THE ST. LUKE'S HOSPITAL GAZETTE

MALTA DECEMBER 1974 Vo!. IX No. 2

Published for the Consultant Staff Committee, 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. P. Cassar, Prof. F.F. Fenech, and Dr. L. Vassallo.

CONTENTS ABOUT OURSELVES About Ourselves 103 With this issue "The St. Luke's Hos­ An I nternational Gathering 104 pital Gazette" concludes its ninth year of Surgery and Advanced Abdominal Malignancy - H. Ellis ... 105 existence. It has been by far the longest More about Weever Fish and their Toxic lived local medical periodical, it is in the Stings - L. Zammit 108 "World List of Medical Periodicals", it Dermatology and Surgery - R.O. Parnis 114 reaches every member of the medical and Parapharyngeal Chordoma - P.J, Damato and J. Pace-Balzan 116 the dental professions in Malta, those of Traumatic Air Embolism - N. Azzopardi 119 our colleagues abroad whose whereabouts Haemang'ioma al the Orbital Bones - F.J. we can trace, many other medical friends Damato 120 abroad and a large number of un;versities Ocular Onchocerciasis - J.A. Coleiro. 127 Determination of Serum Zinc Levels in Normal and learned societies. An initial fear that Maltese Adults - R. Ellul-Micallef, A. it might lack contributors has proved Galdes and F.F. Fenech. ... 128 groundless and in fact papers have been Anatomical' Distribution of Diverticula in the Large Intestine - Marie T. Podesta and of a consistently satisfactory level. The J. L. Pace. ... 133 editorial policy of accepting contributions An Hour for my Thoughts - E. Agius. ... 138 from whoever had anything interesting to Royal Operations. - H. Ellis...... 144 say has also proved right and we have been Malta, Florence Nightingale and the Crimean War. - M. Galea ... 148 glad to publ;sh papers not only by doctors The Serpent of Aesculapius, the Confraternity and dental surgeons but also by a variety of SS. Comas and Damian and the of paramodical norsons and ev"'n bv noonle Bishop of Malta. - P. Cassar.... 156 completely outside medicine; it has also Economics of Medical Practice in Eighteenth Century Malta - P., Cassar.,... 166 fallen to us, sometimes, to return papers Hospital Services in Gozo at the Time of the which did not quite come up to the neces­ Knights. - J. Borg...... 172 sary standard. A Note on Suicide 175 Throughout this period the "Gazette" The Nomenclature for Chronic Lung Diseases 175 has always come out at its appointed time Medical News. 176 Publications List. ... 178 and has published some fourteen hundred Obituarli Notices. ... 178 pages of text. Even from the financial Index to Volume IX 181 aspect conditions are excellent with a very 104 satisfactory bank balance and this is in Medicine recently held here was very spite of a possibly quixotic refusal to raise successful, the organ:sat~on being. excellent. the charge for advertisements, which has The Italian delegation was the largest, but remained unchanged since we started in Britain, France, Belgium, Canada and 1966. Possibly if others also did not raise other countries, including our own, were fees just because it seems the thing to do worthily represented. The Malta represen­ at the moment, inflation might not be such tatives who read papers were Doctors J. A. a grievous problem. Admittedly our finan­ Meilak, P. Cassar and J.L. Grech on ces, besides being on a minute stage, are "Seasonal variations in suicidal deaths in peculiar in other ways. We are some of Malta", Dr. V. Captur on "Traumatic the few who are not interested in making heart disease", Dr. P. Cassar on "The con­ money. This is possible because of consis­ cept of 'permanent' incapacity for work in tent support by our advertisers, of free psychiatric patients applying for an inva­ postal transmission, of the convenient lidity pension" and Dr. L. Vassallo on medical tradition of not paying our contri­ "Aspects relating to gas poisoning fr~m butors and of all staff work being on a water heaters in Malta". Since the fore­ completely voluntary basis. To can it all most representative in Malta of the special­ the periodical, each copy of whic-h costs ties dealt with at the meeting is Dr. J oseph something like forty cents, is distributed L. Grech the main burden of organising free. the meeting fell on him and he and the This state of affairs would appear to members of a special committee, whom he be optimal and so it is from certain points took good care to thank for their assis­ of view. Our relations with the profession tance, acquitted themselves very well. are perfect, but unfortunately conditions One wonders sometimes whether such in the wider spheres are far from being meetings are really worth while. Does one so. The general state of affairs is so bad learn or does one teach much in them? In and appears so hopeless that one person, fact the plain truth is that probably care­ at least, has had enough of it and ful reading of the specialised periodicals or the present editor bows out with this contributing to these would be just as or issue. Whilst one is willing to work for a even more effective so far as pure learning community he could like one does not or teaching is concerned. Still even scien~ feel ready to spend time and energy in tists are human and the actual meeting of supporting, however remotely, something persons who may have exchanged views or he detests. Certain people can command corresponded for years does amount to a anvthing except respect and liking. So, great deal. Besides if circumstances are saluting our colleagues and thanking our favourable, why not please oneself in such helpers, in bitterness and disgust, we bid a direction? our readers farewell until, if ever, condi­ We are indeed glad when such gather­ tions are such that return is possible. ing can take place in Malta and although playing host is often a formidable under­ taking, in the long run it is worth it. Only AN INTERNATIONAL the profession must remember to be grate­ G'ATHERING ful to those who take on such tasks, since on the principle of ars est celare artem The meeting of the International the more efficient the organisers the easier Academy of Legal Medicine and Social the work appears to have been. 105 SURGERY AND J\DVANCED ABDOMINAL MALIGNANCY

HAROLD ELLIS D.M., M.Ch., F.R.C.S.

Professor of Surgery We!stminster Hospital Medical School, London

I am always amazed when I speak to tumour with reconstruction of the vascular doctors in many parts of the world by their trunk. Involvement of adjacent organs by pessimistic attitude towards their patients no means indicates inoperability and we with advanced malignant disease. The have described, for example, six patients same medical practitioners who are in whom the invaded duodenum was enthusiastic in trying every means at their resected together with a carcinoma of the disposal to palliate patients with incurable right side of the colon. cardiac or renal disease seem to give up The presence of secondary deposits, without a struggle when confronted by once considered complete contraindication advanced malignancy. While I agree that to curative surgery, is now no~ longer in many cases the situation is indeed grave, necessarily so and occasional long term I wish to show in this lecture that there survivals follow resection of solitary are some grounds for optimism. deposits in the right or left lobe. I freely The problem divides itself into two admit that the great majority of patients major parts. In the first, we have those with liver secondaries have multiple patients who present with fresh clinical deposits which are unsuitable for any form problems which at first appear to be hop2- of resection. Until recently, many surgeons lessly advanced abdominal cancer. In the taught that the presence of such secon­ second group are patients who have daries completely contraindicated resec­ already undergone what was hoped to have tion of the primary tumour. However, we been curative resection of an abdominal have recently reviewed our experience at cancer, but who now return with clinical Westminster Hospital and of 640 patients features which suggest recurrence of the with carcinoma of the large bowel submit­ disease. ted to laparotomy, 112 (18%) had liver metastasis. 6 had laparotomy only and all Primary Advanced Malignant Disease were dead within a few months. 19 had palliative colostomy or short circuit and The spectrum of what is now regarded 17 of these were dead within a year. Ho\\'­ as surgically removable is ever widening. ever, 32 of the 86 patients submitted t'l Thanks to improved anaesthesia, blood palliativ.e excision of the primary tumouc transfusion facilities and advances in sur­ lived for more than a year and 1 survive"l gical technique such as vascular recon­ for 5 years. We know, in addition, that structive surgery, we are now able to carry death from liver deposits is far kinder than out successful resection of cancer which the terminal illness of the primary cancer. only a few years ago would have been con­ Even when the local tumour itself is sidered totally inoperable. Age, for example, completely irremovable, we must always is now seldom a bar to surgery provided consider whether we can carry out some that the patient's general condition is useful short circuit operation or intubation satisfactory. Involvement of major blood using a plastic tube. The average length vessels by tumour does not necessarily of survival of patients after this procedure contra-indicate resection, since the involved is only in the region of 12 weeks and the vessels can be removed en bloc with the longest survival one can expect is about 106 1 year. However, anybody dealing with It is only after we have been through these unfortunate patients would agree this list that we turn to other procedures that allowing them to swallow fluids such as radiotherapy or chemotherapy. relatively easily up to the time of their It is a common but un.de~')tandable death is a tremendous advantage. In sum­ mistake to attribute every symptom and mary, when confronted by a patient with sign which a patient develops after a suc­ an apparently hopeless abdominal cancer, cessful cancer operation to recurrence of we should first consider whether the the original disease, yet this is by no means tumour is after all resectable even if this an invariable rule. means removal of adjacent structures or Distension, vomiting and constipation distant deposits. We should consider whe­ may be due to subacute obstruction due to ther a palliative resection is indicated. adhesions. An abdominal mass may be due even though we know that secondary to a twisted ovarian cyst or a deeply placed deposits will be left behind. Should the' chronic abscess. An apparent recurrenC'3 growth be totally irremovable, we must ?1. at a suture line may be due to a benign least consider whether some sort of short stricture and even jaundice may be due circuit or intubation should be carried oat. to g~ll ston~s. From time to time we encounter Sus!lected Recurrent Disease patients who develop a second and per­ fectly resectable primary tumour. This may There are few situations which ar" occur in another organ but is particulprly more depressing to the practitioner, the likely to develop as a metachronous surgeons, the relatives or to the patiert second primary tumour in the large bow.;.] himself than when months or years aftel' following resection of a previous growth. an apparently successful resection of:m Many of these are entirely operable so abdominal tumour features develop which that the follow-up of patients after resec­ suggest recurrence of the original lesion. tion of colonic cancers should be most There may be loss of weight or appetite, carefully pursued. development of abdominal pain or disten­ Even if the tumour has indeed sion. There is vomiting or jaundice, or per­ recurred it does not mean that it is neces­ haps a mass has been found in the sarily unresectable, whether the recurrence abdomen. Of course, everyone immediately is at the anastomosis or a deposit else­ assumes that the patient has now deve­ where such as in the abdominal scar or in loped hopeless recurrent cancer and that the ;)erineum following an abdominoperi­ little or nothing can be done about it. neal resection of the rectum. Undoubtedly this situation is true in manv Even if the r3currence is found to be cases, but there are enough exceptions to irremovable at laparotomy, it may still be maintain a flicker of optimism. I advise the possible to perform some palliative sur­ following catechism under the circum­ gical procedure such as a short circut of an stances:- obstructing but irremovable recurrence or by intubation of recurrent obstructing 1. Could the clinical features be pro­ tumour in the oesophagus. duced by some unrelated and benign What sort of results may we expect to condition? get from this programme of aggressive 2. Could the patient have developed . a surgery in which we are prepared to carry second primary tumour in itself per­ out an exploratory laparotomy in a sus­ fectly resectable? pected case of abdominal recurrent cancer, 3. Even if a secondary deposit or recur­ provided there is no obvious evidence of rence has now developed, is this itself widespread hopeless disseminated disease? removable? Over the last 11 years we have carried 4. Even if the patient has irremovable out 39 second look operations in the Sur­ recurrent tumour, is there any pallia­ gical Unit of Westminster Hospital on tive surgery which might relieve his patients who have undergone previous symptoms? "curative" resections for large bowel can- 107 cer and who returned with clinical features abdominal scar, the perineum, ovary, pelvis suggesting recurrence of disease. 3 patients or small intestine. 5 died in from 3 to 15 were found to have a non-malignant con­ months of metastatic disease, but the dition with no evidence of recurrence. I patient with perineal metastasis after an had obstruction caused by adhesions, 1 a abdomino-perineal excision of the rectum granulomatous stricture at the anastomosis lived for 4! years before dying of dissemin­ and 1 a twisted ovarian cyst. The first two ated cancer. patients remain alive and well five and 4 patients were found to have dis­ four years after surgery. The third died seminated deposits at second laparotomy three years after operation without evid­ and all died in periods of up to 17 months. ence of recurrence. To sum up this small series of 39 3 patients developed entirely new can­ patients, 12 achieved good long term cers, a renal carcinoma, a carcinoma of results with survival of 2 years or more, 8 the body of the uterus and adenocarcinoma of these are still alive and 2 remain well of the ovary. The first two died within a and free from clinical recurrence within a year of second surgical excision and the year of their second operation. third patient is alive but with pulmonary We feel that there is much to gain and deposits, within a year of the second little to lose in offering laparotomy to operation. these patients. The occasional case with a 11 patients devolped metachronous completely benign condition is alone worth tumours in another part of the large bowel all the endeavour, and long term survival which were submitted to resection. ·5 of may also follow resection of a recurrence these patients are now dead in periods of or a second tumour. Even if the exploration up to 24 months after the second opera­ reveals a surgically hopeless situation, the tion. 6 patients are alive and well, 2 with­ laparotomy at least defines the extent of in 12 months, 2 at 2 years, 1 at 7 and 1 at the problem so that we can consider whe­ 8 years post-operatively. ther radiotherapy or cyto-toxic drugs 4 patients with local recurrences were should be used. At the very least, in such only suitable for short circuit or colostomy. cases the patient and his family know that All of these died within 14 months. no effort is being spared before giving the 6 patients had recurrences in the final hopeless prognosis. 108

MORE ABOUT WEEVER FISH AND THEIR TOXIC STINGS LOUIS ZAMMIT

M.D., B.Pharm.

This paper is meant to follow that on way and Sweden, and in Denmark particu­ weever fish stings which appeared in this larly in the Kattegat area where we ever periodical in Dec. 1973. In that paper the fishing is lucrative, yielding a profit of immediate and complete relief obtained in almost half a mmon Danish kroner a year. ten patients by means of local Lignocaine Weevers are consumed as fillets but are infiltration in the proximity of the puncture also in great demand as mink fodder on site of we ever stings was described. Since account of their suitable fatty content: that paper was written three other cases (Skeie 1962a). In view of their wide distri­ have been similarly treated and these will bution along the various Europ2an coasts be described further on. An attempt has weevers are known by many vernacular also been made in the last few months to names: weever, adderpike, bishop, dragon review most of the scientific literature fish, otterpike, stangstel\ stingbull (English), available on weever fishes and their toxi­ vive, avive, aragna (French), fjars'ng, fjas­ cological properties. ing (Danish), drakena (Greek), pietermann, arend, stekelvisch (Dutch), Petermannchen, Nomenclature Drachenfisch, Ragno (German), fibersing, foersing (Swedish), tracina, ragno, draco Weever fish can be found in the Mediter­ (Italian), traconia (Turkish), draganja, zanja ranean, the East Atlantic coast, around the (Yugoslavian). Ancient Latin names include British Isles and Ireland, in southern Nor· araneus, draco and tragine. (Fig. I). 109

Some Hist{)rical N ot~s nature of we ever toxin (venom) is due to The toxicological nature and painful Skele's extensive laboratory experiments. effects of weever fish stings have been Earlier crude and poorly successful remarked upon by ancient classical writers. attempts at observing the toxi~ effects of Pliny in his "De Venenatis Marinus" says weever stings had been carned out by that "draco, marinus" and "araneus " h ave Schmidt (1874). He observed the effects on their back and opercula, spines capable after inserting small bits of opercular gland of inflicting dangerous venomous wounds. tissue in the cut skin of frogs. His results Aelian ascribes poisonous properties to the were equivocal. Gressin (1884) obtained the dorsal spines of weevers. In "Haliutica" , a venom by pressing fresh opercular glands. poem on fishing by Oppian, one reads; He described the fluid thus obtained as "Cruel spines defend some fishes, as the "clear, with a slightly bluish tint iJ?- i~<; goby fond of sands and rocks, the Scorpion, fresh state but opalescent and less lIqUId Dragons and Dog fish from their prickly in fish which had been dead for a few mail well named the spinous; These in hours." This extract was noticed to be pun~ture sharp a fatal poison from their coagulated by strong acids, by bases and ~n (1893) spines inject." Dioscorides (cif1ca 50 A.D.) heating. Pohl fOHnd that the toxm in "The Greek Herbalist" (edited by Gun­ can be rendered non-poisonous by the ther 1934), under the subject Drakon addition of alcohol, ether or chloroform thalassios tells us that, "The Sea Dragon, and also that dried stings loose their toxi­ being op,med and soe applyed is a cure for city within 24 hours. Phisalix (1899) made ye hurt donne by his prickles." Galenus has glycerine extracts after crushing opercular also discussed a mode of treatment for and dorsal stings in a mortar. The extract weever stings. was then injected into the thigh of gumea More recently Allman (1840) was prob­ pigs and the effects of swelling, infla~mrt­ ably the first to give an anatomical descrip­ tion and subsequent death of the ammals tion of the opercular (gill cover) apparatus were noticed. Briot (1902) made various of weevers. Byerley (1849) demonstrated observations of the effects of the weever venom in experimental animals as well a~ both opercular and dorsal veno~ gla~ds. Parker (1888) provided a hIstologIcal in vitro experiments with red blood cells. description of the venom glands. Evans He found that the venom had haemolytic effects. Evans (1910) made similar obser­ (1906, 1907, 1910) wrote a note on th~ treatment of weever stings. Halstead (1957) vations. Evans obtained the toxin by remov­ has discussed in considerable detail weever ing it with a sterile syringe direct from tnp grooves of the spines. After injecting the fish stings and their medical managem~nt. He reported the case report of a patient toxin in cats he recorded the effects on who had been attacked by a weever and blood pressure and respiration. A marked stung in the neck, which sting caused a fall in blood pressure leading ~o eventual severe anaphylactic reaction and swelling death of the animals was notIced. Br1of. in the neck leading to respiratory difficulty. was the first to evaluate the immunologIcal The patient however, recovered fully after characteristics of Trachinus venom. He ten days intensive hospital care. Perhaps showed that the venom acted in rabbits 11S the most interesting work in this field ,,:,as an antigen. He was able to immu~iz~ Il carried out by Skeie (1962) for the Damsh rabbit actively by giving it two dIlutefl State Serum Institute. Skeie has not only sublethal inoculations of weever venom. Animals so immunized could then tolerate managed to extract the weever toxin. ~ut doses of full strength venom four times purified and analysed it, . mad~ tOXICIty determinatIons and extenSIve Immunolo- greater than the lethal a~ou.nt effective ~n . gical observations on various experimental control animals. The mam dIsadvantage m animals. the various experiment" mentioned ~bove, was the fact that no stable preparatIon of well defined toxicity had been available. Skeie however found a method of extracting Much of what is known about the we ever toxin by a 'micromethod' tech· 110

LZ

Fig. 2

nique applying suction to narrow tubes and were of varying venom-like activity. Some collecting the to~in in a test tube. (Hg. 2). protein fractions were even innocuous. The Opercular spines yielded more toxin than toxin was found to contain hyaluronidase first dorsal ray spines and the average in a concentration of 38,600 LU. per mY. amount obtained per fish was only about Electrocardiographic studies were carried 0.15 ml. The raw toxin obtained was then out after lllJecting different doses of venom centrifuged to separate solid sediment and in cats and rabbits. Lead II was recorded. fragments. This left a dear solution of Smaller doses produced sinus arrhythmia, slightly increased viscosity with a pH of higher doses showed marked ischaemic 7.1. Quantitive titration of the toxin and changes with ST depression, and lethal potency de terminations were carried out. doses quickly produced ventricular flutter It was found that even a small amount and death. There was a corresponding representing 0.0004 ml of undiluted toxin lowering of blood pressure and increased was lethal to mice. Smaller dilutions pro­ respiration. This shows that besides being duced local reactions of inflammatory neurotoxic the venom is 8.1S0 cardiotoxic. redness and even ischaemia and skin Autopsies on animals showed stasis in the necrosis when injected subcutaneously in lungs and liver, frothy blood-stained dis­ mice. The toxin was found to consist of a charge in the respiratory system and number of different proteins and these haemorrhagic sub-pleural dis':!cloratlon. 111

-I ---I'-. -.-'

-'------.------~-----'

