ment. SC!. It in the psychosomatic group. is obvious MAZER, M. (I967). Am. J. Psychiat. that man is capable and prepared to cope ROESSLER. R. (I96I) Psychosom. Med .• 23. 4I3· with a certain number of unpleasant ROWEN. M.J. (I960). J. Med. Soc. N. Jersey. events, but there are a few events which, SILVERMAN. C. (I968) Am. J. Psychiat. when they occur, cause a break in the WATTS. C.A.H. and CAWTE. E.C. (1964) Brit. Med. adaptive processes of man. According to J .. 2. I35I. 73 HEALTH SERVICES IN THE U.S.S.R.

PETER A. FENECH, M.D.. D.T.M. & H.. D.P.H. Medical Superintendent, King George V Hospital, Malta

As Malta's participant at the recent development, experiment, and research. World Health Organization Advanced The complicated structure evolved in this Course in Health Planning held in the way consists of a number of institutions Soviet Union, I had the opportunity of ob­ and functional units so interlocked that serving certain characteristic features of the result is a unified system embracing the Soviet public health system. This all health disciplines and reaching into W.H.O. course was attended by twelve every locality in the 15 constituent repub­ advanced students from various European lics, to the smallest and most remote countries, with lectures delivered mainly villages and farming areas. The basic by Russians and, to a lesser extent, by prinCiple of this structure is highly cen­ other foreign experts. The teaching was tralized planning and supervision, coupled primarily in English, and partially in Rus­ with some complete executive and opera­ sian. The full course lasted 2 months, tional decentralization permitting the including an interesting trip, for field majority of problems to be dealt with at work, to the Republic of Moldavia, in the local levels, without disturbing the general South-West of the Union of Soviet Socia­ and basic pattern. list Republics. The curriculum provided for lectures, practical and seminar work, Salient Features discussions on various widely diverging topics such as the theory and organiza­ Republican territories are subdivided tion of medicare, health planning, and into oblasts, which have autonomous health economics. The course was run health departments. The oblasts are sub­ jointly by the U.S.S.R. Ministry of Public divided into regions (rayons) and these in Health, and the Central Institute for Ad­ turn are further subdivided into health vanced Medical Training, Moscow where districts or sectors. The large cities have all the lectures took place. their own health departments, and they Health services in the U.S.S.R. are also are divided into rayons and health organized to meet the requirements of a districts. specific social system and philosophy, and The regional health organization of are designed to provide comprehensive the U.S.S.R. at the operational level is medical care for the whole population perhaps one of the most remarkable through the integration of curative and achievements of the Soviet health system. preventive services at all levels of admi­ The rayon (or regional) hospital offers nistration. The basic health philosophy comprehensive and integrated health care, is one of "prophylaxis" by health protec­ both for in-patients and for out-patients. tion, and it places the responsibility for It is responsible for the regular health the health of the people on the State. The screening of the entire popUlation, and for Soviet Government has recognized the the follow-up treatment and surveillance role played by health in a nation's eco­ of specific conditions. This screening and nomy and development, and the fact that follow-up method is known as "dispen­ certain population groups (e.g. children, sarization". The rayon hospital is also workers, etc.) require specialized medical responsible for environmental sanitation attention. The existing health services .of and epidemiological control of commu­ the U.S.S.R. are the result of 40 years of nicable diseases in the area, through a 74 network of sanitary and epidemiological there are also permanent and seasonal day stations. The health officer responsible nurseries, pharmacy stores, and collective­ for the whole area is the director of the farm maternity homes. rayon hospital, while his first deputy is Each rayon is then divided into a in charge of sanitation and epidemiology. number of medical districts. The popula­ The rayon health unit (hospital, out­ tionof a rayon varies between 20,000 to patient clinic and sanitary epidemiological 120;000 whilst each district contains bet­ station) is aided by a network of units ween 7,000 - 12,000. The centre of a ranging from the district unit, headed by medical district is the district or ucha­ a district doctor, to the smallest local stock hospital, having at least 35 beds. health unit, the so called feldscher-midwife These district hospitals are a centre of station. The districts have small cottage­ primary speCialization, having a minimum type hospitals (uchastock hospitals), ma­ of four specialists: therapist or general ternity homes, and preventive-curative medicine specialist, surgeon, gynaecolo­ stations in villages and farming areas. gist, and a specialist in infectious diseases, besides a dentist. Each hospital provides Medical Care in Rural Areas an out-patient and in-patient service, the most important function being the provi­ The most numerous rural health sion of advisory services. Thus each doc­ establishments ~ the outposts of the tor in the district hospital has a schedule health services in the villages - are the of visits to feldscher-midwife posts. feldscher-midwife posts. Medical out­ The next level is the rayon hospital, patient and in-patient services are also having at least 100 beds, and is a centre provided by district hospitals. The basic providing skilled medical assistance. Thus, types of specialist medical care are pro­ it also has E.N.T., paediatric, neurological vided by the rayon hospitals. Finally, and some other units. The polyclinic highly-skilled specialised in-patient, out­ department, which is usually integrated patient and advisory services are the res­ with the hospital, not only provides cura­ ponsibility of the oblast hospitals and tive and preventive services, but also specialised follow-up centres. serves as an advisory centre for all medi­ The basic rural medical establish­ cal establishments in the rayon. Finally, ments are the feldscher-midwife posts, the highest level is the oblast hospital, staffed by a midwife, a feldscher and a usually with 460 - 500 beds; occasionally, nurse. It is usually a separate building, 1000 or more beds. The oblast hospital with two or three beds for normal deli­ is a centre providing highly-qualified and veries. The main function of these posts specialist services. The polyclinic again is the provision of predominantly out­ serves as an advisory centre. patient services for the population. In this case the feldscher acts as an assistant­ Medical Care in Urban Areas doctor. In cases with which he is not capable of dealing himself he sends the There are three levels of medical patient to the nearest district or rayon care: hospital. Other Junctions of these feld­ (a) specialized central institutes; scher-midwife posts are to improve con­ (b) rayon (city) hospitals; ditions of sanitation and hygiene, to carry (c) district units, each with about out environmental health measures, to 3000 adult inhabitants. carry out prophylactic work, and, most The leading figure in the organization important, health education among the of polyclinic services in the district units community. Generally, each feldscher­ is the district physician. The district midwife post operates in a village with a principle makes it possible to carry out a Village Soviet (which is the primary local whole range of curative and prophylactic government body) and serves three to four measures, to detect disease in its early vJlages, i.e. 300 to 900 people, depending stages, and to give active treatment and on the locality. In addition to these posts, to take any sanitary measures. 75