Fig. 3 Case 13 112 The heart was always fnll on the right side weever's opercular spine. This is the first and the left ventricle contained no blood. time I have found a sting in situ. The boy At times the heart was considerably made a full and uneventful recovery. dilated. Case 12. 13/5/74. S.M. a 14 year old Skeie also carried out, extensive boy was stung in the plantar aspect of th3 immunization experiments on animals to left middle toe. In this case three puncture examine the antigenicity of we ever venom. wounds could be seen in a row at a distance He found it possible to detoxicate venom of about 6 mm from each other. This injury without loss of antigenicity. In principle it would be consistent with stepping directly was found quite possible to produce a vac­ on the fish's erected first dorsal ray spines cine or perhaps an anti-serum against whilst the rest. of the fish is lying buried in weever intoxication, but great practical the sand when spawning. Immediate, com­ difficulties are encountered in obtaining a plete and full recovery was obtained after sufficient amount of toxin. It was estimated infiltrating 2 ml of 2% Lignocaine around that about 3,000 weever fish would be the puncture wounds. required for the production of enough vac­ Case 13. 3/6/74. C.D,S. was a 29 year cine for one perso!1 (Skeie, 1966). old lady seen 20 minutes after the accident. She had been stung in the middle plantar Symptoms and Signs aspect of her left foot. With the help of an assistant we managed to apply the four Besides the intense pain at the site of leads of an electrocardiograpbJc machin8 the sting which characteristically spreads and Lead II was recorded immediately proximally (cf. hyaluronidase) and the before, during and after Lignocaine injec­ inflammatory redness and sw::;lling (foreign tion at the puncture site. Part of the protein reaction), weever sting victims quite tracings can be seen in fig. 3 which show often complain of pain across their chest sinus arrhythmia but no definite ST Originally this symptom was not given much changes. Similar changes have b3en importance. It was attributed to thb recorded in cats and rabbits by Skeie patient's extreme fright and fear of death (1962) after experimental toxin inoculation. knowing that he is suff:r~ng from som3 Th:'s leav3s little doubt that weever toxin fbrm of poisoning. There is no doubt, how· affects the human heart as well, and the ever, that this is in fact true typical cardiac precordial pain experienced by victims dur­ ischaemic pain. A sting inflicted directly ing the acute episode is in fact cardiac pain. into a victim's vein can be very serious Immediate and complete relief was indeed, if not immediately fatal. This pos­ achieved in this patient by infiltrating 2 ml sibility should be kept in mind when of 2% Lignocaine near the puncture healthy young good swimmers drown in wound. relatively calm waters for no apparent reason. Lignocaine

Further Case Reports Other synonyms are xylocaine and lidocaine. The immediate and complete Case 11. 28/10/74. J.U. a five year old relief achieved by infiltrating Lignocaine boy was stung on the plantar aspect of the hydrochloride near the puncture wounds right big toe. There was a definite hard of weever sting victims has led me to gritty sensation at the puncture site. The believe that it has the effect of completely boy was extremely restless and crying with eradicating the venomous potency of the severe pain. He stopped crying immediately toxin. The most probable explanation for 1 ml of 2% Lignocaine was injected near this is the fact that Lignocaine HC1 is an the puncture site. A sharp sting was then acid with a pH of 5.0. The weever toxin quite easily removed. This was about 8 mm has a pH of 7.1. It has been variously long and consisted of hard white translu­ established that the toxin is coagulated cent dentine structure; its shape was con­ and loses its potency in in vitro experiments sistent with the terminal portion of a by the addition of acids. In this respect 113 other acid injections might also be effec­ Gen., 6, 271. tive, but lignocaine has the added advantage BYERLEY, I. (1849): On the Trachinus draco, of allowing for local incisions to be com­ or otter pike, sting fish or weever. Proc. Lit. fortably made if required, say to romove Philos. Soc. Liverpool,S, 156. remnants of spines (cf. case 11). Besides, EVANS, H.M. (1906): Note on the treatment of in view of the proved cardiac arrhythmias we ever sting. Brit. Med. J., 2, 23. which occur following weever toxin poison­ EVANS, H.M. (1907). Observations of the ing, its effect in helping to correct poisoned spines of the. weever fish. Brit. this state of affairs ccnstitut~s a further Med. J., 1, 73. indication. It should remain the treatment EV ANS, H.M. (1910): Further studies in haemo­ of choice and it would be extremely difficult lysis by we ever venom. Brit. Med. J., 1, 982. to find a better alternative. It must be GRESSIN, L. (1884): Contribution a l'etude de stressed that the sooner lignocaine is l-appariel a venin chez les poissons du genre injected the better. Vive. Thesis. Fac. Med. Paris. GDNTHER, R.T., Editor (1934): Materia Medica. Acknowledgements The Greek Herbalist. Translated by J. Good­ year (1655). Oxford Dniv. Press. My thanks are due to Nurse Maria HALSTEAD, B.W. (1957): We ever Stings and Muscat of Rabat without whose assistanc~ their medical management. D.S. Armed treating patient C.D.S. and at the same Forces Med. J., 8, 1441. time recording an E.C.G. would have been PARKER, W.N. (1888): On the poison organs of impossible; Mrs. S. Salmento and Mr. T.R. Trachinus. Proc. Zool. Soc. London, 3, 359. Mercier of Pensyvania, USA for their help PHISALIX, C. (1899): Experiences. sur le venin in obtaining photocopies of Bruce W. des vives (Trachinus vipera et Tr. draco). Halstead's papers on weever stings and Mr. Bull. Mus. Hist. Nat. Paris,S, 256. M. Aarkrogh, Secretary, Statens Serumin­ POHL, J. (1893): Bietrag zur Lehre von den stitute, Copenhagen for supplying me with Fischgiften. Prag. Med. Wschr., 18, 31. r1cprints of Dr. E. Skeie's papers. SCHMID'r, F.T. (1874): Om fjarsingens stik og giitredskaber. Nord. Med. Arkiv., 6. References SKEIE, E. (1962): Weeverfish Toxin. Acta Path. et Microb. Scandin. 55, 166. and 56, 229. ALLMAN, G.J. (1840): On the stinging property SKEIE, E. (1962a): The venom organs of the of the lesser we ever fish (Trachinus vipera). weeverfish. Med. fra Dan. Fiskeri - og Ann. Mag. Nat. Hist., 6, 161. Havund. Copenhagen, 3, 327. BRIOT, A. (1902): Sur I-action du venin de la SKEIE, E. (1966): Weeverfish stings. Danish vive (Trachinus draco) Jour. Physiol. Path. Medical Bulletin. August, 119. 114 DERMATOLOGY AND SURGERY R.O. PARNIS

M.B.E., M.D., F.R.C.S.

In this paper I shall describe two der· He was also given daily injections of matological patients who came my way oestrogens and of ACTH. He has recently recently. The first one was a handsome, returned to Malta and I propose to carry fair-haired, lusty individual in his mid·· on the treatment in the shoulder areas. twenties who had been attending the skin The second patient was a nervous clinic for years, certainly for eight years. young man of 25, rather thin who had He emitted a very disagreeable smell yellowish patches over elbows and knees which came from numerous sores all over and big yellow pedunculated tumours the back but mainly on the shoulders and hanging from each buttock. He had a very buttocks. The story was that these ulcers marked corneal arcus and his serum healed only to break down again, they cholesterol level was up in the 400's. No appeared on lumpy skin and they b2camc diminished sugar tolerance was present. active with no obvious cause. This man We are dealing here with one of the like the woman troubled with an issue of lipoidoses, conditions associated with a blood 'suffered many things from many disturbance of lipoid metabolism. The physicians and had spent all that she had subgroup that interests us is that of and was nothing the b3tter but rather worse~ essential familial xanthomatosis which is He did not improve becaus2 his complaint characterised by consistent abnormalities was acne conglobata. This is an unusually of s2rum lipjd concentrations, hereditary severe form of acne, very rare, the hall­ transmission to offspring and typical marks of which are deep abscesses and drain­ cutaneous manifestations. There is a dis­ ing sinuses. There are num erous coms­ order of cholesterol metabolism but its dones, cysts containing a clear viscid fluid cause is unknown. As regards transmis­ and grouped inflammatory nodules. Pro­ sion, the exact mechanism of inheritance nounced scars, frequently keloidal, remain is still disputed but it appears to be either after healing. This severe disease occurs a dominant or an incomplete dominant mainly in males around 16 years old and trait. The form this patient exhibited, it may last even to the forties, especially xanthoma tuberosum, affects young adults on the back. The condition' is extremely of either sex. The eruption consists of pf'rsist.ent and slow healing of one group yellowish papules, nodules, plaques and of abscesses may accompany the progres­ tumours located chiefly on extensor sur­ sive extension of another group of lesions. faces. Lesions tend to group about the Suppurative hydradenitis and dissecting large joints, in our case the elbow and cellulitis of the scalp are sometimes knees, and over areas of trauma and pres­ associated with acne conglobata and sure such as the buttocks. Occasionally squamous carcinoma may rarely develop they are scattered all. over the trunk. By in areas of scarring. The treatment which gradual enlargement and meeting of includes steroids in very severe cases is groups of papules large pedunculated palliative and unrewarding. tumours may form as happened in this This patient was referred to St. John's case over the buttocks. These tumours may Hospital for Diseases of the Skin in Lon­ show pressure atrophy of the overlying don and after a short stay there he was skin, telangiectasis of superficial vessels sent to a plastic surgery centre where th3 and the occasional development of stub­ worse affected skin over both buttocks was born painful ulcerations. The blood s2rum removed and replaced by split skin from shows a marked increase in the cholesterol the back of both thighs, trouble free areas. values as it did in our case but the figures 115 may sometimes reach four or five times referred to the surgical department for the normal. The serum is usually clear or removal of his buttock tumours but he was only slightly opalescent and the fatty acids much more concerned with the flat yellow and phospholipids are normal or nearly so. plaques, relatively inconspicuous at the Arteriosclerotic vascular disease is com­ elbows, and I removed a good part of these mon and early. Half the patients develop being able to do so by reason of the laxity coronary atheroma with angina. Peripheral of the skin. The wounds healed without vascular disease is often seen. The vas­ trouble. As regards his family, his mother cular complications are the most serious is alive and well aged 54 and he has a sister cause of disability and it if; said that every without xanthomas. His father died sud­ case of coronary artery occlusion in child­ denly at the age of 48 while out at work ren and adolescents reported in the litera­ and a younger brother who had lesions ture has been associated with xantho­ similar to his died suddenly at the age of ma tuberosum. Actual xanthomatous 16 while out hiking. This man is engaged nodules consisting of typical foam cells to be married and I am very glad I have occur almost solely in the skin. Rare not been asked my advice as to the wisdQID instances of organ involvement with of this step. epilepsy, for example, have been reported. Treatment tries to deal with the under­ The only exception is the vascular tree: lying disease but as this is unknown we some investigators believe that the plaques are groping in the dark. Very low fat diets in this disease represent xanthomatosis of are recommended, diets which are mono­ the arteries. Because of its pgtentially tonous to eat, difficult to prepare and hard serious prognosis xanthoma tuberosum to pursue. In addition such -diets must be "hould be distinguished carefully from constantly and strictly followed. The lu.mps other similar conditions but this is not and swellings can of course be removed for usually difficult. temporary benefit. In the case described the patient was 116 PARAPHARYNGEAL CHORDOMA A case report

P.J. DAMATO

M.D., D.L.O., F.R.C.S.

J. PACE BALZAN

M.D., F.R.C.S.

The parapharyngeal gutter is a trian­ nasopharynx and distally to the level of the gular space bounded medially by the buc­ hyoid. It was smooth, firm and non-pulsa­ copharyngeal fascia and posteriorly by the tile. There were no palpable nodes. (ii) Para­ pre-vertebral musculature, while antero­ lysis of the last four cranial nerves. laterally it is roofed over by the ster.i10- (iii) Left secretory otitis media. mastoid, strap muscles and the encircling layer of the deep cervical fascia. It Investigations extends from the base of the skull into the superior mediastinum. It contains th~ 1. Audiogram: Lt. conductive deaf·· carotid sheath, the last four cranial nerves ness averaging 30 - 40 db over the speech and the deep cervical and retropharyngea] frequencies. 2. Haematology: normal blood lymph nodes. picture. 3. Radiology: (a) Lateral soft tissut' The commonest swelling in this space views of the neck showed a degree 01 follows enlargement of the deep cervical widening of the retropharyngeal space. nodes. Neurofibroma, chemodectoma and (b) Submentovertical views showed wide11- aneurysm of the carotid artery are occasion­ ing of the left jugular foramen. (Fig. I). ally found in th~s region. (c) Tomography confirmed the above find­ The purpose of this paper is to report ings and showed some irregularity in the an­ an unusual case of a chordoma arising in terior margin of the foramen magnum sug­ the region of the foramen magnum and gestive of early bone destruction. (d) On extending laterally to pre:::ent as a para­ angiography the carotid arteries were pbaryngeal tumour. splayed out by the tumour, but no abnor­ mal tumour circulation was demonstrated. f:ase Report (e) Chest Xray was normal. The mass was removed through ;} The patient, a middle aged male, pre­ lateral cervical approach. It was a iarge sented with a recent aggravation of a lU multilocular cystic tumour filled with jelly­ month history of periodic neuralgic pain like material. It appeared to be well encap" in the left side of the face and head sulated and extended caudaUy to the levd radiating to bmple and throat. He dSI) .of the hyoid. The internal carotid artery complained of left sided deafness, and dif­ was postero-Iateral to the tumour; the ficulty in swallowing both liquids and external carotid disappeared deep to it. solids. His voice was normal. The hypoglossal nerve was stretched Positive physical findings included: across it. (i) Fulln.ess of the left side of the neck The lower half of the turnout was below the angle of the mandible, con­ readily dissected away from the surround· tinuous medially with a parapharyngeal ing tissues with preservation of the hypo>· mass which had displaced the tonsil across glossal nerve. More cranially the mass was the midline. It ext:mded upwards into the:: followed to the base of the skull, above and 117 deep to the transverse process of the atlas to arise from remnants of the notochord, where the tumour broke open. The remain" the primitive axial structure first found in ing cavity, about 1 cm in diameter, was Amphioxus and Tunicata and around drained, its mucoid contents being sucked which the vertebral column is formed in out. There did not appear to be any con­ higher vertebrates (Rewell 1963). What nection between the tumour and the precipitates malignant change in these rem­ pharynx or subarachnoid space. nants is not known, but trauma is believed to play a part. (Utne and Pugh 1955). The theory that these tumours origin­ ate from notochordal rests is strengthened by the following facts: (i) In the cranial region these tumours are never found anterior to the pituitary fossa. In man, the cranial end of the developing notochord enters the basi-occiput for a short distance until it comes into contact with the endo­ thelium of the primitive pharynx caudal to Rathke's pouch, within the body of the sph> noid, caudal to the pituitary fossa. (ii) Noto­ chordal rests have been demonstrated at the three main sites of orig;n of cranio - cervical chordomas viz. the posterior wall of the pituitary fossa, the posterior pharyngeal wall, and the anterior margin of the foramen magnum. (Wright 1967). These tumours may arise at any point in the cranio - vertebral ax:s, but are most common in the sacrococcygeal region and base of skull. The higher incidence of chordomas at both extremes of the axial skeleton may be explained by the greatsr developmental activity in these regions consistent with the development of head and tail folds. Fig. 1. The occasional finding of chordomas at sites away from the axial skeleton is not Postoperative recovery was uneventful so readily explained. Cases have been and marked by immediate relief from pain. described in the maxillary and frontal Histology report: S'cction shows large sinuses. (Pastor et al 1949; Adams 1945). vacuolated cells and in some areas syncy­ The possibility exists that in these situa­ tial strands of cells all within a matrix of tions the tumours arise from persistent mucus. In the more cellular areas pleomor­ foci of chordomatous tissue that has been phism is present. This picture is suggestive displaced more widely than usual. The of Chordoma. subject is however obscure and the possi­ bility of mis-diagnosis cannot be ruled out Discussion owing to the difficulty of distinguishing them histologic ally from the more common Chordomas are rare tumours constitut­ tumours in this region, like mucin - ing less than 1 % of all neoplasms affect­ forming adenocarcinoma. ing the Central Nervous System (Poppins The histological appearance of chor­ and King 1952). They are some of the few doma may vary widely but the characte­ malignant tumours originating from vesti­ ristic feature is the "Physaliphorous cells" gial embryonic tissue which retain primi­ of Virchow - cells blown up by excessive tive histological features. They are believed production of mucus. These cells gradually 118 lose their cell outline and in parts appear bone and recurrences. (Ormerod, 1960; as a vacuolated syncytium with a few cells Boyle and Frank 1966). Chordomas are not surrounded by mucus. The typical chor­ completely radio-resistent, and the chor­ doma 10 a slow - growing tumour which domas of childhood are more sensitiv~ extends into the soft tissues pushing them than those seen in the adult. aside with erosion rather than infiltration. Prognosis is poor, the average survival Bone at the site of origin may show exten­ of cranial chordomas being 3 years from sive absorption. Metastases, which may the onset of symptoms. Cases have, how­ occur in some 10% of cases, are found in ever, been recorded of patients surviving in lung, liver, lymph nodes and subcutaneous good health for much longer periods fol­ tissues. These are less common with lowing repeated excision of tumour cranio-cervical chordomas possibly because recurrences. of earlier presentation and an earlier fatal outcome of tumours at this site. Cranio - Acknowledgement cervical chordomas usually present about the 4th decade i.e. earlier than chordomas We are grateful to Dr. J. Sant, con­ at other sites. These is no appreciable sultant radiologist, and Prof. G.P. Xuereb, difference in sex incidence. Senior pathologist for their help with this Symptomatology varies with the site case. of origin of the tumour, but pain is th2 earliest and most common presenting References symptom and may be due t6 erosion of bone or cartilage or involvement of nerve ADAMS, W.S. (1948). J. Laryng. 62, 93. roots. Visual disturbances wIth loss of BOYLE, T.A. & FRANK H. (1966). J. Laryng. and visual acuity, diplopia and limitation of Otol. 50, 647. visual fields are characteristic of spher.o­ GENTIL, F. & COLEY, B.L. (1948). Annals. Sur­ occipital chordomas, while extensions into gery 127, 432. the hypothalamic area present with en do­ ORMEIWD, K. (1960). J. Laryng. & otol. 74, 245. crinal dysfunction. Cranial nerve involve­ 74, 245. ment occurs progressively with lateral PASTORE, P.N. et al., (1949). Arch. Otolaryngo­ extension of the originally midline tumour. logy 50, 647. Treatment is usually surgical and POPPINS, J.L. and KING, A.B. (1952). J. Neuro­ incomplete because of bone involvement at surgery 9, 139. the time of diagnos!s. The commonest REWELL, R.E. (1963). Pathology of The Upper approach for cranio - cervical chordo­ Respiratory Tract. Edinburgh: Livingstone. mas is the lateral cervical or transpalatal. UTNE, J.R. and PUGH, D.G. (1955). Amer. Jour. High dosage radiotherapy has occasionally Roentgen. 74, 593. been used to control tumour residue in WRIGHT, V. (1967). J. Laryng. and Otol. 81, 1337. 119 TRAUMATIC AIR EMBOLISM

NAZZARENO AZZOPARDI M.D., D.A.

Summary to painful stimulation by a withdrawwai reflex and an attempt to flex his forearms A rare case of traumatic air embolism showed a lead pipe type of rigidity. Ankle and a possible hazard to underwater divers clonus was present and the reflexes at his using SCUBA (self contained underwater knee and ankle were brisk; the plan tars breathing apparatus) mdhod are herein were normal and there was no neck rigidity. described. There was adequate air entry in the lungs but a lot of extra respiratory sounds Case History were also present. The heart sounds were faintly audible and there was an uncommon A 27 year old Austrian 'fit enough to murmur heard all over the precordium, pass all the tests for a pilot with the Aus­ trian Air Force' on an underwater tour Treatmen: using SCUBA, accompanied by his trainer, went down on his fourth din to 30 meters. ./;.Hhough the Ci.iagl1osis was still in He had had a good meal a few minutes doubt a cuffed endotracheal tube was heforc diving. The air cylinders, with no passed with some difficulty and suction ap­ spare one, had just been checked. While plied through another tube to clear all the under water the trainer noticed that his vomitus. Then oxygen was given through a companio:l wal> 'shaking' and had removed Y connection, the other end being left the mouth piece from his l:ps. The trainer open to the air. An open vein was secure<1 put his mouth piece on to his companion's and an infusion of 5% dxtrose started. In lips and quickly ascended. The attending an attempt to relieve the clonic fits 10 mls boat picked them up but the Austrian was of calcium gluconate were slowly given 'stiff all over', unconscious and had to be and also 100 mls of sodium bicarbonate placed flat on his back across the boat. 8.4%. There was no improvement in the Being rowed ashore vomit. started coming tits by these methods though the breathing out of his mouth and he was 'breathing improved and the endotracheal tube was with difficulty and noisily'. removed. Diazepam in 5 mgs uoses was On arrival at the Victoria Hospital, gIven slowly in the Lv. drip and the fits Gozo the patient was breathing stertorously, stopped after the third dose (total 15 mgs). slightly cyanosed, rigid and shaking all Consciousness returned and, through an over. He was unconscious, had dilated interpreter, the patient said he had severe pupils and his eyeballs were roving from burning retrosternal pain. The blood pres­ side to side. Signs of vomit were on his left sure was again checked and was found to cheek and chest wall. His hands were 1n be 120/80 mmHg. Ophthalmoscopy at this the 'main d'accoucheur' position and his feet stage revealed a pale field and though a were in state of exaggerated plantar exten­ special search was made for any air bub­ sion. No signs of external bodily injury bles, none was found. It was noticed that were evident and there was no surgical whenever the patient was disturbed or emphysema. His pulse was faint and very moved clonic fits with opisthotonus rapid, over 120 per minute. An attempt to occurred, causing the patient a lot of take the blood pressure was made. Though muscle pains. The patient was then moved the clonic movements interfered with cor­ to the X-ray room and a chest view was rect reading, the systolic was found to be taken lying down. There was good expan­ about 80 mm Hg. The patient was reacting sion of the lungs, the heart shadow was in 120 place but a rather wide mediastinal shadow the pressure is three atmospheres or 44.1 was noted. lbs per 1 sq. inch. The volume of gas in the An examination was again carried out lungs was 1/3 its normal value. As the when the patient was back in bed. He could depth is decreased the volume of air in the move both his upper limbs but only the lungs is proportionately increased. If tlle right leg. The pupils returned to normality vocal chords are kept closed and air is not and reacted to light but vision was limited allowed. out overinflation of the lungs to perception of light. occurs. If a weak spot exists in the lung The provisional diagnosis of 'bends' parenchyma a rupture may occur with the was made and arrangements were made to opening up of blood vessels and aspiration transfer the patient to the air compression of gas III the pulmonary vessels and. dIS­ chamber kindly lent by the British Naval semination of air emboli in the peripheral authorities at st. Angelo in the Grand ciliculation. If the intra pulmonary pres­ Harbour. Within three hours of the acci­ sure in the overdistended lungs exceeds dent the patient was in the chamber. The ambient hydrostatic pressure by 60 mm Bg pressure was set to three atmospheres and air embolisim may occur. The underlying the patient complained of severe ear achi::;. mechanisim is a pressure gradient from air He still had occasional clonic fits when dis­ in the alveoli to perivascular sheats or turbed and repeated doses of Diazepam underlying septa. Air may rupture blood were given intramuscularly, the intravenous vessels or dissect along sheats and septae drip having come off. and through subpleural tears into the After eight hours in the chamber the mediastmum with such complications as patient dieu. subcutaneous or surgical emphysema. The most serious complication leading Post Mortem to loss of consciousness and focal seizure with paralysis of one or more limbs implies At post mortem severe cyanosis was the entry of air in the cerebral circulation. noticed in the upper chest and face, pete­ The shifting nature of this paralysis follows chiae were pres:mt and surgical emphysem':1 the movement of air bubbles causing pat­ involved the neck and chest wall. On open­ ches of ischaemia which if prolonged can ing the thoracic cavity air was noticed in permanently damage the brain even though the myocardial vessels, the pulmonary the air bubble moves to smaller and arteries and the heart. The arterioles over smaller blood vessels. both lungs were also peppered with air The volume of air that must have bubbles. On opening the skull multiple air entered the peripheral circulation of the bubbles were to be seen in the thin walled case described above must have been con­ cerebral blood vessels especially the basilar siderable. The low blood pressure and the which was empty of blood (though the chest pain suggest severe myocardial patient was all the time lying face upwards) ischaemia which improved spontaneously and the right middle cerebral artery. as the air bubbles moved to other smaller The postmortem results conflicted vessels. with the provisional diagnosis of 'bends' and a massive air embolisim was proposed Prevention as the cause of death. This accident illustrates the risk un· Discussion trained and unprepared divers run when faced with an emergency while deep under How could aIr ernbolisim have hap­ water. The trainer accompanying this man pened while under water? The pressure of suffer~d from no ill-effects (excluding any air at sea level is 1 Atmosphere (14.7 Ibs diagnosis of 'bends') despite the rapid per 1 sq.inch). Boyle's naw -states that the ascent. The importance of not diving after temperature being constant the volume of a hearty meal is made evident by the pro­ a gas varies inversley as the pressure. At bability that the vomiting caused this diver 33 meters depth (3 more than in this case) to pull off the mouth piece while 30 meters 121 underwater. Three Atms pressure is more found fit to be an aeroplane pLot this does than enough to force the contents of a full not exclude the presence of any pUlmonary stomach up the oesophagus. inflammatory lesion that could have caused Taking an untrained person down to a weakening of the tracheo-bronchial tree. thirty meters on his fourth dive is in my opinion too risky as all 'crash courses' are! Treatment To allow air to escape whilst underwater implies a lot of training to overcome the Recompression therapy with oxygen fear that sea water will flood the aIr pas­ inhalation usually brings rapid recovery if sages. Training will help to give confidence the interval between the onset of the acci­ and to handle emergencies better. Cardio­ dent and the pressure treatment is short. pulmonary fitness is most important. Placing a patient in the left lateral position Periodic chest X-rays are called for and an and head tilted down ensures this displace­ electro-cardiogram while performing exer­ m.ent of air to the apex of the right ventricle cise, thus revealing any ST segment depres­ and allows blood to occupy the outflow sion, is needed before the start of a season. tract of the ventricle. Methods of directly The maintenance of clear sinuses and open aspirating air from the heart are described Eustachian tubes calls for periodic visits in books but are impracticable. Recompres­ to ear, nose and throat specialists, if baro­ sion brings about a decrease in volume of trauma is to be avoided. - the air bubbles and allows their easy move­ Though the patient discussed was once ment and resorption. 122 HAEMANGIOMA OF THE ORBITAL BONES Report of a case F. DAMATO

M.D., D.O., D.O.M.S., F.R.C.S.

Summary nective tissue or bony trabeculae. Whether bone Haemangiomata repre­ A case of haemangioma of the orbital sent vascular tumours or malformatiom, bones is reported and commented on. has been extensively discussed. (Guttierez and Spjint 1972). The lesions are osteolytic, Haemangiomata of bone are rather un­ the cause of the osteolysis being obscure; common. They are generally solitary lesions Gorham (1955) thinks that it is due to and make up less than 1.2% of all tumours. hyperaemia. Others (Cohen and Craig More than twice as many females as males 1955) believe that bone destruction takes are affected. One third of the cases were place by gradual pressure of enlarging found in the fifth decade of life. (Dahlin lymphatic channels. Probably, the combi· D.C. 1967). nation of both factors plays an important Seventy per cent of solitary Haeman­ part in bone destruction. The colour giomata were found in the cranium and appearance of the growth is usually blue tc vertebrae, Many of the latter tumours were violet. The bone is spongy and profuse asymptomatic and were discovered during bleeding is usually encountered during roentgenographic examination for other surgical removal. Haemangiomata usually reasons. Physical examination does not respond well to surgical treatment. contribute any specific information. The lesion is usually multicentric with involve­ Case repoN ment of more than one bone. Otis and others suggest that tumours with multi­ On 19.2.73, Mrs. A.A. 38 years old, was focal involvement are associated with a seen in my clinic complaining of puffines::. better prognosis (Unni et aZ 1971). As of the lids of left eye (Fig. 1). Closer regards roentgenographic features in the skull, haemangiomata produce a well cir­ cumscribed zone of rarefaction which may show a honeycombed appearance and i& often associated with expansion of the bony profile. This expanded zone may show striation of bone radiating outward from the centre of the lesion. The osseous pro­ cess tends to become stabilized with variable degrees of lytic and sclerotic changes. (Dahlin D.C. 1967). Histopathologically, most haemangio­ mata of bone are basically cavernous in Fig. 1. type, lined by a simple layer of flattened endothelial .cells. Sometimes, a capillary examination revealed a very small degree component is present and may even be of proptosis of the left eye. Fundus exami­ dominant. The vascular channels may be nation did not show any abnormal changes. empty or filled with red blood cells or pro­ Vision and visual fields were normal. How­ teinic eosinophilic material. They are ever, the X-ray report was as follows: separated from one another by loose con- (9.3.73): "There is erosion of the greater 123 wing of the sphenoid and part of the lesser anterior temporal branches of the middl~ wing of the sphenoid and of the frontal cerebral, showing the position of the mar­ bones on the left side. Appearances are gin of the intracranial portion of the suggestive of a retro-ocular space occupy­ tumour. The middle meningeal artery is ing ....esion." (FIg. 1, 2, 3, 4.) General exami­ hypertrophied and supplies an enormous nation did not show any abnormaliEes. amount of blood to the tumour in the region Tbe patient was transferred to tIlo:': described on the report of the plain X-Rays. National HospItal, Queen Square, London Some of the vascular spaces in the tumour (25.11.73) for further investigation and are of aneurysmal dimensions and the con­ treatment, under the care of Dr. K.J. Zilkha trast medium pools in them for a consider­ and Mr. Laurence Walsh. When examined able time. The middle meningeal artery on 25.4.73, Fundus L.E. showed discfJlur­ appears to be the sole supply to the rng of the nasal and to a lesser extent upper tumour. margin, that is, early papilloedema. IThere Although rather bizarre in appearanc3, was also an axial irreducible proptosIS of there is little doubt that this is a meningio­ ~everal mms Left eye. There was a feel­ ma. Mr. L. Walsh favoured exploration ing that proptosis was increasing slowly all because the patient had a peculiar vascular the t1me. condition in the left orbit. The condition Here is the radiological report (Dr. G. appeared progressive and there was :=t du Boulay): "There is an area of abnormal slight swelling of the left disc. tlone extending from the left Pterion dow.:­ The operation was performed on wards and forwards into the lateral part of 9.5.73. A left fronto-temporal craniotomy the greater wing of the sphenoid and the was carried out. A decompression was made lateral wal1 of the orbit. The abnormalIty at the base and attention was directed consists of a mixture of coarse trabecula­ toward the upper part of the sphenoidal tions and large vascular channels, possibly ridge in the region of the pterion where an with some sclerosis at the pterion itself. Sur­ abnormality was seen and where consider­ rounding these more obvious abnormalities, able hemorrhage was occurring. there is an area in which the bone is hypel­ The bone in the upper part of the translucent. The pineal is calcified and not sphenoid ridge in the region of the pterion displaced. The sella appears normal. Th:; was abnormal and obviously infiltrated with bone change is probably due to a tumour. Abnormal bone was removed from meningioma, but it is unusual because of this region and as far as the superior orbi­ the forward extenSIOn into the lateral wall tal fissure where normal bone was encount­ of the orbit. It may be a very vascular ered. Abnormal bone removed also from tumour. Optic canals are normal. the lesser wing of the sphenoid and as Brain Scan: Knowing where the abnor­ far as the superior orbital fissure. The roof mality is, one can see that there is some of the orbit was dealt with similarly and increase in uptake in the region, but this is also the bone in the floor of the middle largely masked by the activity in the sur­ fossa. In this way, it app2ared that all rounding muscles. abnormal bone had been removed. A small Left carotid arteriogram: repeated at­ incision was made in the dura above the tempts at catheterisation of the external pterion and the subfrontal and temporal carotid ran into so much difficulty that it regions were inspected intradurally. No seems better to do without, particularly as tumour was seen. A temporary tarsorraphy a common arteriogram makes the position was carried out at the end of the operation. extremely clear. The patient's post operative progress was There is a good filling of the anterior satisfactory. Proptosis and early papilloe­ middle and posterior cerebral arteries and dema soon disappeared. Three specimens of the ophthalmic artery from the internal were sent for a histological report. carotid. The portions of bone examined showed The only abnormality of the intra­ marked distension of the intertrabecular cranial circulation is the slight upward and bony spaces which are filled with elongated backward displacement of two small cells like connective tissue and numerous 124

Fig. 1. Fig. 2.

Fig. 3. Fig. 4. 125

Fig. 5 blood capillaries which show hyperplasia the endothelial cells lining th3m~ Occasio:: . osteoclasts occur in the tissue. The histol( gical appearance suggests that the bom; the seat of a haemangioma. Fig, 5.

This tissue consists of spindle shap;:( cells. Evidence of meningioma 'Nas no' found in it. Fig. 6.

This tissue consists of vascularil>2o connective tissue in whi~h occur collections of round cells. No evidence of meningiom:: was found in it. From the histologiC

An examination of the section of the lesion carried out by Dr. H.A. Sissons of the Department of Morbid Anatomy of the Institute of Orthopaedics confirmed the diagnosis. l<'jg. 7 126

Evidence of left fronto-parietal craniotomy with removal of the greater part of the lesser and greater wlngs of the sphen~id. No evidence of new patho­ logical changes. Comment: (frontal bone) and to the lateral side of the Although the patient was operated orbit (zygomatic bone). upon for excision of a sphenoid wing The changes found in the X-Ray meningioma, there was already a suggestion examination carried out one year after the that it was a peculiar and unusual vascular operation confirmed the fact that the tumour. tumour had no invasive oharacter. (Fig. 8.) Histological examination of the sp3ci­ A review of the literature on bone mens removed during th2 operation hemangiomata did not show any report of revealed the real nature of the growth. It this kind of tumour in the orbital bones. gave us also an explanation of the radiolo­ gical report which showed the presence or I would like to thank Mr. L. Walsh, a mixtur2 of coarse trab2culae and large Mr. KJ. Zilkha, Dr. G. du Boulay, Dr. G.P. vascular channels pOSSibly with som2 Mair and Dr. H.A. Sissons for use of their sclerosis at the pterion a::ld the presence of reports and Dr. A. Mercieca for X-ray work. an area in which the bone is hypertranslu­ cent. All these changes may bO) considered References typical of a bone haemangioma. COHEN, J., and CRAIG, J.M. (1955). J. Bone Jt. It explains also tht' changes seen in Surg., 37 A, 585. the left carotid arteriogram, namely the DAHLIN, D.C. (1957). Bone Tumours. C.C. hypertrophy of the m'ddle meningeal Thomas, Springfield, Illinois, 2nd. Ed. artery and the fact that some of the vas· GO RH AM and STOUT, A.P. (1955). J. Bone Jt. cular spaces in the tumour were of Surg. 37 A, 985. aneurysmal dimensions and that the con­ GUTTIEREZ and SPJUT. (1972). Clinic, Ortho­ trast medium pooled in them for a con­ paedic and related research. No. 85, Jan. siderable time. Though the great and lesser 8395. wings of the sphenoid were mainly UNNI, KK, IVINA, J.C., BEABOUT, J.W. and involved, the growth extended to the roof DAHLIN, D.C. (1971). Cancer, 27, 1403. 127 OCULAR ONCHOCERCIASIS Case Report J.A. COL,EIRO

Senior Reigistmr, Princess Alexandra Eye Pavilion, The Royal Infirmary, Edinburgh. Clinical Tutor in Ophthalmology, Unive:1tsity of Edinburgh

Onchocerca volvulus is a threadworm Ocular findings first recognised in 1891 in African. natiV2s. It is found in two continents, in Central and Visual acuity 6/5, N.5 in either eye. West Africa along the 20° meridian, and in The conjunctiva of. both eyes was injected parts of Central AID'~rica, Columbia, Ecua­ and chemotic. The cornea of both eyes first dor, Peru and Guatemala. Th3 worms are examined by a X 10 hand loop and sub­ white and filiform, the male measuring sequently confirmed by s1it-Iamp examin­ 4 cm. in length and 0.2 mm. in diameter, ation, showed the characteristic:1+: limbitis. the female up to 40 cms. in length by Lesions resembling 'broken ice' and 'snow­ 0.4 mm. They live in fibrous subcutaneous flake' patterns were defined in the super­ nodules above or below the shoulders, ficial stroma, particularly in the inter-pal­ depending on the biting habits of the flies pebral area close to the limbus. No discoid which serve as intermediate hosts. The or nummular forms were seen. Keratitis female discharges millions of tiny micro­ occurs in practically every case and is due filariae into the nodules, whence they are to the presence of dead microfilariae which ingested by the insect vector, the black fly enter the cornea from the limbus. No pan­ of the genus Simulium which breeds in and nus was observed. The anterior chambers close to shallow, rapidly flowing, well bhowed a very faint aqueous flare with an oxygenated streams. Live microfilariae occasional microfilaria seen swimming in migrating in the subcutaneous tissues, give the aqueous on the right sl de only. Th~re rise to little reaction; the damaging agent was no abnormality of the sclera, iris or is the toxin derived from dead microfilariae. fundus. The diagnosis was suggested by the The worm does not enter the blood stream. typical ocular lesions in a person from an endemic area, supported by the character­ Clinical features istic eosinophilia. A Mazzotti test. admin­ istering a small test dose of Diethylcarba­ The patient, a female, M.W., aged 47, mazine, was positive in that ocular symp­ was admitted to the City Hospital, Edin­ toms were exacerbated. This drug kills burgh in September 1974 while on vacation microfilariae in large numbers, but has no from Ibadan, Nigeria where she had Effect on adult worms. The patient was resided for the past 22 years. She had been therefore treated with Suramin (Bayer) 1 feeling generally unwell for the past month, gram intravenously every fifth day. How­ and for several months had had transient ever, following the second dose, the patient acute ocular symptoms such as photophobia showed early signs of nephrotoxicity with and watering and itching of both eyes. She protein and casts in the urine. ThiS drug also gave a history of painful itching was therefore withdrawn and substituted by episodes in the skin of her legs. General Diethylcarbamazine (Banocide) 1.5 mgs. examination revealed two small subcutane­ per kilogram body-weight, three times ous nodules at the back of the neck. daily for three weeks. Ocular symptoms Routine blood examination showed a were supprpsspd by topical b~tamethasone. marked eosinophilia. One month later, all corneal lesions 128

appeared inactive and no micro filariae tion in the skin, and the distance from the were detected. nearest nodule to the eye. This patient appears to have had a relatively mild form of the disease; this con­ I am grateful to Dr. P. Ball, who forms with the accepted view that the invIted me to give an ophthalmological degree and extent of ocular involvement opinion depends directly on the density of infesta-

DETERMIN'ATION OF SERUM ZINC LEVELS IN NORMAL MALTESE ADULTS BY ATOMIC ABSORPTION SPECTROPHOTOMETRY

R. ELLUL-MICALLEF M.D., Ph.D.(Edin),

A. GALDES B.Sc.,

and

F.F. FENECH M.D., F.R.C.P.(Edin.), M.R.C.P.(Lond.)

Department of Physiology and Department of Medicine, Royal University of Malta

Introduction This enzyme is found in high concentration in red blood cells, gastric acid-secreting The importance of zinc as one of the cells and in renal tubular cells. Zinc was essential trace elements in the living shown to be essential to the mechanism of organisms is becoming increasingly re­ action of this enzyme, which catalyzes the

cognised. Raoult and Breton (1877) were the reaction: CO 2 + H20 '10,...... -~ Ho C03 • Zinc first to report its presence in the human was thus confirmed as an essential trace ele­ organism, having detected it in the liver. ment and a significant role in metabolic Because of difficulties in methodology, processes assigned to it. invest;gations were for a long time of a In the process of carrying out measure­ purely qualitative nature. Keilin and Mann ments to establish normal reference values (1944) isolated and purified the first metal­ for our laboratory, it was noticed that the loenzyme carbonic -anhydrase, containing values being obtained, generally appeared 0.33 per cent zinc as part of its molecule. to be higher than those published in the 129

Table I Normal Values for Zinc in Serum or Plasma Reference No. of Sample Mean ± S.D. subjects (fLg Zn/100 ml) Prasad et a1. (1965) 14 men plasma 104 ± 14 Davles et a1. (1968) 30 men plasma 96 ± 12 30 women plasma 97 ± 11 Pekarek et a1. (1972) 99 m,m serum 102 ± 11 Oon et a1. (1974) 33 s3rum 102 ± 9 Beeley et a1. (1974) 57 S"'fllm 89 ± 11 Thind and Fescher (1974) 15 plasma 113 ± 4

lit-::rature where sim'lar t~chniques had Th~ zinc conc~ntratjon in the protein­ been employsd (Table I). R ~sults obta;ned free sup"rnatant was determ'ned using Gl from a few North European (Scandinavian tJnj"am S.P. 90A atomic absorption spec· ald Br'Vsh) medical stud:nts cbrking in trophotom~ter with an air-acetylsne flams. Malta f<:>n within the range of published Standard curves (10, 20, 30, 35, 40, 45, 50, normal values, It was thus decided to obtain 55, and 60 {J,g/100 ml) were obtained using samples from other North European a standard zinc solution (1 mg/ml, Analar) studsnts attendin2: a Summer course at the dilubd with deionized water before each University, and to compare the results with s"ries of measurements. The standards those of the local po!mlation. were made in sodium chlor'de solution (50 m mol/1), which is the approximate Subjects and methods final sodium concentration in the diluted serum, as it has been reported that sodium Altogether 61 subjects were studi.ed. re:dec€s absorbance readings for zinc Venous blo9d was obtained with minhnal (Prasad, Aberleas and Halsted, 1966). Equal venostasis, the blood being w:thdrawn into amounts of T.C.A. were added to the a plastic syringe. The blood was allowed to standard solutions and the serum samples. clot, after which the supernatant was Individual al;quots of serum were diluted removed, and centrifuged it 1500 r::;volu­ 1 : 3 with de ionized water, Samples of tions per minute for an hour, in order to deionizect water and T. C.A. showed -that no remove any remaining blood cells. Serum extraneOus z'ne was present either in the specimens in which haemolysis had reagents or in the centrifuge tubes. Serum occurred were discarded. Plasma -proteins s::lmples from Maltese subjects were run were precipitated with 10% trichloracetic concurrently with those obtained from acid (T.C.A.) as described by Davies, Musa for;;igners .. Sign;ficance was tested by and Dormandy (1968). The specimens were Student's paired t·test (Snedecor & Cochran, again centrifuged to remove the resultant 1971), All computations were performed on precipitate.