The polyclinic provides all the basic first-aid stations - and an emergency forms of specialized care, domiciliary service is provided by emergency depart­ services and emergency services. Reflect­ ments in the polyclinics. In smaller towns ing the general tendency in modern public­ both services are combined in a single health practice towards further specializa­ establishment, the first-aid and emergency tion, the polyclinics have now begun to station. The ambulances are equipped open cardio-rheumatological, gastro-ente­ with modern apparatus and instruments rological and other specialized units. for blood transfusions, artificial respira­ The leading method used in the poly­ tion, electro-cardiography and other ur­ clinics is the follow-up method - "Dis­ gent procedures, thus making it possible pensarizations". In addition to treatment, to give the necessary treatment on the it entails the use of extensive measures spot or on the way to the hospital as a of individual and social prophylaxis, en­ specially-trained doctor goes out in ans­ sures that the health of the population in wer to the first call. They are usually the medical district concerned is kept equipped with two-way radios to keep in under regular observation, and leads to contact with the dispatcher at the first­ the detection of disease in its early stages aid station. and the use of combined therapeutic and prophylactic measures to deal with it. Hospital Beds and Polyclinical Aid Th~s follow-up system covers people suf­ fering from many groups of diseases The Soviet system, in all its various (cardiovascular, chronic disease of the spheres, is geared on a tight assessment gastro-intestinal tract, chronic nervous or norms, and their public health planning disorders, etc.) and also certain population and standards are necessarily based on groups independently of occupation, such normative standards. On the basis of as children, pregnant women, and school­ these standards it is then possible to deter­ children. mine the values and indices in public Besides the polyclinic departments of helath plans, and the correct ratio bet­ the combined hospitals and the indepen­ ween certain specialities. The following dent polyclinics, a considerable volume of table gives an indication of the standards out-patient work is carried out by spe­ cialized follow up centres ("dispensaries"). There are tuberculosis-control centres, SPECIALITY [per 1::lOO Per1000 cancer-control centres, and centres for the i I of child pop. of all pop. control of skin and venereal diseases, trachoma and goitre, and for physical I Surgery anrl orlhopliedics 1-- 0.8 0.2 I culture therapy. These centres usually include spe­ I Jtolaryngo!ogy I 0.5 0.125 I cialized in-patient and out-patient depart­ I fuberc::illsis 0.5 0.125 ments, giving all types of curative and I preventive care. The centres work on I Neurology 0.12 0.03 I the district principle and are responsible for carrying out in the area they serve I Ollhthalmolilgj 0.12 0.03 I a full range of prophylactic measures 'I Cardiology 0.05 0.0125 I against the diseases they cover, for regu­ lar surveillance of the people's health and . Child gynaecology 0.08 0.2 I for early detection, registration and I All the others 0.53 prompt treatment of cases. I 0.1325 I In the Soviet public health system i Psychiatry 0.5 0.125 I a very effective network of first-aid and I emergency services has been established I Psycho-somatic 4.8 1.2 I in close cooperation with the hospitals and TOTAL 8.0 2.0 I polyclinics. In large cities this service is I provided by special establishments - 76 of specialized Beds (from the general Oncology (- cancer) 5 1.25 standards) per 1000 of all the population Paediatrics 5 1.50 and per 1000 of children population (with Obstetrics/Gynaecology 5 1.25 25% chUdren population in the country). Ophthalmology 8 1.25 The next table gives the standards for Otolaryngology 8 1.25 the urban population's requirements for Dermato-Venereology 8 1.25 out-patient on polyclinical aid calculated Tuberculosis 5 1.25 at a rate of ten visits on an average per Neurology 5 1.25 person per year:- Psychiatry 4 1.25