Table 11 Serum Zinc levels in Maltese and Foreign Subjects N ationaIity Sex No. of subjects Mean ± S.D. (fLg Zn/lOO m!) Maltese males 31 124 ± 16 Maltese females 12 117 ± 13 Foreign males 11 107 ± 9 Foreign females 7 110 ± 15 130

MALTESE SUBJECTS

Fig. 1 Histogram and distribution curve for serum zinc values in Maltese subjects. (X = mean, S = 1 standall."d devi,artl:oll1).

Fig. 2 Histogram and distribution curve for serum zinc values in foreign subjects. (X = mean, S '- 1 standard devia1!1on). 131 a Hewlett-Paokard 9100B Calculator fitted son, 1974), amongst other conditions. The with a 9101A Extended Memory. significance of the change in zinc concen­ tration in these conditions remains unde­ termined. R~sults It is important to gain further under­ standing of this metal in both health and The distr~bution of serum zinc levels in disease as it appears that zinc is essential Maltese and in foreign subjects as shown in to an important variety of metabolic pro­ Table II and figures 1 and 2. The mean value cesse:;; in man. Under normal conditions for Maltese males was 124 p,gj100 ml, for z'nc maintains a fairly stable consistency Maltese females 117 p,gj100 ml. The cor­ in the body fluids and tissues, in spite of a responding values for foreign subjects were rapid and continuous turnover (Pekarek, 107 p,gj100 ml and 110 l;g/100 ml. No Beisel, Bartellonl and Bostian, 1972). statisEcal sex differences in serum zinc HOWever, Kubota and h~s associates in concentrations were present, either in the 1968 reported a 5-fold difference in zinc ]i'lcal (P < 0.10) or foreign (P < 0.35) sub­ values measured in blood from 243 subjects jects. This is in agreement with previous from 19 different locations in the United published data (D~vies, Musa & Dormandy, States. They suggested that this may be due 1~68). Maltese subjects showed significantly to the influence of air contaminated with h:gher serum zinc levels, 122 p,g, than the zinc and to d:fierent dietary conditions. We values obtained from foreign subjects are unable to offer a satisfactory explana~ 108 p,g (P < 0.01). ' tiol1 for the difference in serum zinc levels in the two groups reported in this paper. Discussion Local water does not appear to have a high zinc content and Maltese soil is known to Zinc has now been detected in all the be zinc deficient. It is known however that cells and fluids of thEj human organism local farmers use a zinc containing fungi­ ~nn th~ 7.jn~ cont.ent. of the hllm;:m hodv is cide (Zineb) on a large scale. 'Zineb' is zh1l' equal to that of iron and about ten times ethylene 1, 2 bis-dith;ocarbamate and is hig~er than the copper content (Mikac­ sprayed on potato and onion crops and on DevlC, 1970). Zinc is now recognised to be vines for foliage protection. Serum zinc an integral constituent and cofactor of a values increased to the reported levels ~1Umbe~ of enzymes. The presence of zinc appear to have no untoward -effect and no IS reqmred for collagen synthesis (Fern an­ clinical condition has as yet been reported dez-Madri?, Prasad and Oberleas, 1971), in which zinc levels are elevated. This, of and alkalme phosphatase, which is a zinc­ course, excludes cases of zinc toxicity as a containing metalIo-enzyme, is essential for result of zinc oxide fumes inhalation, where norm!'!l bone formation. Recent evidence levels of serum z~nc are markedly increased. indicates that it may have a fundamental 'Zineb', however, is a carbamate and there­ role in DNA, RNA and protein synthesis. fore has goitreogenic effects, although True zinc-deficiency states, although th3se are reported to be very small when reported, are rare (Prasad Halsted & it is used in the recommended concentra: Madami, 1961). Plasma or se~m zinc con­ tions. It is perhaps 'important that even centrations have been measured in a large greater emphasis should be laid on explair­ number of different clinical states. Roduced ing to IO!2al farmers the possible dangers levels have been reported in patients with of this fungicide when recommended dos­ chronic pulmonary infection (Halstead & age schemes are exceeded. Smith, 1970), bronchial carcinoma (Beeley Darke, Owen & Cooper, 1974) leprosy Refer~nces (Oon, Khong, Greaves and Plummer, 1974), chronic renal failure (Mahler, Walsh and BARBEAU, A" and DONALDSON, J. (1974). Haynie, 1971), in hypertensive patients with Arch, Neurology, 30, 52 renal artery stenosis (Thind and Fescher, BEELEY, J,M" DARKE, CB., OWEN, G., and 1974) and in epilepsy (Barbeau and Donald- COOPER, RD. (1974). Thorax, 29, 21. 132

DAVIES. I.J.T .. MUSA, M., and DOR~ANDY, T.L. OON, B.B.,· KHONG, K.Y., GREAVES, M.W. and (1968). J. Clin. Path., 21, 359. PLUMMER, V.M. (1974). Br. Med. J., 2, 531. FERNANDEZ-MADRID, F., PRASAD, A.S., and PEKAREK, R.S., BEISEL, W.R., BARTELLONI, OBERLEAS, D. (1971). J. Lah. Clin. Med., P.J., and BOSTIAN, K.A. (1972). Amer. J. 78, 853 Clin. Path., 57, 506. HALSTED, J.A. and SMITH, J.C. Jr. (1970). PRASAD, A.S., HALSTED, J.A., and MADAMI, M. Lancet, 1, 322. (1961). Amer. J. Med., 31 .• 532. KEILIN, D., and MANN, T. (194.0). Bioehem. J., PRASAD, A.S., OBERLEAS, D., and HALSTEAD, 34, 1163 J.A. (1966). Zinc Metabolism p. 27·37. Ed by KUBOTA, J., LAZAR, V.A.. JTHACA, B.S., and Prasad, A.S. Charles C. Thomas, Springfield, LOSEE, F. (1968). Arch. Environ. Health, Illinois. 16, 788. RAOULT, F., and BRETON, H. (1877). Compt. MAHLER, D.J., WALSH, J.R., and HAYNIE, G.D. Rend., 85, 40. (1971). Amer. J. Clin. Path., 56, 17. SNEDECOR, G.W., and COCHRAN, W.G. (1971). MIKAC DEVIC, D. (1970). Advances in Clinical Statistical Methods, 6th edn. Iowa State Uni­ Chemistry p. 271. Ed. by Bodansky, O. and versity Press, Ames, Iowa. Stewart, C.P. Academic Press, New York and THIND, G.S., and FESCHER, G.M. (1974). C;i.n. London. SeL and Mol. Med., 46, 136. 133

ANATOMICAL DISTRIBUTION OF DIVERTICULA OF THE LARGE INTESTINE

MARI£ T. PODESTA

and J.L. PACE

Department of Anatomy, Royal Univer'sity of Malta

IntroducHon Materials and Methods

The anatomical distribution of diverti­ The literature on the anatomical dis­ cula of the large intestine as reported by tribution of diverEcula of the large intes­ different authors varies widely. This may tine was reviewed and compared with the be due to s~veral factors, including the findings obtained from a survey of 5094 geograph:cal since the r:ght colon is much barium investigations carried out in more oftsn involved in Orientals than in the period 1967-1972. Of 310 patients with Europeans (Peck et al., 1968). The methods colonic diverticula the anatomical distri­ of investigations used by different authors bution of the diverticula was studied in 259. (viz. surgery, radiology, necropsy) involve population selection and so influence rresults. Thus surgery is undertaken for Observations symptomatic or complicated cases only and small d:verticula scattered throughout the In the present survey, diverticula colon are liable to be missed at operation. were found to involve predominantly the Barium investigations are usually under­ 12ft colon (98.4%). Involvement of the right taken because of alimentary symptoms and colon was uncommon (18.9%) and generally may not give a true picture of the distri­ occurred as part of more extensive involve­ bution of diverticula due to inadequate ment (18.1). The commonest regions filling by barium. Necropsy studies include affected were the sigmoid only (48%), thl:. older subjects but allow direct examination sigmoid with the descending colon (24.4%) both of mucosal and serosal colonic sur­ and the descending colon (13%). The sig­ faces and are probably the most reliable moid was involved alone or in combination method of study of the anatomical distri­ with other regions in 84% of cases. The bution of divert:cula. Furthermore, the average age of patients with extensive number and age of the patients studied involvement was 62.6 years, while that 01 varies with the different investigations; the patient8 with diverticula limited to the greater the number of patients surveyed sigmoid or s:gmoid and descending colon the more reliable is the investigation, was 61.1 years. Patients with few diverticula while the average age of the patients were on an average significantly younger investigated is also important since diver­ (60.5 years) than patients with many t~cula of the right colon occur in a younger diverticula (64.6 years), age group. 134

Discussion

There is general agreement that diver­ ticula occur most frequently in the sigmoid colon whilst involvement of the adjacent rectum is extremely rare (Table 1,. The sigmoid may be involved alone or in com­ bination with other regions, usually the o descending colon (Table 2). Some investig­ ators state that diverticular disease invol­ ving initially the sigmoid region may spread proximally until sometimes the entire large intestine and even the rectum may be affected (Homer, 1958; Painter, 1968). Others maintain that the progress of the disease is usually limited to the seg­ ments affected initially because patients o:l with extensive involvement are younger than patients with disease localised to the lower colon (Parks, 1969). In our survey the average age of patients with extensive involvement was not significantly different o from that of patients with diverticula o:l limited to the lower colOl!. ~ It has been previously observed and .... ~= this has been confirmed in our series that Q,) j;;, o o o o there is much variation in the distribution ~ ~ of diverticula along the colon. Thus diverti- is ..... cuI a may be limited to the transverse colon o or to peculiar combination of sites (eg. sig­ o o .s o 0) .... Cf:) moid with ascending colon) with the inter­ CIl vening area free from disease. The right colon is infrequently affected by diverticular disease: its involvement may be manifested as part of more exten­ sive diverticular disease, as localised diverticular disease or as a solitary diverti­ culum. In our survey the former type of involvement was by far the commonest. The number of diverticula appears to increase with the passage of '3fme, since patients with many diverticula are, on average, older than those with few diver­ ticula (Parks, 1969). This was confirmed in our own study since patients with few diverticula were appreciably younger than those with many. Right-sided diverticula occur at an earlier age than the more com­ mon left-sided form and are eq'.lally distri­ buted between the sexes (Anderson, 1947). We found that the distribution of right­ sided diverticula was equal in both sexes. Table 11 Location of Diverticula (in percentages)

Author No. in Sigmoid Sigmoid and Sigmoid not R. Colon Whole Colon Series Desc. Colon involved only McGrath (1912) 27 74 0 22.1 0

Rankin & Brown (1930) 111 29 3

Ochsner & Bargen (1935) 208 47 19 6.25 3.8 11

Willard & Bockus (1936) 72 39 5.5 5.5

Brown & Marcley (1937) 518 56 24 2.5 8

Homer (1952) 364 47.9 29.6 8.5 2.7

Homer (1958) 503 47 33 5 1

Brassinne e't al. (1960) 86 51 18.6 25.4 11.6 4.6

Slack (1962) 26 88 4 0

Torsoli et al. (1966) 152 34 16

Molteni (1967) 154 4 6

Parks (1968) 111 44 27 6.3 2.7 5.4

Hughes (1969) 90 40 30 7 5 16

Parks (1969) 461 65.5 18 4 0 6.8

Tagart (1969) 98 78.6 16.3 2 1 3

Painter et al. (1972) 70 44.3 34.3 8.6 1.4 5.7

I-' CoO Present Survey (1972) 259 48 24.4 16 0.8 0 e.n 136

The s;gmoid colon is the s~te of elec­ fistulae open into neighbouring organs, tion for diverticula becaus3 its spscialised usually the bladde:r. function is to hold up the faecal stream by segmentation. A deficiency of dietary fibres Conclusion alters the viscosity and speed of trans~t of the stools and may cause the s.i.gmo:d to The literatuI'c on tlle anatomical distn­ s~gment excessively (Painter, 1969). Thick­ bution of diverticula in the larg:c intesEne ening of both longitudinal and circular has been reviewed and compared with the layers of muscle occurs and appears to find:ngs from a survey of 259 barium precede the development of diverticula investigatlOns in which diverticula were (Morson, 1963). The circular muscle and present. Though there is general agree­ mucosa are thrown into ridges which !:lur­ ment that the commonest s~tes of mvolve­ round and narrow the lumen like in­ mem are the sigmoid and descending colon complete sphincters (Painter, 1968) causing the anatomical distribJ.tion of diverticula obstruction to outflow and producing zones as reported by various authors shows con­ of high pressure by contraction of the siderable variations; possible reasons for muscle wall in the segmented region; the th8se variations are ment~oned. The rela­ puls'on force generated drives the mucosa tion of the age of the patient to the extent through the inner segmental wall (Painter or involvement and to the number of diver­ and Truelove, 1964). In diverticular disease ticula and the age and sex differeno3s lim:ted to the right colon, hypertrophy of between paCents with right sided and those the colon:c musculature has not been with left sided colonic d:verticula are observed (Peck et al., 1968). discussed. Weak areas in the colon wall are exploited. The circular muscle coat is fa!:lCl­ culated and diverticula are usually situated Acknowledgemems between the muscular fascicles in the parts of the colonic wall not strengthentd by the Our thanr.:s are due to the surgeons taeniae. The relation of diverticula to the ana pi.lysicians and to the Radiology blood vessels has been much d:sputed. Department of St. Luke's Hospital, Malta, According to Fleischner et al. (1964) for permission to review their surgical, arteriography shows that the relation of the medical and rad:ological recordS. diverticula to the penetrating vessels is inconstant; this was confirmed by Noer's studies (1955). In contrast, Edwards (1954) References related the site of the diverticula to the point of entry of the blood vessels, and ANDERSON, L. (1967). Surgery, 22, 479. Slack (1962), studing the locafon of BRASSINNE, A., RUYTERS, L. & NAOME. J. sigmoidal diverticula reached a comparable (1960). Acta gastro-ent. beLg., 23" 828. conclusion. He observed that sigmoidal BROWN, P.W. & MARCLEY, D.M. (1937). J. Amer. diverticula occur pr:ncipally in 4 rows on med. Ass., 109, 1328. both sides of the mesenteric taenia, though CASE, T.C. & SHEA, C.E., Jr. (1953). Amer. J. smaller divert'cula are occas onally present Sum .. 92, 616. between the 2 antimesenteric ta:miae. EDWARDS, H.C. (1954). Ann. ray. CaLL Surg. The clinical manifestations and com­ EngL., 14, 371. plications of diverticular disease of the FLEISCHNER, F.G., SI·CHUN MING & HENKEN, colon are intimately related to the anato­ E.M. (1964). RadioLogy, 83, 859. mical d!str~bution of the diverticula - thus, GOODWIN, F.R. & COLLINS, E.N. (1948). CLeve- pain is usually referred to the left lower Land CUn. Quart., 15, 194. quadrant, haemorrhage, if it occurs, is oftsn HORNER, J.L. (1952). GastroenteroLogy, 21, 223. massive due to the close relation of diver­ HORNER, J.L. (1958). Amer. J. dig. dis., 3, 343. ticula to large blood vessels (Nigro, 1 ~66), HUGHES, L.E. (1969). Gut, 10,336. and the disease in the caecum and ascend­ LLOYD WILLIAMS, K. (1960). Brit. J. Surg., 47. in~colon often mimics acute append:citis; 351. 137

MARATKA, Z., ROUBKOVA, H. & KOCIANOVA. PAINTER, N.S. (1969). Lancet, 2, 586. J. (1965). 16th Congress of the Italian Society PAINTER, N.S., ALMEIDA, A.Z. & COLE· of Gastroenterology, Bo~ogna, 916. BOURNE, KW. (1972).Brit. med. J., 2, 137. MAYO, C.W. & BLUNT, C.P. (1950). Sura. Clin. PARKS, T.G. (1968,).Proc. roy. Soc. Med., 61, 932. N. Amer •. 30, 1005. PARKS, T.G. (1969). Brit. med. J., 4, 639. McGRATH, B.F. (1912). Surg. Gynec. Obstet., 15, PECK, D.A., LABAT, R. & WAITE, V.C. (1968). 429. Dis. CoLon Rect., 2, 49. MOLTENI, F., PEDRONI, G., CARESANO, A.. RANKIN, F.W. & BROWN, P.W. (1930). Surg. SCOTTI·FOGLIENI, C. & DE SANTIS. L.A. Gynec. Obstet., 50, 836. (1967). Chir. Ital.. 19. 209. SLACK, W.W. (1962). Brit. J. Surg., 50,185. MORSON, B.C. (1963). Brit. J. Radiol., 36, 385. TAGART" R.E.B. (1969). Brit. J. Surg. 56, 417. NIGRO, N.D. (1966). Sth. med. J., 59, 1019. TORSOLI, A., ALESSANDRINI, A., RAMORINO, NOER. R.J. (1955). Ann. Surg., 141, 674. M.L., AMORUSO, R., ARULLANI, P. & OCHSNER, H.B. & BARGEN, J.A. (1935). Ann. CASSANO, C.C. (1966). Arch. ital. Mal. Appar. Intern. Med .. 9, 282. dig., 33, 202. PAINTER, N.S., & TRUELOVE, S.C. (1964). Gut. WILLARD, J.H. & BOCKUS, H.L. (1936). Amer. 5, 20l. J. dig. Dis., 3, 580. PAINTER, N.S. (1968). Brit. med. J., 3, 475. 138 AN HOUR FOR MY THOUGHTS

E. AGIUS

B.Sc., M.D., F.R.C. Path., D.P.H. D.Bact.