Speciality A verage number of visits Maternal and child health Therapy 2 Surgery 1.5 This is regarded as most important in Otolaryngology 0.4 the U.S.S.R. and this policy is reflected Ophthalmology 0.5 in that both programmes are to be found Dermato-Venereology 9.7 permeating the general health services at Tuberculosis 0.7 all levels. Neurology 0.4 The women's consultation centres Obstetrics / Gynaecology 0.9 provide the most easily accessible and Paediatrics 1.2 widespread form of maternal health by Stomatology (dental keeping a constant watch on expectant treatment etc.) 1.7 mothers throughout the entire period of pregnancy. On the average each pregnant Total 10 Wbman vi~its the doctor 6-8 times during a pregnancy. During 1970, 98% of mater­ nity cases in the U.S.S.R. were admitted . 'From such data it has been worked to maternity homes (as independent enti­ out that doctor/patients contacts/year ties or as the obstetrical department of a amount to 6 visits, and the future plan is hospital). In urban communities 100% of to increase this figure to 9 visits/year. deliveries took place in institutions, whilst the comparable figure for rural areas was Medical personnel 82%. Average length of 'Stay after delive­ ries in urban is 10-11 days, and in rural At the end of 1970 there were 31.8 areas 6 days. Legal provision is made for doctors per 10,000 population in the adequate maternity leave, both antepar­ U.S.S.R., and the target is to have 35 tum (56 days), and another 56 days post­ physicians per 10,000 population. Of these partum. It is well to point out that all 25 per 10,000 will be for ambulatory ser­ women are at work. vices, whilst 10 per 10,000 will be for the The main establishment providing in-patient hospital services. Female doc­ medical services for children are child­ tors total no less than 73%. ren's hospitals and children's polyclinics, The following table shows the norm while creches, children's homes and kin­ (work-load) of an out-patient doctor per dergartent help in bringing up the younger 1 hour: children. The children's polyclinics keep all babies and infants under regular obser­ Speciality No. of Doctor-Patient vation, and carry out many different kinds Contacts/Hour of sanitary and prophylactic work, home at Polyclinic at home visiting, regular examinations, etc. and all Therapy 5 2 types of curative treatment. Schoolchild­ Surgery 9 1.25 ren are also looked after at school itself Traumatology and by the school d.octors. Small children, up Orthopaedics 7 1.25 to the age of '3' years, are cared for in per­ Urology 5 1.25 manent creches or nurseries, and there 77 are also a number of seasonal creches. In have to be provided in all large plants and some areas up to 30% of these children factories. In smaller plants ambulance are admitted to permanent nurseries as all rooms are provided. These health units the women (uP. to age 60) have to be at are independent organizations and provide work. Some of these children stay in the all health services needed by the emplo­ creches, and are only taken home by their yees. A unit consists of a hospital, an out­ parents during weekends. patient clinic, ambulance rooms, "prophy­ Vaccination against smallpox and lactoria" and creches. The head of these B.C.G. are compulsory in the U.S.S.R. medical units is at the same time the head Immunization with triple vaccine, and of the hospital. against poliomyelitis are carried out as The medical department in Soviet routine measure, and the child popUlation industry carries out the same functions is for all practical purposes fully immu­ as industrial medical departments in other nized. B.C.G. is given at the first 3 days of parts of the world, and provides in addi­ life, and smallpox at 10-12 months. In tion a comprehensive medical care pro­ between, D.T.P. is given. gramme for the employees, and in some cases for their families as well. Special Occupational health emphasis is placed on the following: (a) Periodic physical examinations (which This is apparently given an important are termed prophylactic examinations) place in the public health programme to carried out by a special committee of keep pace with the rapid industrial deve­ all the specialists attached to the de­ lopment of the country. There are at pre­ partment. sent 12 institutes of industrial hygiene and (b) Safety committees, depending to a occupational diseases under the control of great extent on the active participa­ the Ministry of Health. In addition, the tion and support of the trade unions. All-Union Council of Trade Unions con­ (c) Health education. trols six institutions of labour protection. The institutes of industrial hygiene (d) First-aid organization. In each factory and occupational diseases are engaged of 1200-1500 workers, 20 to 30 volun­ mainly in experimental and research work, tary workers are trained in first-aid both basic and applied. They all partici­ techniques. pate in the formulation of codes, rules and (e) Physiotherapy and physical medicine regulations for the protection of the health are practised on an extensive scale of the workers at the places of employ­ and appear to receive much more at­ ment. These institutes also study the va­ tention than elsewhere in the world. rious types of industrial processes, with (f) Prophylactoria (day and night sana­ the object of changing the techniques and toria), where workers in need of some devising new methods and procedures for medical supervision are accommodat­ the health protection of the workers. They ed during their free time, but still also have a few beds and act in a consul­ carry out their everyday work without tative capacity in regard to the diagnosis interruption. and treatment of occupational diseases. The number of medical and paramedi­ The institutes participate in the training cal personnel employed in occupational of personnel by offering research oppor­ health programmes is greater than the tunities to junior specialists and by pro­ number usually found in other countries. viding refresher courses for factory doc­ For example, a plant employing 10,000 tors (sanitary industrial inspectors). The workers has 26 doctors and 161 nurses institutes of labour protection on the other and nurse-aides, and a plant employing hand, are mainly concerned with the im­ 20,000 workers (with 25,000 dependants) provement of industrial safety. has 135 doctors and 853 paramedical per­ The occupational health programme sonnel. is carried out by a network of medico­ It is well to bear in mind that the sanitary departments (health units) which budget of all health services in industry 78

is included in the total budget of the Mi­ Gamaleya Institute of Epidemiology and nistry of Health. Microbiology, Institute of Oncology, and various hospitals and polyclinics. But ge­ Conclusion nerally speaking I wasn't at all too im­ pressed, maybe because I kept comparing I have highlighted the basic principles their standards with the Scandinavian of public health services in the U.S.S.R. countries which I had visited earlier in which presumably under the existing State the year. I saw quite a lot of overcrowding system must be the best for this vast con­ in the hospitals, where most of the equip­ tinent. The overall emphasis on centrali­ ment is rather poor and worn out, and sation and on the rigid normative stan­ where the diet is meagre, and has not dards which have to be followed must shown any improvement since 1953. On certainly have their drawbacks. an average patients seem to spend an ex­ Naturally I visited a number of top cessively long time in hospitals, and sone Soviet establishments such as the Sema­ conditions, such as influenza have also got shko Scientific Research Institute of to be hospitalised because of the poor Social Hygiene and Public Health Organi­ housing standards. When all is said and zation, the Institute of Clinical and Expe­ done I can honestly say that in a number rimental Surgery, the Central Institute of of public health services we are better off Traumatology and Orthopaedics, the than people in the U.S.S.R.

NOTICE

This periodical is published biannually in June and in Decem­ ber. Contributions for the December issue are to reach the Editor at the Bacteriology Laboratory, St. Luke's Hospital, Malta, by the 1st November. They must be typewritten, with double spacing. References should be given by the author's name and by the year of publication. Papers, which are accepted on the understanding that they have not been published elsewhere, are to consist of reports of original work or studies or case histories. We thank our advertisers for their continued support. 79