This is a slightly abridged version of Abraham Lincoln and Pope John XXIII the St. Luke's Day Lecture delivered to the who, in spite of starting under similar Malta Branch of the British Medical Asso­ auspices, eventually pulled through on thelr ciation on the 18th. October 1974 at the own quite creditably. Medical School of the Royal Univers_ty. There is also another and probably a more likely explanation, why it was I who The proposal that St. Luke's Day was asked. The organisers probably should be celebrated in some special way, believed that in asking me they were nOl in this hospital named after the great really abandoning the custom of asking et evangelist, was first put forward by one of iayman since, in the view of some, bacterio­ our late colleagues the highly esteemed logists are not really doctors at all. This is J oseph Demartino. The Malta Branch of the also something with which I disagree only B.M.A., which has for eightysix years mildly. Whilst I maintain we are medical flourished in our country, took upon itself yet it is true we do not thump chests or the pleasant duty of organising a St. Luke's take a pulse and hardly ever even see et Day Lecture. I know all about the custom patient. This has the unpleasant side effect that this lecture should be delivered not by that whilst w,e work pretty hard yet it never a medical man but by an invited layman passes the mind of any patient, whose ill­ because this was done on my proposal. You ness we may have diagnosed and whose will wonder then why it is I who have been curing antibiotic we will have prescribed, this year given the honour of addressing to show any sign of gratitude and, when you and there is more than one reason for Christmas comes round, we always have to it. Mainly, to be quite frank, the organisars, buy our own turkeys. who, as all doctors are, are always very C.P. Scott, that famous editor of the busy, were this year exceptionally so, and "Manchester Guardian" once said, as you they forgot all about it until the last few all know, that "Comment is free but facts days. It is difficult to get a lecturer at short are sacred". Cynical journalists have modi­ notice. People's wisdom must take time to fied the statement to "Comment is free, but be garnered and then to be distilled into facts are expensive". So it is in science. those pregnant phrases which should pour Had I been asked to read to you a scientific forth like jewels from a casket and dazzle paper, I would have needed much time to the audience by the brilliance of their produce the work on which that paper corruscations. In view of this, the organisers would have been a report. As,,' it is, I was thought the custom might be departed from told I could speak almost about anything if they could find a doctor who would and it was on this understanding that I undertake the task. Even amongst doctors accepted. G.K. Chesterton, in those blissful it is not easy to find a more or less extem­ days when a book of essays could be and pore speaker, so, in despair, suspecting that was sold for a shilling, once published such my vanity wuold not be proof against so a collection and called it "A Shilling for My tempting an offer, they asked me if I Would Thoughts". Realising only too well that step mto the breach and, as you see, their time is money, I have ventured to entitlA prognosis was, in this as in so many other this talk "An Hour for My Thoughts". Of occasIOns, correct. I do not even find that course I agree only too readily that it is being a stop-gap is particularly undignified, presumptuous of me to expect you to be because I can recall cases, such as those of interested in my thoughts. I can say, how- 139 ever that most of what follows will not 03 patron's footsteps.·· Luke was an exc~llent really mine but the thoughts of others his biographers. Chesterton said that a good much wiser than me, which have impressed novel tells us the truth about its hero but me and which I will be passing on to you. a bad novel tells us the truth about its Field 1\1arshall Lord Wavell once published author. The poor writer will let his per­ an anthology of verse all of which he sairl sonality intrude too much and so it will he could recall from memory and prefaced become evident in his writings. Because the book by a quotation which ran: "1 have Luke wrote well his two books tell us noth­ gathered a posy of other men's flowers and ing about him except that he had a sharp, nothing but the thread which binds tbem concise style and that he was accurate -­ is my own". Perhaps I could plead at t.he both medical characteristics. It is, however, end that I will have done something like almost impossible to learn anything from that. As for charging you an hour of your his books about him. We know, of course, life for this, it is quite possible I will relent that his voyaging brought him to Malta and and let you go at 55 minutes or even less it was he who started the tradition of - but one can't really call a talk "55 accepting our hospitality and then speak­ minutes for my thoughts". "An hour" j!': ing of us as "barbarians". I say this only aesthetically more satisfying. as an expected humorous touch since the Several of my predecessors have word used did not then have its present thought it hardly worth while in their S1-. connotations. The late Monsignor Knox in Luke's Day lecture to mention St. Luke at his translation of the Acts uses the wQ.rd all. I do not quite agree with this procedure "natives". Such are the oddities of language and I will pay my tribute to the master. My that even that word has acquired special predecessors did not want to repeat each associations and fools could find it offen­ other and were probably intimidated by the sive. Luke will not have thought of our belief that we do not know much about forefathers as anything except brothers in Luke but in actual truth we do know a fair Christ and we have evidence for this in the amount and all that we know is to Luke)s fact that he painted a picture for them -­ credit. Luke by the evidence was a man of a portrait of the Madonna. He always did heroic stature and not one of those mon­ so for his friends a..l1d many places rounll strosities, creations of present day novelists, the Mediterranean revere the scanty rem­ styled rather sickeningly antiheroes. He nants of his brushwork. Historians and art was a Greek and a physician whom Paul critics doubt the authenticity of such relics called, "beloved". The evidence of his being but then historians and art critics are cold a member of our profession does not seem blooded animals who wouid doubt anything. to have been stronger than this assertion Luke would probably have been with Paul but the assertion is clear enough. Luke when the great apostle cured Publius's believed in the teaching of Christ and seems father of an illness which in the old version to have dedicated his life to the propagation of the Ads was called "a bloody flux". In of this teaching. He linked up with Paul the Knox version it is "fever and dysentery" of Tarsus with his very strong personality, and may well have been amoebic dysentery. and together they went on adventurous When Paul left, Luke went with him on a voyages. Although I have never myself ship, whose sign was "Castor and Pollux" been very venturesome yet my admiration and they were together in Rome. Paul is great for persons who believe in a code writing to Timothy says that Luke there and are ready to endure great travail for was his only companion. Luke is said to their belief. I like doctors, I admire writers have died, unmarried, in Greece at the age and I have a special interest in the art of of 84. So you can see that when the late painting. In Luke I find a combination of professor Albert Bernard named this hos­ all this. Luke almost certainly wrote one pital after the evangelist, as so many other of the gospels and the Acts of the Apostles. hospitals throughout the Christian world Many doctors since have taken to literature are named, it was a fitting tribute to our and in this they have been following in their visitor of nineteen centuries ago. writer which, in a way, is a drawback to In the United States nearly every hotel 140 room has its own little bathroom or shower. student was disciplil1ed for unlawful entry There is also a plastic shower curtain which into girl students' dormitory. I honestly users are always asked to draw to prevent believe that one must be stubborn in sup~ water splashing too haphazardly all over porting what one bslieves to be right. ThIS the floor. Once there was a great hotelier is not being bigoted but being consistent. who had built a score of huge hotels and One must not be afraid to be- considered had been in the trade for many years. When out of date. "There are some dates", wrote finally he announced his retirement he was Christopher Hollis, "which it is very good interviewed for the newspapers. Onc to be out of, and it is most possible that the reporter asked him if, as a person of vast present is of that type." To put it in an­ experience, a captain of industry and a other way, one must have principles and leader of men he had now at this crucial the courage to stand up for them. moment of his life some message which h3 Organisations which should have the wanted to give to his fellow men, to man­ right principles and stand for them in any kind in general. "Yes", said the hotelier, country are the universities. I will concede "please ask them to draw the curtain before it is not always easy to decide which prin­ using the shower". Similarly now. having ciples are right and tihs is important since made my genuflection to St. Luke and I am insisting on the obligation of support­ being free to give to a more or less captive ing them but I do believe rightness or audience any message I please, I could go wrongness can be determined._ What one into a long talk about the submission of must resist is being swayed by fash~ons. laboratory samples and the necessity of The vagaries of costume and such things reading the pages about this at the back of are not really important. Within certain the hospital formulary. You will be limits I do not care whether a student, male relieved to learn that my sense of what is or female, wears his hair short or long. I appropriate removes any danger of my say within certain limits because there are doing so. such things as neatness and simple clean­ One conclusion which it seems can liness. Any medical student who dress2s reasonably be drawn when we think of st. and poses as a tramp is a sham and a cheat Luke is that being a physician does not because he is not a tramp and is falsely pre­ debar one from eventually becoming a tending to be something which he knows saint. Luke was not the only one of our he is not. Still what one wears does not profession to attain sanctification and, impress me much either way, but I am indeed, it may well be true that to be d impressed by what a student has in his good doctor, a rather rare thing, one has head and I want, if it happens to bs my in fact to be a saint all the time. I do not duty to fin-d this out, to know about this think that in any other profeSSion are such and I still believe the only practicable way demands made on one's patience and on to find this ,out is by examinations well one's moral strength. Still it is a curious conducted. I believe that in matters such world and we find ourselves these days as these - no great matters of principle quite often faced with an inversion of after all - the University should not allow values and of standards. In spite of this, I itself to be swayed by whims and fancies. still believe that there is right and wrong Only last May a team of dons and students at and that it is our duty to fight for one and Manchester University, a 10-man work;ng against the other. One finds surprisingly as party which had deliberated for no less it seems to me, that there is nowadays no than 5 years, reported to their senate that certainty about this and one is considered the tradtional three-hour examination a little odd (which is a polite way of say­ paper remained, in their view, the best ing "stark, raving mad") if one insisted un method of assessing a student's academic this attitude. To illustrate the extent to ability. This is not the sort of thing which which such distortions can be accepted by will make one popular with students or large groups, I remind you that the famous which will hsighten one's reputation as a student revolutions in France and elSewhere progressive, but being popular or getting of a few years ago started bscause a known as a member of the avant-garde is 141 not what a right thinking p3rson should stood on an individual and on a national aim at. Talking of the avant-garde ps.;\udo­ basis. When a teacher opens his ward or intellectuals, by the way, I wonder whether classroom or laboratory or operating you are as sickened as I am by the hair theatre to his students or to his colleagues, splitting and strategically highly dangerous this should be accepted as a gift of high antics of some writers in the correspondence quality and received with gratitude. Some­ columns of our local papers. They create times it suits the books of demagogic politi­ vagueness, they condone the insertion of the CIans to sow dissent where there should b3 thin end of the wedge. They forget the old frlendship and insolence where then~ Roman warning: "Dum Romae consulitur, should be respect. The man of principle Saguntum expuniatur" (Whilst in Rome we should not swallow the bait however spend time discussing strategy, the city of seductive the nationalistic flovour may Sa,guntum is being conqu,ered. So never make it. I detest the emphasis on the word be fooled into a maze of thought which "foreigner" when it is applied to some leads you nowhere. Y.ou must think, Kipling people in a certain :special Itone. People warned, without letting thought be your who have taught me, giving to me of their aim. Belloc pointed out the dan,:~r in a b3st unreservedly are not to me "foreign­ different way: ers" but my teachers, linked to me by c. "Pale Ebenezer thought It wronf; to bond which I will not risk breaking, and fight, certainly not because to do so will earn me But Roaring Bill (who killed him) the favour of some mountebank at the thought it right". moment in power. One other thing which I like to insist This matter is very much akin to an­ upon, and this seems to me a corollary of other one which also interests me greatly having principles, is a seriousness in one's but is, or should be, not contentious and work - the possession of a proper sense therefore my views 'on this arh, I hop,·, of accuracy and precision. Every week widely shared. This is the necessity that when I open the "British Medical Journal", we in Malta should keep in good repair om I admire the reports of work which has links with Britain and alf>o with the rest 01 been carried out as carefully and as accur­ Europe. I am constantly asking my ately as is humanly possible. Perhaps it is students, on the assumption that they know only the best work which reaches the English and Italian well already, to leam pages of the B.M.J. (and periodicals of the French (of which I have a scientific reao­ same standard) but to judge by this, one ing knowledge only). Since I want to avoid feels one must respect workers who are political discussions, let me make it cleal" capable of producing such papers. I will say that I am now reterring only to cultural I have similarly admired many persons, aBpects and indeed to medical and scientific our own countrymen as well as our relations (although being, I hope, a. man 01 occasional visitors from Britain. who have principles I will not deny I think similarly stood where I now stand and shared with on the political aspects.) Some politicians us their hard earned learning. These (in fact at this time both our main parties) people set before us an ideal which we play the game of inflaming national pas­ should strive to imitate. It is along these sions. My concern in this is that this should lines that students should be trained. It is not be at the expense of our links with those of my colleagues who are so inspired the outside world, the most important of that I feel I can respect. It is to such which are with Britain. I am not in the people that we owe debts of gratitude. least denying that we are Maltese and as Gratitude is, it seems. an outmoded virtue. such should ,cherish such things as our own But it is a virtue and to my mind virtues own language. Incidentally amongst a can never be outmoded. I am very much scientific audience it need arouse no pas­ annoyed when I find gratitude to those who sion to say that being Maltese or British or have taught us substituted by insolence and Patagonian or whatever is an accident of the virtue itself regardpd as a weakness and birth f6r which one should not be blamed misnamed servility. This is to be under- and which does not earn one any merit. 142

The basis of patriotism is, in fact, a slightly suitable opportunity before my retirement. widened egotism. Anyhow I for one like 1 am very uncertain about th:s retir6ment my own language and am pleased to be a business and do not think I like it very member of the "Akkademja tal-Malti". much. After all Clemenceau was guiding Onc friend of mine with whom I fight, the destinies of France in his late seven­ verbally, nearly every time we meet, once ties, De Gaulle was doing this even later, asked aloud how I came to be in it. The Adenauer presided over the resurgence of truth was that without my asking and with­ Germany at a similar age and Churchill was out my knowledge, I had been elected to it still Prime Minister of Britain at 81. One because somebody thought I deserved the could quote several other instances. Under honour. So I do like Maltese but we must the present system it could be said that be careful not to allow such liking to cut when a man really learns his job, he is then us off from the rest of the world. Providen­ pensioned off. It is true that when one has tial historical" accidents forged our links been at work for several years - and I with Britain and we are, and should remain, have been at it now for forty - one tends, happy that we have become Britain's cul­ not to lose one's enthusiasm, but to become tural ambassadors in the Mediterranean, a wee bit cynical and more than a wee bit Incidentally this should also be to our Impatient with the annoyances of bureau­ advantage and I appeal to doctors especially cracy. to see these precious things are not lost. My perIod of serYlce has been a I appeal also, briefly, for a cultivation specially fruitful one. When I started as a amongst our profession of what one COUld, i10useman at ti1e old Central Civil Hospital, for lack of a better word call culture or a typhoid and Brucellosis (it wasn't even higher education. We have now got to a called Brucellosis then but Undulant Fever) stage (and apparently not only in Malta) were extremely common and quite often where an 0 level pass in 2 languages, fatal. The famous mould spore had already besides our own, can get one into a medical floated into Alexander Fleming's laboratory. course. This is producing a type of doctor I was going to say through his laboratory who has no academic background whatever. window, but Ronald Hare, who was there The tragedy is that when one does not know at the time, assures us the window was so about something one does not realise what grimy it could not possibly have ever been he is missing. I know we are all ignorant openea. The Penicillium therefore was still though on different subjects. Let us, how­ being industriously sub cultured until its ever, try to be knowledgeable on some sub­ hour of destiny was to arrive. Eventually jects, even on a few which do not seem to the hour arrived and an Australian Rhodes have any immediate relation with medicine. scholar and a German-Russian-J ewish You may be surprised to find how closely re1ugee from Nazi Germany got together related some subjects are and also how a team which radically changed the course pleasing and satisfying it is to get to know of medical history. Then there was the war them. Sinclair Lewis said (or, to be more ana in Malta we lived though a time of accurate, he makes one character in one of intense medical interest. We did not have, his novels say) that the three basic books not even at the height of the siege, any for a doctor are Gray's Anatomy, the Bible specific deficiency diseases, since we had and the works of Shakespeare. That may learned how to prevent them. Many of my be a little fantastic but the- idea behind it is audience were not even born then, or per­ very sound. haps some of them were at the time being So there are some of my thoughts, fed on vitamin A, which was carotene which have turned out after all to be more mixed up with chocolate and spread on personal than I had ithought they would bread. We did have for a brief period non­ be. I have ridden several of my own hobby specific deficiency diseases, or in other horses and I apologise for this, though not, words, we were seriously short of any kind I must confess, very sincerely. When I was of food but it never came to anything like asked to speak to you it was hinted in a eating rats. Then we had murine typhus, sort of unde,);tone that this would be a unfortunately still with us but luckily not 143 too serious a disease. There was also robiology had been played out the impact plague and I was in it up to my eyebrows of its daughter science immunology began - a very thrilling period, bacteriologically to bf! felt and the virology branch began to speaking. We are now accumulating rubbish blossom most abundantly. again; all the attempts to keep Malta clean, Looking backward I feel the microbio­ having been half hearted to start with are logists have a very great deal to be proud not even half successful so far. If plague of. After bringing about antiseptic surgery. were to turn up again, which heaven forbid, they created public health. Having curbed the rat population is large enough to create the wilder ravages of infectious disease, a very serious situation. In my time we have they have now presented immunology to seen the end of diphtheria as an epidemic the doctors to play with, not to mention disease, so that to-day even the E.N.T. various techniques to the geneticists. It has specialists have hardly ever seen a case. I been a grand time, but in spite of this I was at Copenhagen when Fleming there believe neither that one should rest on his met Waksman - the Penicillin man meet­ laurels nor that the future holds nothing of ing the Streptomycin man. Tuberculosis, interest. On the contrary it may well be that the long standing, versatile cause of so we shall see as great triumphs as those of much illness was at length curbed. I have the past There are still problems to b~ met many great men: Fleming himself, solved, such as the provision of more and Chain, Waksman, Rene Dubos. Maxwell better food for the populations which infec­ Finland, Paul Durand, Edmond Sergent, tious disease has not wiped out. Perhaps Twort, Bedson, McCartney, MacFarlane microbiology by harnessing the metabolic Burnet, Wilson Smith ,C.H. Andrews, the actions of yeasts and bacteria and by the great Sabin, and Sir Graham Wilson and cultivation of yeasts and fungi themselves W.W.C. Topley who were my teachers. may at least for a time find better remedies There is no merit in this for me but meet­ for the population explosion than prevent­ ing them has inspired me and I hope som~ ing there being a population. of their charism may have rubbed on to me. I don't believe in looking backwards. I have seen the end of poliomyelitis as a The past is the prologue. The best is yet to killing and a crippling illness, one of the be. Whether on the playing field or on the greatest triumphs of applied science. All side lines I hope, by God's grace, to be with this time the microbiologists have been very you for some time yet watching the great successfully working to put themselves out game being played, the game without an of business, but the prophet's job has very end. great risks. When everybody thought mic- 144

ROYAL OPERATIONS

HAROLD ELLIS D.M., M.Ch., F.R.CoS

Pr'ojessor of Surgery, Westminster Hospital, Medical School, London

Based on a lecture given at the Medical treatment. These were either to incise School in Malta 011 the 31st July 1974. boldly through the neck of the sac or to carry out the lesser procedure of lancing A study of the surgical histories of the fundus of the hernia in order to release Kings and Queens of the past can be re­ any of th3 pent up fluid therein. Ranby commended as a rewarding hobby for any favoured the latter and in this he was no surgeon. In the often detailed documents doubt correct. In those pre-anaesthetic that have been handed down to us comes days, in the presence of obstruction in a a wealth of information about medical and grossly obese patient, he rcalis3d that social customs of former times which well incising the neck of the sac would release repay study. Perhaps by recording a few coils of distended intestine into the wound of these case histories the author will which it would be impossible to reduce. persuade others to go back into the warmth The decision was taken and the following of the past and to escape for a short time day Ranby gingerly incised the dome of from the cold reality of modern surgery. the hernia. A little blood-stained fluid escaped but, as we can well imagine, thert' A Queen's Rupturo> was little relief of the symptoms. The fol­ lowing day, the Sunday, we were told that Caroline of Ansbach, wife of George "the lips of the wound began to mortify" II of England, ascended the throne as a and the Queen's doctors despaired of her pretty young girl. Six children and survival. Caroline called her husband to innumerable banquets later, at the age of her bedside and was heard to tell him that 55, and at the time of her fatal illness, she when she died she expected him to marry was no longer particularly attractive and again. George was beside himself in misery had become grossly obese. Severe abdo­ and in tears; between his sobs he was heard minal pain and vomiting commenced on to say "no, I shall never marry again, I shall Wednesday, November 9th 1736. In those simply live with other women". The next few days, even a Queen would not readily con­ days of continuous pain were borne with sult a surgeon and so she submitted her­ great bravery by the royal patient. On the self to the apothecary's bleeding, purging Wednesday the strangulated coils of intes­ and medicines, including Sir Walter tine within the hernia ruptured, soaking Raleigh's cordial and Duffy's elixir, which the royal bedclothes, sheets and mattress were the popular cure-aIls of the day. Her with excrement but without any relief of symptoms persisted and on the Thursday her suffering. Caroline died on the Sunday, and Friday' she was bled and purged again. the 11th day of her illness, her last words Only then did she consent to call in a sur­ being to her daughter, Princess Emily; geon. She was examined by John Ranby, they were "pray". Nowadays, one would be Surgeon to the King, who discovered, to disappointed to lose a feeble old patient his horror, an enormous strangulated with a strangulated hernia, yet only 20 umbilical hernia. Other surgeons were years ago the first lady in the land in the called to the sick bed and in consultation prime of her life, treated by the best that Ranby discussed the two possible lines of medicine in those days could offer, died 145 miserably of this simple abdominal emer­ dinner he would sleep for a few minutes gency. then off again to lecture or visit and seldom home until midnight. One is hardly sur­ A Royal Sebaceous Cyst prised that he died without issue - there is a limit to what a man can crowd into In 1820 King George IV of England a day! consulted Astley Cooper of Guy's Hospital Cooper was the first surgeon to llgate because of an inflamed sebaceous cyst of the abdominal aorta. This was no piece of the scalp. Cooper wisely advised against its surgical adventure or showmanship since removal while in its infected state. The he had already shown by experiment that following year Cooper was summoned to the aorta of the dog can be successfully Brighton and the King demanded that the ligated. A beautifully injected specimen cyst should now be removed there and then still exists demonstrating the efficient at one o'clock in the morning. Cooper collateral circulation which develops wisely said "Sire, not for the world now, around the site of occlusion. His your life is too important to have so serious patient was a Charles Hutson, 38 a thing done in a corner". The King was years of age, who had a rapidly enlarging persuaded to have the operation performed and leaking iliac aneurysm. The operation in London - during daylight! This was was carried out on the evening of June duly carried out at Carlton Palace and 24th 1817. The abdomen was opened and Astley Cooper was assisted by his old chief within a few minutes Cooper turned to his Henry Cline. George bore the operation audience saying "gentlemen, I have th~ without a murmur and indeed requested pleasure of informing you that the aorta that there should be no hurry in its per­ is now hooked upon my finger". Th'e formance. His recovery was uneventful patient died 40 hours after the operation; apart from an attack of gout. After the the circulation had indeed been adequate operation he said to his surgeons "What do in the normal limb but on the side affected you call this tumour?" To which Astley by the aneurysm the collaterals' had replied "a Steatoma, Sire" The King said obviously been damaged and the Emh "Then I hope it will stay at home and not become ischaemic. bother me again". For this small but im­ portant service to the King, Cooper was Roval Bladder Stone!' made a Baronet, ,becoming Sir Astley Cooper. As he had no son of his own the We turn now to the extraordinary title passed to his adopted nephew and the story of the English surgeon who operated line of succession stIll contfnues to this on two European Kings for stone in the a day! bladder. Sir Astley Cooper was perhaps the The history of bladder stone itself is hardest working surgeon the world has full of fascination. Cutting for the stone is, ever seen. He would invariably rise at six of course, mentioned in the Hippocratic o'clock in the morning even in the depths Oath and again in the writings of the of winter, often at five or even four a.m. ancient Hindus. Up to the sixteenth cen­ After dressing, he would go straight to his tury stones were removed by lithotomy private dissecting room where he "ould through the perineal approach. The patient carry out his own dissections or experi­ was held in the lithotomy position by ments for two or three hours. He would strong assistants. The perineum was mas­ then breakfast on tea and rolls and then saged with grease to render it more pliable see a continuous stream of patients at his and the surgeon would then sit facing his; house until lunch time. He would then victim with his knife gripped between his hurry in hip coach to Guy's Hospital, go teeth, rether like a pirate about to board round his wards surrounded by his adoring a ship. Two fingers of the left hand were students, lecture for one hour, then spend inserted into the rectum in order to fix the the time until evening seeing patients or stone against the perineum. The surgeon carrying out private operations. After then took the knife from his mouth with 146 his right hand, thrust it into the p~rineum, fore when Astley Cooper removed George dropped the knife on to the floor, and then IV's sebaceous cyst. Brodie gave the King hooked out the stone with his finger or excellent advice; to go home and call in else with a hook. Because of the few instru­ Civiale of Paris. Civiale made two attempts ments required (a knife, a hook, and four to remove the stone with his lithotrite but or five muscular assistants,) the operation each attempt was not only unsuccessful was known as the "Aparatus Minor". In but was followed by severe, pain, fever and the sixteenth century the formidable bleeding. Langenbeck of Berlin, then at operation of the "Aparatus Major" was in­ the height of his professional success, was troduced, in which the wound in the peri­ summoned and made four further attempts, neum was tom open with fierce retractors, but each was again unsuccessful and ac­ often with serious complication of haemorr­ companied by violent catheter fever. hage, extravasation of urine and tears Henry Thmpson, then only in his early into the rectum. forties, was called from London. Thompson In the seventeenth century, an extra­ crushed the stone and removed it without ordinary thing happened. We all know the bleeding, pain or fever: he received a fee French nursery rhyme "Frere Jacqu2s, of £ 3,000, he was knighted by his de­ "Frere J acques, dormez vous? dormez lighted Queen and overnight achieved vous?" but perhaps fewer realise that universal fame. In fact, no one was more Frere J acques was, in fact, a French litho­ surprised than Thompson at this success tomist. Indeed his name was Jacque Baulot and it was only some years later, when the and he was born in 1651 of humble parents. work of Pasteur and Lister had become He served as a trooper in the French well established, that he realised why his cavalry, from which he wisely deserted; he patient had made such smooth progress. On then adopted a religious habit and became being summoned to Brussels, Thompson an untrained itinerant lithotomist. Appar­ had not unnaturally ordered a new litho­ ently purely by chance he hit upon the trite and used it fresh from its wrappings; lateral perineal approach to the bladder presumably this was the first time that a whic~ traversed the base of the prostate sterile instrument had been passed into and which gave roomier and safer access. the Royal bladder. It is perhaps worth In one session at Versailles he performed reflecting on what hvists of fate fame no less than thirtyeight lithotomies with­ often depends. out a single death. In 1872 Sir Henry Thompson, together Over the centuries attempts have been with Sir William Gull, leading physician of made to evacuate bladder stones though the day, was called to Chislehurst, then a the urethra but it was not until 1824 that little town outside London now an outer Civiale of Paris developed a satisfactory suburb of the metropolis, to see the ~xiled apparatus to crush the stone per urethram, Napoleon Ill. He had suffered for many the lithotrite. A young surgeon called years from th? severe symptoms of the Henry Thompson of University College bladder stone and indeed his illness must Hospital London, came over to Paris, have' played at least a part in the French studied Civiale's methods and took a litho­ defeat in the Franco-Prussian was of l870 trite back to London with him; he was to in which Napoleon had been Supreme gain international fame by operating on a Commander. The stone was crushed at two King of Belgium and on an Emperor of sessions under Chlor0form administered France. by Dr. Clover, one of the pioneers of anaes­ In 1862 Leopold 1st of Belgium came thesia. The Emperor died three days after to London to visit his niece, Queen the second application of the lithotrite. Victoria. He was an old gentleman of 73 Post mortem showed gross bilateral pyone­ but while on his visit he developed th2 phrosis and half the stone still lying with- severe symptoms of bladder stone. He in the infected bladder. . consulted dear old Sir Benjamin Brodie, Thompson was an interesting man. the serjeant surgeon, who, interestingly He was born in relatively humble circum­ enough had been present many years be- stances, his father being a corn merchant, 147 and young Henry started life serving How should the Royal patient be behind the counter in his father's shop. He treated? To this we can only turn for did not become a medical student at Uni­ advice to the late Lord Dawson of Penn versity College Hospital until the age of 24, who well deserved his nickname "Physi­ but after qualifying he progressed with cian of Kings" from the extraordinary extraordinary rapidity and became the number of members of European Royal first specialist urologist in Great Britain. families who were his patients. His very Apart from his eminence in this fielcl (for first Royal consultation was Edward VII example, he crushed more than 1.,000 whom he attended in his terminal illness bladder stones with the lithotrite), hE:' was of chronic bronchitis complicated by a man of many parts. He was a distin­ cor pulmonale in 1910. When Edward asked guished painter, who exhibited iD the this young man how he propofled to treat RoyaL Academy, an authority on pottery, him, Dawson replied, no doubt to the con­ a pioneer of cremation, a notable cook, a sternation of his more senior colleagues, distinguished conversationalist, and one of "Sire, I shall treat you in the best possibb the first surgeons in London to visit manner, in the same way I treat my patients by car. He was even the father of patients in my wards at the London Hos­ the modern fashion for medical novels, in pital". This must indeed be the answer; that he wrote a book called "Charlie the Royal patient is much safer if managed Kingsley's Aunt" about the escapades of a by standard and routine treatment than young medical student which was based by attempts at taking short-cuts or by very largely on his own experiences. He sparing the indignities of some examina­ was well named by Sir Zachary Cope "Th€' tions and nursing procedures. Eminent Victorian". Our former and much loved senior surgeon at Westminster Hospital, Clement Royal patients and their management Price Thomas, knowingly or unknowingly followed the precepts of Lord Dawson of What must it be like to be called upon Penn when he was called upon to perform to treat a Royal patient? Naturally success a pneumonectomy on George VI, in 1952. brings with it international fame and in The operation was carried out just like any Great Britain, an undisclosed sum ~f other operation performed by this M?ster money paid from the Privy Purse. Failure, surgeon. He operated with the assistance however, must be disastrous, although not of his registrars and house surgeon, using as dreadful now-a-days as in the time of the rather battered operation table brought Blind King John of Bohemia, who in the over from his theatre at Westminster Hos­ Middle Ages, had his surgeons drowned in pital. Just like in any other routine opera­ the River Danube when they failed to res­ tion, all went smoothly. tore his sight. This operating table, now looking even . The Royal patient will prove to be, older and more tired, is still in daily use WIthout doubt. brave, polite and grateful. at Westminster Hospital but now bears a When Lord Lister drained the axillary proud inscription on its plinth, which. we abscess of Queen Victoria (incidentally thp. are always glad to show our visitors, com­ first time that a sterile tube drain had memorating its Royal patient. ever been employed) she said, as only The author of this paper does not envy Queen Victoria could possibly have said, the responsibility of a surgeon called upon on recovering from the anaeasthetir, "A to perform a Royal operation, nor dor;:s he most unpleasant task, Lord Lister, most deny him the honours which he so richly pleasantly performed". Her bravery .and deserves following its successful outcome. politeness were onyl in the tradition of Indeed, each time he removes a ssbaceous' her predecessors, poor Queen Caroline and cyst from a scalp he breathes a sigh of King George II who bore their operations, relief at its conclusion that the patient is without an anaesthetic, with extraordinary just an ordinary citizen of the great City stoicism. of London and not George II of England. 148

MALTAr FLORENCE NIGHTINGALE AND THE CRIMEAN WAR

MICHAEL GALEA D.P.A.

When the French steamer 'Osiris' cheers which rent the air - the leave tak­ entered Malta's harbour on April 7, 1854, ing by the officers and men, of their wives it was soon rumoured that she had brought and families, forming a painful contrast to with her "news of the most exciting the joy which otherwise so generally per­ interest - War has been declared." (r) vaded. As the vessels moved slowly from The news referred to the opening of hosti­ their buoys dense masses of people lined lities between the Allied Forces (Britain, the batteries, and yet more dense crowds France, Piedmont and Turkey) and Russia. of soldiers, the forts - those of St. Angelo This war has gone down in European his­ and Ricasoli, in the Great Harbour - and tory as the Crimean war. For the next year those of Manoel and Tigne' in the qaran­ or so the expedition to the Crimea was tine, St. .A!llIgelo, (sic, an 'Obvious error "the all-absorbing topic in Malta, as every­ for st. Elmo) forming the central point where else." (2) The anxiety which pre­ between the two harbours, from which the vailed in Malta "for the arrival of advices soul stirring cheers arose. The most cor­ from the seat of war in the Crimea, is most dial shouts rent the air, as either vessels intense." (3) in either harbour moved along which had Russia's demand of the right of pro­ hardly faded into echo from one fort, ere tection over all Greek Christians living in they were taken up by the troops in the the Turkish Empire was asserted by Tur­ other, and as joyously responded to from key to be a direct interference by the on board. And yet the thousands of brave former in her internal affairs. Brita;n, fellows, about to shed their blood on France and Piedmont soon came to the sup­ foreign shores, are ill provided with com­ port of the Turks, and so the first great fort, or in some instances with neces­ European war since the fall of Napoleon saries." (s) began. (4) The news reached Malta, on the very The war was given ample coverage in day that a parade of the whole expedition­ the local papers, more especially because ary force was ordered at the Floriana the Island served as an important military Parade grounds. The parade was suddenly station for the training of troops prior to broken up, and orders almost immediately their despatch to the front, as a supply issued for the embarcation to the Crimea. depot of foodstuffs and ammunition, as a In Malta at the time there were some repairing yard, and as a base hospital. 15,000 troops, belonging to the Companies No wonder it could be written that of the various British regiments. There "since the arrival in Malta of the news of were hardly any ships to convey the troops, the declaration of war, the embarcation of so that mail steamers arriving from India troops has continued with unremitting had to drop their passengers in Malta, and assiduity, and the excitement produced in be employed instead for the service of the the Island is almost indescribable." - troops. Thousan,ds, of these gallant fellows "The scene which occurred on the embar­ had, indeed, taken' ':$ last fond look of the cation of the troops was singularly inspirit­ valley, and the vmi;l.ge church and the cot­ ing. In either harbour, crowds of people tage near the br0~_.'· assembled - the crash of trumpets inton­ Meanwhile naval and military mQye­ ing the most popular and patriotic airs ments on the Island continued to gather were almost drowned in the enthusiastic momentum. Thus, for instance, the P. & O. 149 steamship 'Simla', the second largest in muleteers. the company after the 'Himalaya', arrived Local papers published regularly lists from Southampton with a number of staff of those wounded or killed in action. The officers and their horses - horses of th2 English Hospital at Scutari has since be­ Royal Horse Artillery - and 1500 caskfl come famous. The rapid increase in number of provisions for the Black Sea Fleet. At of wounded soldiers induced the authorities the time, it was said that that was th,e to seek medical help from Malta, and, fol­ largest stock that had ever been s~nt oj'f at lowing a request by the Admiral Superin­ one despatch from any victualling yard in tendent, four young Maltese Doctors England. Whilst the war was raging more immediately offered their services. These than one hundred thousand dozen oranges were Dr. P. Grillet, Dr. A. Bellanti, Dr. A. were ordered at Malta at. one time for the Arpa and Dr. Vincenzo Muscat. They left sailors of the Black Sea Fleet. With regard Malta for the Crimea on Saturday May 14 to the continuous naval movements at 1854, on board H.M. screw ship 'Algiers' Malta, one would mention particularly th2 (Capt. C. Talbot). Dr. F. Ellul, Assistant Sur­ giant screw ship 'Himalaya', which arrived geon of the Royal Malta Fencibles, who from Gibraltar with some 500 mules on had volunteered for service in the East, board en route for Costantinople and alRo left Malta for the same destination on Balaclava. Foreign ships calling at Malta, that same day on board the steam corvette and carrying troops, officers and ammuni­ 'Fury' (Corn. E. Chambers); Dr. Ellul was tion included French vessels from Marseil­ subsequently appointed to the staff of the les and Toulon. All planks, scantling timber, British Army. When the term of duty of carpenter's tools, and similar articles these private doctors was completed, soon readily available on the Island were pur­ after their return to Malta, Dr. Grillet, Dr. chased by the Commissariat for conveyance Bellanti and Dr. Muscat were, early jr to the East, these being required for the May 1855, called upon by the Principal erection of huts for the troops in th.e Medical Officer to give their services to the Crimea. Simultaneously, the Commissariat garrison without the city walls, as regimen­ in Malta notified that "that Depot was tal surgeons. All three doctors accepted desireous of purchasing masons', carpen­ the post. When in September 1855, Dr. ters', miners', and blacksmiths' tools, Bellanti resigned his post, Dr. George stoves, etc." Meanwhile, several steam Cousin, another Maltese who was attached vessels, laden with wooden huts, which to the Military Medical Department was were to shelter the troops from the cold appointed in his place and took charge of of a Crime an winter, passed through the troops at Fort Ricasoli. Also at Scutari, Malta. At the naval dockyard in Malta, a there was yet another young Maltese doc­ number of shells were made; these were tor, who had distinguished himself so much used in blowing up the Russian ships sunk as to win the appreciation of the celebrated at the mouth of the port of Sebastopol, the Florence Nightingale. Miss Nightingale main seat of severe fighting. These shells, addressed a personal letter of thanks to Dr. spherical in shape, varied in size containing Salvatore Luigi Pisani for his services in from 250 to 1000 lbs of gunpowder. Dur­ her hospital at Scutari, and she was "so ing the war vessels from the Crimea were greatly pleased with him" that she urged sent to Malta for repairs at the naval yard. the military Authorities to secure his Barracks accommodation was available for services as a military surgeon. In fact, soon thousands of "raw recruits" who were sent after his return to Malta - he had left out from England to Malta "to be drilled in Scutari on sick leave - he was appointed the necessary military exercises before Medical Officer to the garrison stationed at joining the army in the Crjmea." Transport St. Julian's. However, he soon relinquished vessels conveying hU:2dreds of mules and this post as he preferred to practise medi­ muleteers - some h<,;lin~ from Spain - cine with his father, himself a distin­ passed through Malta. '!'he Land Transport guished physician. Dr. Salvatore Luigi Corps on active service in the Crimea also Pis ani was the only son of Dr. Luigi Pisani, included hundreds of Maltese engaged as whose memorial is at the Mall in Floriana. 150

He studied medicine at the University in St. George (CM G) was conferred upon him Malta, in Edinbul'\gh and in Berlin. He prac­ by Her Majesty Queen Victoria. In his late tised the medical profession in London, years he suffered from loss of memory. He Paris, Munich and Vienna. In Munich he be­ died at the venerable age of 80 years. came acquainted with hygiene and sanita­ Another Maltese citizen who distin­ tion through his friend, Dr. Pettenkoffer. guished himself throughout the Crimean Meanwhile he became proficient in conflict was the Most Rev. Canon Paolo Le languages, getting to know German, Brun. He was one of Malta's most eminent French and Italian, besides English. He ecclesiastics and in his late years occupied was appointed professor of Anatomy and the place of Treasurer of the Cathedral Surgery at the Malta University and Chief Chapter. This prelate, in his younger days, Government Medical Officer. As the h~ad accompanied the English troops through­ of the medical profession in Malta, he was out the Crimean Campaign, his devotion the C!cknowledged leading doctor of the and gallantry being especially mentioned Island. Dr. Pisani's merits were recognised in despatches, and earning promotions in beyond our shores. The dignity of Com­ rank and many honours granted in that mander of the Order of St. Michael and protracted campaign. After his retirement

H 0 S PIT A L S.

1'\'

FLOHE~CE NIGIlTINGALE

[eir~· ~~iliOIl,

l:.'III",r!lttl (wd lvr till! 1I1().~! }I ue R:·l(1ritlo:lt. ,.23!l4'1 . \.. ·,ly.·: .: ., ..