MEDICAL NEWS sociation of Malta"; Or. Peter Fenech of Villa Chanticleer, Upper Gardens, St. (continued from page 2) Julian's is the Honorary Secretary. Mr. A.H. Beckett, professor of phar­ Surg. Capt. J. H. Mercieca has been maceutical chemistry and head of the de­ elected President of the Malta Dental As­ partment of Pharmacy at the Chelsea Col­ sociation for 1971-72; Prof. George Camil­ lege of Science and Technology of the leri is the honorary secretary. University of London, visited the phar­ The Gothenburg Dentists Association macy department of the University having held an intensive seminar on periodontal a very close look round. He also lectured, disease, between the 21st, and the 28th on the 12th May, on "The Effect of Drug April, at the Preluna Hotel, in Sliema. Formulation on Biological Availability Many of the leading Scandinavian teachers from Medicinal Products". There was a of the subject participated and the oppor­ large and appreciative audience, mainly tunity was taken to establish academic consisting of pharmacists. Interesting as and social contact with their Maltese col­ it surely was for them this was the type leagues. of lecture attendance at which should be The tenth session sub-committee of "required" for doctors. Professor Beckett specialists on blood problems of the Coun­ also lectured on the 14th May, on "The cil of Europe met in Malta between the Importance of steric and stereochemical 24th, and the 29th. May. Dr. Francis Purl­ features in biological action of drugs". licino, government blood transfusion offi­ Dr. Wallace Gulia, acting for the cer was the host on the Malta side. Inter Economics Department of the University, alia many members of the medical pro­ has organised a series of discussions on fession had an opportunity of meeting the various aspects of medicine in Malta. One visitors at a reception given by the such, held under his own chairmanship, honourable Minister for Health in the new­ concerned "The general practitioner, the ly restored main hall at the Health De­ National Assistance Scheme, Welfare Of­ partment office. Although one could doubt ficers and Hospitalization". Mr. P. Mus­ whether this is the best use to which the cat of the Social Services Department, Mr. hall could be put, there is no doubt that C. Messina, Almoner in the Health Dept., the CasteHania Palace seems to have re­ Dr. H. Grech Marguerat and Or. Anthony gained some of its old splendour. The Zammit were on the panel. party itself, at which local wines and even At another meeting the subject was local pastry was served, had a welcome "The Hospital Management Committee touch of originality, although we shudder and the Advisory and Executive Board in at what could happen if emphasis on relation to St. Luke's Hospital". Prof Jo­ "being Maltese" should be allowed to get seph Galea was chairman, with Professor out of hand. Walter Ganado and Mr. Joseph Muscat to Dr. Vanni Cremona ('64) is back in answer questions. On the 22nd April "The Malta after working at the Royal Post­ Treatment of the Mentally Ill" was dis­ graduate Medical School at Hammer­ cussed by Dr. Paul Cassar, Dr. A:braham smith. Dr. Paul Grech ('49) of Sheffield, Galea, Dr. Joseph Pisani and Dr. Joseph was in Malta for a brief visit in May, Pullicino, under the chairmanship of His taking part in a seminar and speaking on Honour Sir Anthony Mamo, with Dr. AI­ "Placentography" and on "The Radiology phonse Gerada as Rapporteur. "Private of the Pylorus and the Duodenum". Hospitals" were the subject of a meeting Dr. Gordon Blake (,61), we are happy on the 7th May, with Sister M. Aidan of to learn, is in the Physiology Department the Blue Sisters Hospital, Mr. Raphael At­ of the University of Rhodesia, fitting in tard, and Or. Luis Vassallo on the panel, very well indeed in endocrinology research with Professor Griffiths as chairman. work. Mr. Victor Amato and Dr. J.L. Grech We mourn the death of Dr. Joseph have been elected President and Vice­ Azzopardi (,22), a pathologist who dedi­ president respectively of the "Medical As- cated all his life to laboratory work. He 80 had a great fund of common sense which GRECH, P. (With PLATTS MARGA­ earned him many friends. Another dis­ RET. M., MOORHEAD, P.J. and KEN­ tressing event was the untimely death of WARD, D.H.) 1970. Radiology in the Ma­ Or. Carmelo De Lucca (,43), one of Malta's nagement of arterio-venous shunts. Re­ few real scientists. Mr. Mario Gauci, a view of 60 poorly functioning shunts. great friend of his and a fellow naturalist, Nephron, 7, 559. kindly accepted our invitation to write VASSALLO-AGIUS, P. 1971, Some for us a description of his work as a bio­ reflections on the Rhesus problem. Chest :logist, which we publish in this issue. piece, 24, 31. At the University students keen on their anatomical studies have founded and BOOK REVIEW launched the "Royal University of Malta Anatomical Society", with Prof. J. L. Pace General Microbiology. By R. Y. Stanier, as honorary president and Mr. R. Cara­ M. Doudoroff and E. A. Adelberg. chi as President. An inaugural lecture Macmillans: 55s. 1971. was given on the 17th March by Prof. Griffiths . on "The History of Anatomy", This book of 872 pages, profusely which dealt with many known and some illustrated and well supplied with dia­ quite surprisingly unknown great men. At grams and tables, is by two professors of the end, Professor Griffiths was solemnly the University of California at Berkeley, inducted as an Honorary Member of the and by one from Yale. This edition has Society. On the 4th May, Lord Gayre, of been almost entirely rewritten and exten­ Gayre and Nigg lectured on "The Ethno­ sively reorganised so that it is practically logy of the Maltese people". a different book from the first edition of The new X-Ray department at St. 1957. It is excellently printed and very Luke's was opened by the honourable Mi­ attractively presented with one broad mar­ nister for Health, Dr. A. Cachia Zammit, gin, which often provides place for illus­ on the 30th March, in the presence of His trations. It deals, as its name implies, only Grace Archbishop Gonzi. It was a pleas­ with the general aspects of microbiology, ant little ceremony permeated by an air but, so vast has progress been in this field, of cleanliness and newness. The latter especially as far as biochemistry and gene­ will pass off; we can only hope that the tics are concerned, that an extensive book former will. stay. like this is needed to provide the basic knowledge. One of its merits is that it PUBLlOATIONS LIST deals, though perhaps not in exhaustive detail, with algae, fungi and protozoa. The following are recent publications Somewhat surprisingly it hardly deals at by graduates of our medical school: all with antibiotics. GRECH, J.L. (With I.R.F. Brown) The book does not have a medical 1970. Separation and characterization of slant and, in actual fact, I would hesitate a foetal haemoglobin variant by means of to recommend it to the ordinary medical isoelectric focussing. Life Sciences 10, student whose curriculum is crowded part Il, 191. enough already, but for anybody who GRECH, P. (With F.J. FLINT) 1970. would like to extend his knowledge or who Pyloric regurgitation and gastric ulcer. would make a hobby of the purer side of Gut., 11, 735. a faSCinating subject, this book is excel­ GRECH, P. (1970) A technique for lent. assessing pyloric reflux. Gut., 11, 794. E. A. In Overweight It's simple-it's logical The fatter they are, the higher the dose ® PONDERAX FENFLURAMINE