LO~DO:\ : LONGhlAN, unE~::\, LUN\DIAN, lWllER'l'S, A"II Um:E:\. Isua. 151 from the active list, with the honorary of nuns, sisters and nurses each in their rank of Captain, he was popular in English separate quarters, and made them as com­ and Maltese society. His piety, learning and fortable as the very restricted space kindliness of heart elicited great admira­ allowed. But she could do no more; whom tion. He died aged 90 years. stormy weather began and they were all In Malta it was learned from th 3 ill and many of them terribly frightened, English papers that public interest in the only Mrs. Bracebridge, who was never sea­ Metropolis in the care of the wounded in sick, could go round like a ministering the English Hospital at Scutari had induced angel. The discomforts of the voyage wer3 some philantropic individuals to assist in indeed terrible. The three parties, forty providing nurses. Amongst these public women in all, were packed like sardines spirited people, there was the benevolent into the three divisions of the fore cabin. Miss Florence: Nightingale. She had The little shelves in dark recesses on which engaged at her lwn expense, II number of they were expected to sleep were like cof­ female nurses - including Sisters of fins and full of hundreds of young cock­ Mercy - and had undertaken to conduct roaches and other crawling creatures. a party of forty to Scutari. This initiative. Water came continually into the cabin, but enjoyed the patronage of the Duke of New­ no air. The Sisters perhaps suffered more castle. The greater number of the members than the nurses who were accustomed to forming the party was selected from Miss slum conditions. "Oh for air, air!", cried Sellon's Establishment, Bishop's training one of them, who was very ill and in high hospital for nurses and the Roman Catholic fever. "What does the lady mean?" said a Seminaries of Norwood and Bermondsey; nurse who overheard her. "Who is Air? 1 all concerned were "acting from a religious never heard of him." (7) sentiment of doing good to their fellow During the few hours that the steamer creatures." (6) Fifteen of them were paid was calling at Malta, the party came nurses recruited from various hospitals. ashore. According to O'Malley: "At Malta, The whole party was under the direction Mr. Bracebridge took all who were well and charfZe of Dr. Cumming and Dr. Spen­ enough ashore sight-seeing. Putting his cer, Deputy Inspectors General of Hospi- ideas of discipline into force - 'Perhaps 1ats, who were proceeding "under imme­ he learned them in the Militia' said one of diate orders" to the same destination. the Sisters maliciously - he marched them Florence Nightingale was accompanied by through the street. Protestant Sisters first, Mr. and Mrs. E. Bracebridge. A few months Catholic nuns last, nurses in the middle later Miss Stanley, daughter of the Bishop where they could do no harm. In the of Norwich, sailed from England with Cathedral, Mass was being celebrated, the additional nurses to reinforce Miss Night­ nuns began to fall out of their ranks and to ingale's contingent. sink upon their knees; he was much dis­ Florence Nightingale and her party concerted and annoyed. The sun was left London on October 23, 1854, Travel­ blazing, the streets were insufferably hot, ling on the P. & O. steamer 'Vectis' (Capt. the glare from the sea and sky was blind­ H.W. Powell) - especially hired by the ing, and everybody was worn with sick­ British Government to convey them at ness. On the whole therefore the Sisters once to Constantinople - they sailed from were relieved when they got back to the Marseilles on the 28th. of the' same month, ship." (8) arriving in Malta two days later. O'Malley The party did not remain unnoticed, in his standard biography of Florence and all the local papers carried the news Nightingale describes the journey from of Florence Nightingale's stop on the l\.llarseilles to Malta in the following terms: Island. According to the Malta Times: "The "The 'Vectis' was a ship constructed party landed and visited the objects in Val­ entirely for carrying mails, and sailed for letta most worthy of notice, and in passing speed rather than comfort. Florence was through the streets attracted the sympathy almost immediately incapacitated by sea­ and admiration of the inhabitants, many of sickness. She had settled the three parties whom expressed themselves highly gratified 152 with the interesting and cheerful appear­ Christ, for thy Charity, ance of these persons." Take thee to joy when hand and heart Later in the day, the 'Vectis' resumed are still! her journey to Costantinople. On her pas­ sage, it was reported, the streamer had The poem was signed "E.A.". experienced "unusually severe weather"; As evidence on how her work was "She had a considerable portion of her bul­ appreciated it may be enough to mention warks knocked away, deck-houses washed that Florence Nightingale was presented overboard, and, it is said, has altogether by the Sultan of Turkey with a magnificent been more strained and injured from this bracelet, set in brilliants, as a mark of his one voyage, than from all the trips to Mar­ appreciation of the devotion evinced by seilles during the whole of last winter. The her in the British hospitals. ladies on board, in charge of Miss Nightin­ It is of particular interest to record gale, we are informed, behaved without that, on humanitarian grounds, prominence exception throughout this trying weather was given in the local papers to the hospi­ in the most exemplary manner and not a tal conditions and the treatment of the murmur was heard to escape from one of sick and wounded throughout the period them." (9) The work of the 'Lady with the of hostilities. Opinions were ventilated Lamp' at Scutari is too well known to need even in editorial comments. One such mention here. However, it is interesting to example is culled from the "Malta Mail" reproduce a poem dedicated to Florence (5/12/1854): Nightingale and published at the time in "As the events of the fruitful war now "Malta Mail" (5/10/1855): waging in the East, are made public, it is impossible for the most indifferent reader Whereto sore - wounded men have to peruse the despatches without a feeling looked for life, of pride at the success which has attended, think not that for a rhyme, not only the arms of our own countrymen, nor yet to fit the time, but also that of the arms of our intrepid I name thy name, true victress in this allies .... An eye witness, who has lately strife; visited the hospitals, is loud in his praise But let it serve to say of the unvarying attention paid to the sick that, when we kneel to pray, - the studious regard paid to the ventila· Prayers rise for thee thine ear shaH tion and cleanliness of the wards - the never know; unremitting care of the medical attendants And that thy gallant deed, - and the anxious solicitude of the pro­ For God, and for our need, fessional and voluntary nurses, at the bed­ Is in all hearts, as deep as 10Vf~ can sides of the sufferers." go Late in September 1855 the French 'Tis good that thy name springs steamer 'Simois' entered the Grand Har· From two of .8arth's fair things - bour bringing with her "most important A stately city, and a soft-voiced hirValletta on the 28th and 29th Septemb2l' The Royal Standard was hoisted OIl 1855. Whilst stressing the significance of th€! Palace and the Palace Toower "was that victory, in an editorial note, the literally concealed under flags of all Portafoglio Maltese commented in Italian: descriptions." - "Looking like a huge tent "Malta, as an important marItime station which was waving in the wind in the heart in the Mediterranean, gives praise to the of the city." (rr) Flags were flown on all Almighty who presides over the destwy of the forts, public buildings and official nations, because in a single day it has seen residences of foreign consuls. Also the the destruction of a large and terrible ships in harbour carried flags. enemy fleet, which threatened the liberties The main squares of the historic city of the populations of the south of Europe. of Valletta were profusely decorated whicli Two principles stand out in the great enhanced the atmosphere of jubilee. The struggle in the East: the principle of free­ facade of the Palace was festooned with dom and of political and social emanicipa­ garlands, and between the two main doors tion represented by England and France appeared "in large green letter the talis­ and that of autocracy and servitude most manic word Sebastopol." The coats-of-arms promin'.mtly represented by Russia". A of France, England, Sardinia and Turkey solemn funeral service in honour of those embellished one side of the Palace Square. who died "in the cause of liberty and the fountainSl at each end of the Palace independence" was held at the Jesuits' Square werE; surmounted by a painted Church by the rector of that church, the decoration representing the fiags of the Rev. Canun Dr. Calcedonio Falzon. A four allied forces. Over the Main Guard a select programme of sacred music was transparency was erected which depicted conducted by Mro. Vincenzo Bugeja. A Queen Victoria, the French Emperor and symbolic catafalque was erected in the the Turkish Sultan. The scene was pro­ main nave of the church; with an inscrip­ minently dominated by the names of Pelis­ tion written by the well known Latinist sier and of Simpson. Marshal A. Pelissier and epigrammist, the Rev. Father Giuseppe had been given the Grand Cross of the Zammit (Brighella): Order of the Bath - G.C.B. by Queen o Magnanimi VirijQueis Patriae Vir­ Victoria and General James Simpson the tutis Gloria/ Ipsa Vita Carior Fuit/Post Grand Cross of the Legion of Honour by Grande Proelium/ Aeternae Palm am Vic­ the French Emperor. toriae/Donet Vobis in Coelo/Misericordia­ From Porta Reale (Kingsgate) down to rum Pater/Christus. the Palace Square, in the city's main street, The singing of the Hymn of Thanks­ Kingsway, the lamp-posts were decorated giving, the Te Deum, by the congregation with banners and burners and balconies of brought the sacred function to its con~lu­ private houses were covered with damask. sion. Present at the ceremony were H.E. The decorations of the facade of the the Governor, Sir William Reid, civil and Public Library on the Treasury Square military authorities, foreign consuls and a (now Queen's Square) attracted special large concourse of people. "There never attention. Here appeared the names of the was a more tender or more moving cere­ heroes of the allied troops: Lyons, Bruat, mony." (10) Raglan, St. Arnaud, Omer Pasha, Canro­ On the facade of the church the follow­ bert, La Marmora. mg inscription, composed by the said KC. Lyons, Rear Admiral Comman­ Father Zammit, was erected: der-in-Chief of Her Britannic Majesty's Piis Manibus/ Amissorum Militum/ Naval Forces in the Black Sea, the son of Catholicum Nomen Profitentium/Qui Sub Lord Lyons, had been fatally wounded in Validissimis Sebastopolis Moenibus/ Admi- the night attack on Sebastopol; Bruat was 154 the Vice-Admiral 'commander-in-Chief of Square. Singers and orchestra from the the French Squadron in the Black Sea and Opera Company, under the direction of French Marshal St. Arnaud commanded Sig. G. Le Brun, sang and played a hymn the expedition to the Crimea, whilst arranged for the occasion by Mro. Dome­ General de la Marmora was in command oi nico Amore; the hymn was a combination the Sardinian troops. There were allegorical of 'God Save the Queen', 'Partant Pour La scenes of the towers of Malakoff and Redan, Syrie', a Turkish aria, a Sardinian tune and carrying the French and the English flag a popular song known as 'Cheer, boys, respectively. A Latin inscription by Father cheer, we're going to fight the Russians'. Zammit dominated the scene: The concert went on almost till midnight, Tauride Expugnata/Hostium Classe when the Band of the Royal Malta Fen­ Deleta/Ingentem Victoriam/Salutant Po­ cibles under the direction of Captaino Cav. puli. "Il Mediterraneo", however, attri­ G.P. De Marchesi Testaferrata Olivier buted the authorship of this distich to. Dr. wound up the festival with a selection of Nicholas Zammit, another scholar of the popular arias. time, who was also a doctor· of medicine On the occasion of those celebrations Ilnd an architect. the flags of the four allied power::; were hoisted on the steeple of the Protestant On the Square in front of the Law Cathedral Church of St. Paul, whilst the Courts (Auberge d' Auvergne) a large Jewish Synogogue was brilliantly illumin­ pyramidal, gothic stand was erected and ated in the evening. The august event elaborately ornamented with hundreds of "fQJusto QJvvenimento" - was also marked lamps. in Malta by the distribution of a sonnet in In Strada Reale (Kingsway) the next Italian "par to di una dotta persona mal~ point of attraction was the Auberge de tese" (",the brain child of a lerned Maj· Provence, which housed the Union ClUb. tese" .) The columns of the main door were The Sultan of Turkey issued medals festooned with garlands. "Over the door in gold and silver to commemorate the fall and attached to the balcony were four of Sebastopol; these were distributed to all knights in armour, bearing the flags of the the officers of the allied armies who had allied powers. The three who lJore those n,f taken part in the siege. The medal showed France, England and Sardinia wore the the Imperial Sign with the word Sebastopol Cross of Malta, on their shield; the one written in Turkish on the obverse: a who carried the Turkish banner had also wounded Russian Eagle, surmounted oy the Turkish emblem emblazoned on hi3 the four Allied flags, a Cannon, a scroll shield, the Cross of Malta having been map of the Crimea and the word Sebasto­ covered with a piece of red leather, on pol in European letters. With the cessation which was painted in white a half moon of hostilities the troops began to return to and star." (I2) From each window the Malta; others, including foreign troops, historic edifice projected a white flag passed through Malta on their return having the names inscribed in black letters: journey nome. SiIistria, Alma, Inkerman, Oltenitza, Since in thIS essay, 1 have mentlOnell Tchernaja, Sweaborg, Malakoff, Sebasto­ Florence Nightingale's short visit to Malta, pol. it may not be amiss to record yet another The celebrations included Royal affecbonate link that e1(ists between thIS Salutes from Fort st. Angelo, from St. illustrIous lady and the Island. I am refer­ James Cavalier, and from the Saluting Bat­ ring partlcularly to her standard work tery; this latter was furnished by a Com­ entitled: "Notes on Hospitals", publIshed pany of the Maltese Militia under the com­ in London in 1863, a copy of which, now mand of Capt. Cav. Giacomo Tagliaferro. at the Royal Malta Public Library, had Horse races were held in the afternoon. In been presented by the writer to the the evening a grand fire-works display took Hon. Sir Ferdinand Inglott, Comptroller place outside Porta Reale. This was fol­ of Charitable Institutions, with the follow­ lowed by a concert held on the Palace ing autograph dedication: 155 "The Honourable F.V. Inglott - Malta. details of both plans contain everything offered by a fellow-worker required for ensuring a healthy state of the F. Nightingale buildings. They were prepared at the London Dec. 10/63." instance of the government of Malta, by No doubt, this book by so famous a Mr. T.H. Wyatt; and when completed, they personality is of special interest to th~ will place this small island in the foremost student of medical h:story in :Malta, rank as regards its charitable institutions." because it contains a set of plans on Malta The autographed copy mentioned showing, for instance, the proposed Gene­ above, contains a marginal note in Sir Fer­ ral Military Hospital in Valletta (Plan VII), dinand's own handwriting stating: "The the Asylum for the Aged and Infirm (Plan Block Plans and details of internal arrange­ VIII), and Hospital for Incurables (plan ments, were all given by me. Wyatt IX). reduced the whole to 'Architectural pro­ Besides, this book also contains long portions' and no more was done by him. passages, even whole chapters on Improved Documentary proofs are in my possession, Hospital Plans for Malta. Thus: "It is pro­ bearing the Governor's signature". posed to erect a gem~ral military hO'spital on the pavilion principle for 300 beds, with References the pavilions differently arranged from any existing example .... The hospital will (1) Malta Mail - 7/4/1854. overlook the sea at a height of 170 feet (2) Il Mediterraneo - 27/9/1854. above its level." The site chOSen for this (3) Il Mediterraneo - 25/10/1854. hospital, which was never built, was (4) Ch. D. Hazen: Modern European History enclosed by Strada Molini, Strada Genio, - London 1917. and Strada San Andrea and projected on to (5) Malta Mail - 13/4/1854. the bastion. (6) Malta Times - 31/10/1854. "Other two establishments are pro­ (7) LB. O'Malley: Florence Nightingale (1820- posed to be erected by the enl;ghtened 1856). local government of Malta. One of these is (8) Ibid. an asylum for 1000 aged and infirm per­ (9) Malta Times - 14/11/1854. sons, 500 of each sex .... Connected with (10) Il Mediterraneo - 3/10/1855. this establishment, it is proposed to build (11) Il Mediterraneo - Ibid. a hospital for 300 beds .... The sanitary (12) Malta Times - 2/10/1855. iM THE SERPENT OF AESCULAPIUS, THE CONFRATERNITY OF SS. COSMAS AND DAMIAN AND THE BISHOP OF MALTA A Medico-ecclesiastical Controversy 0.f1859

PAUL CASSAR S.B.St.J., M.D., B.Sc., D.P.M., F.R.Hist.S.

Hon. Fellow of the ROyQJl University of Malta

In the Middle Ages it was the usage doctors and surgeons being entrusted with for artisans engaged in a particular craft the application of leeches, the extraction of or art to combine together to form confra­ teeth and bloodletting. ternities and corporations under the aegis The confraternity of SS. Cosmas and of the church. The former were associations Damian held its religious functions at thE' aiming at fostering religious piety among church of St. Francis of the Minor Conven­ their members and assisting them when tuals in Kingsway, Valletta, where it had sick or unemployed; the corporations were an altar, still in existence, dedicated to the guilds concerned with the promotion of a two brother saints. The altar piece is from high standard of worksmanship among the brush of Filippo Paldini (1544-1614?) their craftsmen, the proper training of (Cassar, 1972). apprentices and the protection of the eco­ nomic interests of their members. The saints' feast day was commemor­ In Malta these associations emerged ated with great pomp and solemnity on the into prominence in the early seventeenth 27th September. A notable feature of this century. The confraternities (called also celebration was the procession from\ the sodalities and consodalities) and corpora­ Conventual Church of St. John to the tions bore the name of the tutelary saint church of St. Frands already mentioned of their craft; thus the carpenters formed and in which the Grand Master of the the confraternity of st. J oseph, the jewellers Order of st. John with the Chaplains of that of St. Relen and the shoemakers that of Obedience and the members of the confra­ st. Crispin. Their meeting place was usually ternity, in their distinctive tunics, took part the sacristy or oratory of the church where (Cassar, 1965b; Suppliche 1741-61). It is on their patron saint was venerated (Cassar, record that these functions were already in 1965a). existence in 1644. The medical practitioners and sur­ We are unaware of the other activities geons of Malta were organised in a confra­ of this confraternity until we reach the ternity named after the protective saints of years 1720 and 1754 when the barbers the profession Saints Cosmas and Damian. asked the Gand Master of the Order of St. This confraternity, founded on the 10th John to allow them to form their own October 1635, was also known as the brotherhood independently of the medical universitas barbitonsorum (Cagliola, 1644), practitioners. We catch a further glimpse the reason being that the physicians and of the confraternity of SS. Cosmas and surgeons shared the membership of this Damian on the 3rd June 1797 when ,by a association with the barbers as, in those government decree of this date the barbers days, the latter were ancillary assistants to were completely separated from the physi- 157 cians and surgeons and authorised to form Pace Forno took over th3 administration of their own corporation under the name of the diocese (1857-75), he gave the same St. Ludovicus of France (Cassar, 1965b; order to the Minor Conventuals and the Suppliche 1741-61). rector of the confraternity through the We again lose sight of the confra­ Vicar General but he, too, was ignored. ternity of SS. Cosmas and Damian for the The confraternity of painters, under next fifty years when we read of a funeral the patronage of St. Luke, also possessed service held by its members for the repose an altar in the same church. They too had of the soul of Dr. Luigi Gravagna on the decided to rebuild their altar dedicated to 29th March 1849 at St. Francis Church this saint. "Encouraged by the disobedience Il Piortafoglio maltese, 1849). By this time (of the doctors)" they adorned it with the oQThfratemity was know as the pia "sculptures of the square, the compass, the societd medico-chirrurgicGi-farmaceutica. In hammer and other symbols of the arts; but 1856 and 1857 the feast of the two saints as in Malta these (tools) are recognised as was celebrated on the 27th September with masonic signs many were scandalised and High Mass and a panegyric in which the Lh:> press criticised" the new designs. preacher exhorted the congregation to Arr:hbishop Pace Forno again repeated imitate the virtues of the two martyrs. The his instructions to the Minor Conventuals attendance in 1856 was, however, poor as t.o have these "inconveniences" removed less than a dozen medical men were pre­ hut "everything was in vain". sent. The expenses of the ceremonies were On the 31st August 1859 the Minister defrayed out of funds collected from m~m­ Gp-ueral of the Friars of St. Francis, Fra bers of the profession but it was being Salvatore Cali' of Catania, Master of Arts found difficult to obtain the money as som? and of Sacred Theology and Adviser to the declined to contribute, others made pro­ Sacred Congregation of the Index. came to mises which they never fulfilled while a Malta to visit the convents and churches of few agreed to pay only after much cajoling his Order and to hold a Chapter General. (L'ordine, 1856 & 1&57). It appears that the Bishop Pace Forno took the occasion to call religious celebrations were not held in the the attention of the Minister General to the following years. dispute about the two altars. During his visit Towards the end of 1859 we come 1:0 the church of St. Francis, Fra S. Cali', across a record of a few letters exchanged having seen the "equivocal emblems of the between the confraternity and the Minor fine arts" adorning the altar of st. Luke Conventuals. The topic which gave rise to and the "symbols of Aesculapius" decorat­ this correspondence was the altar of the ing the altar of Saints Cosmas and Damian, confraternity in St. Francis Church. Some concurred with the Bishop that they were time in the first half of the ninetef!nth out of place. century the altar was rebuilt in the form of On his d?-parture from the Island on "a sepulchral urn flanked by two large tlhe lOth September (L'ordine, 1859), he trunks or rods of Aesculapius entwined by gave orders to the Father Guardian to per­ serpents and serving as columns to support suade the owners of the altar of St. Luke the altar slab". These trunks and serpents to take away the emblems of the fine arts were meant to symbolise the medical and and to induce tbe confraternity of Saints allied professions but in the view of the Cosmas and Damian to "remove' from sight Archbishop Bishop Mgr. Publio Maria thos~ entwined s~rpents representing Sant (1779-1864) they were pagan symbols medicine and reminiscent of a pagan so that one could not say whether "the altar myth . . . , it being inappropriate to have was Christian or pagan or a mixture of both. emblems of paganism in Catholic The people who had remarked on this churches" . inappropriateness were scandalised". For It appears that the Father Guardian, this reason the archbishop requested thp. Fra Giuseppe Bonaventura Farrugia, had removal of the "pagan" emblems but his no difficulty in convincing the confraternity order was ignored. of painters, who were in charge of the altar As soon as his successor Fr. Gaetano at st. Luke, to take away their emblems. 158

In fact "they obeyed" and no such symbols ~ommitted by anyone against the altar can be seen to-day surrounding the altar of Y/ill have unpleasant consequences. St. Luke. In the case of the brotherhood of I am, with all due respect, Saints Cosmas and Damian, the medical Dr. Cal. Parnis." fraternit.y adopted a different attitude and reacted quite strongly. It is not known what was the decision The Father Guardian duly informed reached by the general meeting of ,the the med:cal confraternity of the instruc­ Society. It is certain, however, that the tions he had received from his Minister emblems were not removed. The Bishop, General. He wrote thus to Dr. Calcidonio therefore, through the Chancellor of the Parnis, the procurator of the confraternity Episcopal Grand Court sent this letter to on the 28th S-=ptember 1859 (translated the Father Provincial of the Minor Con­ from Italian):- ventuals, Fr. Michele Scl).embri, on th:~ "ID accordance with the written 15th October 1859 (translated):- ord:rs given me by the Rev. Minister General I have to ask you, as Pro­ "Very Rev. Fr. Provincial, curator of the Venerable Consodality His Excellency Rev. Mgr. Arch­ of Saints Cosmas and Damian, to take bishop Bishop of Malta was informed steps to take away and remove from at the commencement of his adminis­ sight within eight days those entwined tration (of the dioces2;) that in the serpents, symbolising medicine and church of St. Francis of Valletta there recalling a pagan usage, which are was an Clltar with two large staffs of qui.te improper and intolerable in C1 Aesculapius. In view of the fact that sacred place. these are wholly pagan symbols and, I await a written reply to this therefore, inappropriate in the house letter as I am responsible towards th3 of God and more so, in an altar on Head of the Order for the execution which the bloodless' sacrifice (of the of his c~mmands. In the meantime I Mass) is celebrated, he has already sign myself with all due esteem, twice suggested both to the religious th::l most humble and obedient community and to the confraternity, servant, which cJilims to own the altar, to have them removed. Fra Gius. Bonaventura Farrug"a, His directions repeatedly ex­ Father Guardian." pressed in the most explicit manner have remained unh«:>eded. Meanwhib the Very Rev. Fr. Salvatore Cali', Dr. Parnis repUed_ the next day in the Minister General, during his recent following terms (translation):- visit to the convent of the Order, has ordered the removal of the said pagan "Very Rev. Father, emblems from that altar. Since not In answer to your letter of even this mandate has been obeyed, yesterday, I have to inform you that it His Excellency, in his capacity as is not within my power to remove any Diocesan and as Apostolic Delegate, one of the emblems existing in our commands that from to-day until the altar of Saints Cosmas and Damian as said staffs of Aesculapius are remond, the said altar is the property of th3 the said altar of Saints Cosmas and medical corps. I have, however, com­ Damian is being interdicted so that municated the contents of your letter no one is allowed to celebrate Holy to the President of the Society who Mass (thereon). has }instructed me to call a general Your most humble and obedient meeting to which pertains the duty servant, to deliberate on the matter. Sac. Emmanuele Corsoni, In my capacity as procurator I Chancellor of the Episcopal solemnly affirm that any aggressive act Grand Court." 159