Dosage is the same for all overweight patients for the fi rst two weeks then it is related to the severity of the overweight

SEVERE MODERATE MILD Tabs. per day Tabs. per day Tabs. per day 1stWeek 1 + 1 1 + 1 1 + 1 2nd Week 1+2 1+2 1+2 3rd Week 2+2 2+2 1 +2 4th Week and maintenance 2+2+2 2+2 1+2 Percentage overweight >20% 15-20% 10-15% Men> 25 mm 20-25 mm 15-20 mm Skinfold thickness Women> 30 mm 25-30 mm 20-25 mm

Where twice a day dosage is shown. tablets are taken morning and evening. If three times a day, the third dose is taken at lunchtime When weight has been stabilised the dosage should be reduced in reverse to starting treatment, to two tablets daily before stopping Note,' Weight loss will not usually be apparent during the first two or three weeks of trelltment. Contra Indications: Precautions: Secondary Effects: Although both human and animal Do not administer concurrently with Principally mild sedation and increased studies have demonstrated that there MAOI's, or to depressive patients. bowel frequency. Very occasionally IS no harmful effect on the foetus, it is PON OERAX may potentiate the action gastric upset, nausea, dizziness and not recommended that PONOERAX be of some anti-hypertensive ,anti-diabetic headache have been reported. administered during the first trimester of and sedative drugs. All these effects are reversible by pregnancy. unless the physician The dosage of these drugs should be reduction cir cessation of dosage. considers the benelit outweighs any re-assessed when the patient possible risk. is taking PON 0 ERAX. Ponderax produces sustained, substantial weight loss through its unique glycoliptic action without stimulation. Full proceedings of the World Symposium and full information, patient dosage pads and skin fold calipers are available ftOm: Servier Laboratories Limited Percival House, Pinner Road, Harrow, Middlesex, England ~ Galepharma (Malta) Limited 9 Strait Street, Valletta. Telephone 20595 SO PBticrlfs "'1,0 ';'<"""':<'<1 ''''nlldra~ • .... ' nO'{'d, 1Itl)1 'hi" il) ""~l' "H" J'«ti , ,,,,,1, Und r,"'l, Ofl"""i"" ,I",,,, H'",enf « 'I, ItJ!JrltltJu

" h t 'General malaise' in the debilitated patient Ig pO ency is frequently due to a deficiency?f vit~mins H Band C. There may also be Impairment of "" normal carbohydrate metabolism. B vitamin therapy Orovite and Parentrovi~e have , been shown in years of practice to ~or the provide the balanced formulation <;>fNitamins I' Band C required to restore the patient's "l" cellular metabolism to normal. genera I de bIlty Orovite is an easy-ta-take oral " preparation that meets all the requirements for successful B vitamin therapy. Parentrovite is patient injectable, and ideal where even faster, more powerful therapy is needed.

Fuii information is available on request.

Orovite and Parentrovite are products of Bencard Brentford, England. • Distributed by: Charles de Giorgio, 40, South Street, Vallelta •1, 1 0 Experience shows 7 out of 8 patients are trouble-free l with K ori:n.yl-1 .. '. from the very first pack FIVE IMPORT ANT FACTS:

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Each Norinyl-l pack contains 21 tablets of Norethisterone B.P. 1 mg and Mestranol B.P. 50 mcg. Full prescribing information on request.

References: 1. Multi-centre clinical trials involving nearly 6,000 patients. Data available to the United States F. D. A. 1968. 2. Swyer, G.I.M. (1969) Brit. med. J. 4: 803. 3. Brit. med. J. (1969) 4. 789.

SYNTEX Syntex Pharmaceuticals Ltd. St. Iv:~ House, 'Maidenhead, Berkshire. Appointed distributor: V. J. Salomone Ltd., Valletta, Malta.