The reply of the confraternity was influence gradually waned; or else resolute. They did not write to the Arch· were, from the very beginning adoptea bishop but they addressed the following by the Christians, although they had letter to the Fr. Provincial on the 19th been previously used by pagans, a~ October, that is four days after the declara­ they represented id.eas common to tion of interdiction of their altar (transla­ both Christians and pagans. tion):- In the particular instance of the entwined serpC'llts, which are the cause "Very Re\>. Father, of such fear to Your Paternal In answer to your esteemed lettei Reverence, we have to add that they of th~ 28th September addressed to were placed on the altar belonging tf> one of us, we have been directed to this noble corporation as insignia of inform you, as deputies of the Medico­ the medical profession twenty-foUl chirurgical-pharmaceutical Corpora­ years ago with -the full knowledge and tion under the title of Saints Cosmas after Cl serious and mature considera· and Damian, that the coiled serpents tion of the ecclesiastical authority as to which you refer are the symbols of we shall prove if and when the the medical profession and as such occasion arises. For this reason the quite suitable as an emblem of this medical corporation which we repn:· corporation. In fact this emblem was sent does not consider it decorous and adopted at the very inception of the incumbent on them to adhere to the corporation following the example of request made by Your Paternal similar corporations elsewhere and Reverence. especially in the capital of the Moreover, as the medical corpora­ Catholic World. tion ig the possessor of the altar of The coats-of-arms of families and Saints Cosmas and Damian and as of corporations are to be seen, with­ ownership is safeguarded by the out any incongruity, in all the churches sanctity of the law and the authority of the diocese; and in some instances of our Queen, we deem it our duty to quite independently of the object inform Your Paternal Reverence and represented. To avoid drawing up a anyone else whom it may concern long list of examples, it is sufficient to that the medical corporation, in order call the attention of Your Paternal to ensure the inviolability of its rights Reverence to the insigna adopted by on the said altar, will not allow anyone the Cathedral Chapter which appears to lay his hands on it and will take on the silver frontal that adorns, on 1!;\gal steps against anyone who the most solemn feast days, the main 2tt.empts to do so. altar of the church of Malta. Here the Most humble and devoted servants, serpent, or rather the viper, is seen Cav. Gaetano La FerIa, curled round the sword and sur, Dr. Paolo Grillet mounted by that form of crown with which the pagans decorated their At this point the correspondence gods. Furthermore, does not the cl)mes to an end and we have to search bishop himself carry a serpent coiled ~lsewhere for a clue as to how the dispute round his pastoral staff? Besides if all was resolved. It is convenient, therefore, the objects which recall pagan rites and at this stage to pause in our search and usages were to be eliminated from our c.ast a glance at the corpus delicti and at churches - this being the reason on the personalities involved in the case. which Your Paternal Reverence The caduceus or staff or rod with one seems to base your request - our cult or two serpents entwined round it appeared will be deprived of its outward and as an attribute of the healing Greek god imposing majesty since many, not Aesculapius after the sixth to the fifth cen­ to say almost all, of its features were tury B.C. As a pagan deity of medicine, derived from the pagan rite as it~ Aesculapius aroused the antagonism of 160 Christians in the second century A.D. In later years the Christians adopted when h~ was regarded by the early the brass serpent as an image of Christ. Th~ Fathers of the Church as an evil spirit and bronze, which withstands the ravages o~: even identified with Sata"!l himself~ Inspite time, signified His Divinity: the serpent of this hostility, however, the concept of symbolissd His Humanity; and the pole Aesculpaius as a beneficent div:ne physi­ stood for the wood of the cross on which cian survived in the Christian guise of He was crucified for the salvation of the miraculous healing saints. Prominent world (Th~ Messenger of St. Anthony, among thes~ were the physicians Saints 1969), Cosmas and Damian who l:ke Aesculapius In sixteenth century Germany silver effected cures during incubation i.e. by m2dals were struck depicting the brass appearing to the patients in their dreams, serpent on the obvers~ and a crucified connselling them, prescribing remedies or Christ on the reverse s~de. They were healing them by the laying on of hands as worn as a protection against the plague was practised in the Asklepian temples at (Schouten, 1967c). Epidauros, Pcrgamum and Cos. The rod and serpent motif was Aesculapius with his traditional sym­ accepted within a Christian context by bol of the rod and serpent re-emerged in 1762 when it was incorporated in a painting the sixteenth century in Christian Europe of Sa:nts Cosmas and Damian by ,Johnn during the humanist culture of the Renais­ Anwand2r for the Maria Himmelfahrt sance when the visual arts ceased to be th(~ Kirche in Dilligen-on-the-Danube (Schoe­ handmaids of religion and attained an t.:n, 1967d). independent existence and expression. These remarks regarding the place of Since then the rod and serpent have the serpent in pagan and Christian thinking become the symbol of the medical and show how well read were Drs. La Ferla and pharmaceutical professions (Schouten, Grillet about the role of serpent symbolism 1967a). in ancient times. Their reference to the In Malta it was adopted as an emblem crowned serpent or viper coiled round of the Societa medica 'd'inconaggiamento the sword is an allusion to the coat-of-arms on its foundation in 1837. The serpent and of the Cathedral Chapter of Malta. This rod are emblazoned over the white and red device is derived from St. Paul's shaking shield of Malta (Statuti, 1843) and form the viper into the fire on landing on the part of the design by Nioola Zammit of the Island of Malta after his sbip'Nreck (Luke, diploma of membership of the society (Ms. Acts, 28,3). The crown symbolises the glory 491). of martyrdom and the sword the instru­ In mythology the serpent symbolises ment by which the apostle was put to rejuvenation, an idea derived from the death. This emblem is displayed on the top periodical shedding of its skin and the of the steeples of the Cathedral Church at formation of a new one, The rod represents Mdina and on the facades of farmhouses the renewal of vegetative life; hence both and other buildings belonging to th~ stand for the indestructibility of life and, Chapter of the Cathedral. by analogy, for recovery from illness and Some of the protagonists - Fr. M. for restoration to health (Schouten, 1967b: Schembri, Fr. G. Bonaventura Farrugia Geddes, 1945), and the Rev. Em. Corsoni - who were Among the Hebrews the serpent stood dragged into the controversy only in view for salvation. When the Israelites com­ of their official positions in the ecclesiastical plained about their food, while wandering hierarchy, have eluded all my attempts to in the desert round Sinai, God punished get to grips with them as personalities. them by sending fiery serpents, many dy. Mgr. Fra Gaetano Pace Forno, the son ing of bites from these animals. When the of the lawyer Dr. Fco.. Pace, was born in Israelites repented the Lord told Moses to Gozo on the 5th June 1809. His mother be­ make a brazen serpent and mount it on a longed tot the family of the barons Forno of pole so that whoever was bitten would Palermo. He joined the Augustinian Friars recover by looking at it (Numbers, 21:4). eventually becoming the Father Provincial 161 in 1847. In the following year he founded ing labour (Laferla, 1855). He stressed the the school which is still run by his Order. need of studying the natural history of the In 1857 he was appointed coadjutor to Mgr. Maltese Islands (1838-39) and proposed the Archbishop Publio M. Sant and when the compilation of a series of biographies of latter resigned in December of the same Maltese medical men (Sboria societa year, Fra Gaetano Pace Forno assumed the medica, 1845a; Ms. 1404). direction of the diocese. He became bishop In 1844 he went to the R~gency of of Malta on th~ 31st May 1858. Tunis to deal with a "contagious illness" His tenure of office was marked by a that spread among the troops of His Excel­ few episodes of friction with the British lency Ahmed Bey who honoured him with authorities who governed the Maltes9 a decoration as a reward for his successful Islands in those days. The first clash efforts. In 1853 he drew the attention of the occurred on the very day of his installation British Consul General at Tunis to the as bishop when the commander of the Bri­ plight of the Maltese settlers in that tish troops in Malta refused to fire the ar­ Regency and interceded with him to pro­ tillery salute that in the past had been tect them from the Mussulmans without accorded to the bishop of Malta on his charging them the prescribed fee. He was installation. In 1860 he was at variance with back in Malta in 1854. In 1856 he was the Governor when an Italian operatic elected a member of the Council of Gover­ company made some uncomplimentary ment (Ricorsi e lettere 1854; The M2Ita allusions to the temporal power of the Pope Government Gazette, 1856). He belonged although the Governor had ordered the to various foreign medical ass-ociatiollS company to withdraw the play in question. among which the Societe Royale de In the following year he was again at log­ Medecine de Marseille (1835), the Societd gerheads with the Governor when some fmnopatica italiana (1862), the PhYSICtJ­ roofing stones were removed from the Medical Society of Moscow (1862) and the vaults in st. John's Co-Cathedral to ascer­ Accademia medico-chirurgica di GeniQlVa tain whether certain structural alterations (1857). He died on the 30th August 1865 at could be carried out in a nearby cellar. A sixty-three years of age at Siggiewi (The far more serious discord arose in 1865 Malta Observer, 19(5). concerning the question of the validity of The Grillet family was established in marriages between Catholics and Protes­ Malta in 1645 when the Frenchman Stefano tants whicb lasted for many years before Grillet (or Grigliet) married Margerita a final solution was reached (Laferla, Cannolo at Birgu. By the end of the cen­ 1938). tury the Grillets had become a "medical" Very little is known about Dr. Ca1ce­ family there being a surgeon Sebastiano donio Parnis. The son of a doctor, he and his son, a physician, also named S8bas­ studied belles lettres at Pis a before he tiano, who lived in Valletta in the first two turned to his medical education at Malta. decades of the eighteenth century (Libr. He had a very short professional career Ad. 53). Dr. PaoIo Grillet studied medicine dying at thirty-s:x years of age on the 18th and surgery at the University of Pisa where August 1864. He is buried In the Carmelite he qualified in 1845. He appears as a mem­ Church at Valletta having been the Rector ber of the Societa medica d'incomggia­ of the Confraternity of Our Lady of Mount mento on the 16th June 1846 when he took Carmel (L'arte, 1864; L'ordine, 1864). part in a discussion on purpura haemorr lha­ Dr. Gaetano La Ferla, born on the 16th gica. His name occurs again in the proceed­ April 1802, qualified in medicine and sur­ ings of this society in 1848 in connection gery in 1825. He was a founder member of with a debate on hydrophobia and with a the Societa medica d'incoraggiamento proposal for plans for the preparation of a when this association was set up in 1837 standard nomenclature of diseases to (Guida, 1855; Pronostku malti, 1960; L'arte, oibv?:atet the confuSion caused by doctors 1865). He wrote a monograph on the use of who referred to different diseases by the asafoetida resin in the prevention of foetal same name and to the same diseases death in cases of inertia of the uterus dur- by d~fferent names. In 1849 he was 162 elected a member of a commission set up more so (in a country) under the influence by the society to study measures for a port of a Protestant government" (Le. the Bri­ medical service at a time when cholera had tish Government). The Sacra Congregazione appeared in various Mediterranean pons concluded its letter by inviting the Arch­ (Stona societa medica, 1845b). bishop to inform Rome what was "the real During the Crimean War (1854-56) he reason that gave rise to the interdiction of went to the Crimea where he dedicated the altar." himself to military surgery. On his return Archbishop Pace Forno replied on to Malta he served "with zeal and self-abne­ the 11th February. As his arguments and gation" in the cholera epidemics of 1865, observations throw a revealing light on 67 and 1887. He spent the last years of his the complex pattern of social and religious life as District Medical Officer of Valletta, life in Malta in the mid-eighteen-fifties it Quarantine Medical Officer and Visiting is worth reproducing extracts from his Physician to the Lazzaretto. In recognition letter at some length. After giving an ac­ of his services to the Italian community in count of the events leading to the interdic­ Malta he was created Cavaliere dell'Ordine tion, he remarks that if the serpents and della Corona d'Italia in January 1890. He abacus "were sculptures within a shield, died on the 29th July 1890 (La rivista one may allow them outside the altar pro­ medica. 1890), per on the pilasters at the sides of the altar As already stated. after the letter of as is the custom with coats-of-arms of noble the 19th October 1859 over the signatures families; they cannot, however, be permit­ of Drs. La FerIa and Grillet. the archives ted as they actually are and as an integral of the Minor Conventuals at Valletta dis­ - or rather a principal - feature of the close no further information on the sub­ slab itself on which the I',amaculate Lamb ject (Fiorini, 1973). Efforts to track and is sacrificed. Such strictness would not locate the registers of the confraternity seem necessary abroad; but it is not so in have given no clues as to their whereabouts Malta where we live in the midst of a but a search in the archives of the Archie­ thousand critics and especially among Pro­ piscopal Curia has revealed further docu­ testants who grasp every opportunity to mentation from which we learn that the accuse us of idolatrous rites. It is neces­ crisis had deepened and reached a climax sary for the Societa medico-chirur:giCa when the issue was referred to Rome whose deputies, to justify their disregard. through a memorial submitted by the of my order and that of the Father Friars. General, stated that . . . . if the Catholic In a letter of the 23rd January 1860 Church were to do away with its pagan the Sacra Congregazione dei Vescovi e (rites) nothing wilL be left. Such is the COll­ Reg,olari at Rome informed Archbishop cept of the church held by these men ... Pace Forno that it had learned that the some of whom, as is publicly known, do doctors had opposed the removal of the ser­ not believe in the Christian religion." pents on the ground that these animals The doctors, however, were not the were not meant to recall pagan rites but to only persons to earn the strictures of the symbolise the medical profession. The doc­ Archbishop; in fact he openly expressed tors claimed the right of setting up their his disapproval of the conduct of the Minor heraldic emblem in any place that belonged Conventuals (Sammut, 1860) who, on the to them. It had also been brought to the pretext of being regular priests and of their knowledge of the Sacra Congregazione that church being outside the jurisdiction of the the Minor Conventuals had been advised Archbishop, "do and allow everything to be to sue tl1em in a lay Court of Law to induce done without his sanction". He alSo them to remove the serpents in question deplored the fact that one of the friars had and that, as the Friars were reluctant to do insulted him and his officials not only in so, the Archbishop had reacted by inter­ public but also in church and that the friars dicting the altar. The Sacra. Congregazione endeavoured to have the interdiction did not consider it "prudent to i~itiate revoked by the Sacra Congregazione to be court proceedings in a lay tribunal much in a position to "boast that they had 163 shamed the bishop of the diocese". many occasions and, it must be truly said, As to the involvement of a lay tribunal that due to the integrity and independence in the dispute, commented the Archbishop, of the judiciary we never had any reason there would be no need to take this step ';it to complain". The friars themselves, con­ the friars had been prudent enough. Having cluded the Archbishop, had felt no qualms lmown since some time that those emblems on a past occasion to sue their own superior were not suitable in a Christian altar they in the Police Courts. should have endeavoured, with good mall­ While the Archbishop had no anxieties ners, to make the members of the sodaHy, about the administration of justice in the among whom there is no lack of reasonable Island, he was quite alarmed at the alleged (men), understand the whole question. But inroads of freemasonry among his flock." the friars did not care about the remarks "It is well known", he observed, "that in of the public neither about the Malta the numb2r of (masonic) sects has remonstrations of the bishops nor the increased considerably and that many Mal­ latter's orders. It was only when they tsse have joined them; if we go on like this, were prohibited from celebrating Mass ou we will one day see on our altars the image the altar that they began to stir. But what of a head of a sect and, under the pretext did they do? They irritated the member!'; of exemption or of ius patronatus, one of the sodality. It is well known that one of would have to tolerate this abomination. the friars, who is eager to have the inter­ Most Eminent Fathers, Malta is an excep­ diction revoked, has been insulting them In tional country. One must be on one's guard the streets saying that they neglect to ful­ to resist profanation; otherwise there is the fil their paschal duties and even threaten­ risk of losing the purity of the Catholic cult ing to break the rods with his own hands. and also of every religion" (Pace Fomo, In the end. when the friars. with their lack 1860). of prudence , had rendered any agreement The Archbishop's preoccupation about impossible they came to ask what they the diffusion of freemasonry in Malta should do. They were told to have recours':) was not altogether unjustified; indeed a to the law courts. What else, under the prominent freemason, writing in 1880, circumstances, could one do? Either remain stated that there was probably no part of with the altar mterdicted or else take steps the world where freemasonry had so to remove those emblems through court greatly prospered during the nineteenth action. This was a necessary consequence. It century as in Malta. As early as 1815 the every time that anyone refused to obey an Bishop of Malta had remonstrated with the order that order were to be rescinded, then Governor, Sir Thom~s Maitland. against tho. all the laws of the world would have to be weekly meetings of free masons in Valletta. abolished" . In 1843 he publicly condemned all secret Regarding the reluctance of the Sacra societies and especially freemasonry Congregazione to start court proceedings, (Broadley, 1880). he hastened to assure them that they had The dispute between the doctors and been very badly informed about the lav the Archbishop caused no furore in the judicature of the Island. "In Malta', he press in spite of its unusual nature but it says, "the tribunals ... are independent of was summarily referred to in a jocular vein the executive administration in fact they by the Fa,antropo maltese. In its issue of deal with law suits even against the govern­ the 31st January 1860 this paper repre­ ment itself . . . and the judges are so up­ sented Saints Cosmas and Damian nursing right that they deliver judgments even a grudge against the Maltese first because against the gover:;:nlent when the latter is their altar had been interdicted and at fault. Besides, the judges are all secondly because none of the medical men Catholics ... and before reaching a deci­ - Drs. Gaetano La Ferla, Felice Grech, sion they would ask for the opinion of Francesco Adami, Luigi Calleja and Nicola theologians and of experts on the Catholic Mamo - who had presented themselves as rite. Both my predecessors and myself candidates for the Council of Government have had recourse to these tribunals on had been elected (ll portafoglio, 1860'=t.~ 164 In fact the Council resulted formed of six and gave their approval for two shields lawyers and two business men (Filantropo with the symbols of Aesculapius to be fixed maltese, 1860). But the dawning of the year to the pilasters on each side -of the altar "in 1860 was of great concern not only to Saints conformity with the design" forwarded to Cosmas and Damian but also to Bishop them. These gilded emblems of Aesculapius Pace Forno. Grave events, triggered by the have survived and to this day they grace the Risorgimento in neighbouring Italy were altar of Saints Cormas and Damian in the seriously upsetting his peace of mind: no Church of the Minor Conventuals. less, in fact, than the "impiety" of those The serpent coiled round the abacus is who were struggling to destroy the tem­ picked out in bold and gilded relief on a poral power of the Holy See to further their shield which is framed by branches of ideal of a united Italy. Faced with this laurel (Laurus nobilis) which, like the rod "sorrowful and tragic" crisis the Arch­ and serpent has asklepian associations bishop directed all his energies to exhort­ for the god of healing is sometimes figured ing his Maltese flock to pray for, and to crowned with laurel while in the past an show their solidarity with. the Pope ethereal oil was obtained from the leaves (L'indipendente, 1860). He showed his pre­ and fruits of this shrub and used as a oooupati:on in a pastoral letter issued at medicament. the beginning of Februa,ry 1860 (Il porta­ From 1860 onwards the emblems of foglio, 1860b). Compared with this threat Aesculapius no longer called forth the to the Head of the Catholio Churoh, the dis­ wrath of the Maltese ecclesiastical authori­ pute about the "soulptured emblems of ties; so much so that henceforth the rod and Aesou~apius, which sinoe years had serpent were incorporated in the ornamen­ adorned" the altar of Saints Cosmas and tation of memorial inscriptions on the Damian was a trivial matter indeed. In faot marble tombstones of physicians and sur­ the inte~dktion was withdrawn, the lifting geons buried in our churches. Random of the !ban being amrounoed in a looal paper examples are those of Dr. Antonio Mifsud on :the 9,th February 1860 (Il messaggie'r'e, (1883) and Dr. Daniel F. Chetcuti (1895) at 1860). the Rotunda Church at Mosta and of Dr. The campaign against the incorpora­ Giuseppe Rocco Peralta (1896) at the Parish tion of "pagan allegorical insignas" in Church of Balzan. sacred art, however, did not slacken. The The subsequent fate of the various editor of the "politico-religious" new~­ personalities involved in the controversy paper L'ordine while referring to certan can be told in a few words. Mgr. Fr. Gaetano mosaic gravestones in our churches, Pace Forno died at Naples on the 22nd deplored the "horrible profanation" by July 1874 (11 portafoglio maltese, 1874). He SCUlptors, painters and other artists who had lived long enough to witness the had dared to represent sacred objects with dreaded fall of Rome in 1870 when, on the mythological symbols (L'ordine, 1860a). 20th September, the Italian army under The rift between the Archbishop and General Cadorna breached Porta Pia and the confraternity was eventually healed entered the city bringing to an end the apparently after the emblems of the rods temporal power of the Pope. and serpents supporting the altar slab were Of the three medical protagonists - removed; in fact the present altar of the Drs. Parnis, La FerIa and Grillet - the two saints conforms to the conventional first two preceded the Archbishop to the pattern of other altars in our churches. We grave; the third one was laid to rest in have not succeeded in tracking down a pic­ 1890. torial record of the lost altar and we wonder The pia societd of Saints Cosmas and what were its artistic merits. But not every­ Darnian faded into obscurity. It did not thing was lost. In a letter of the 30th Sep­ figure in a list of eighteen confraternities tember 1860, the Sacra Congregazione that contributed with other constituted expressed their satisfaction at the "conclu­ bodies to a fund of fifty-four thousand sion of the conciliation" between the Arch­ francs which was sent to Pope Pius IX by bishop and the Societd medico-chirurgica the Maltese Diocese as a sign of solidarity 165

when his temporal power was threatened by References the armed forces of the Italian Risorgmento in 1860 (L'ordine, 1860b). From now on we BROADLEY, A.M. (1880). The History of Free­ lose trace. of the confraternity which has masonry in the District of Malta, London, disappeared without as yet giving us a hint pp. 1, 15, 24 & 34. as to how and when its extinction came CAGLIOLA, Ph. (1644). Almae siciliensis pro­ about. In fact nothing has been found in the vinciae Ordinis Minorum ConventuaUum S. way of its records. Francisci, Venice, p. 121. CASSAR, P. (1965a). Medical History of Malta, Comment London, p. 485. CASSAR, P. (1965b). ibidem, p. 486. This excursion into a byway of Maltese CASSAR, P. (1972). The Cult and Iconography of medical history shows how the religious SS. Cosmas and Damian in the Maltese Islands, factor has moulded the pattern of the Melita Historica, 1972, 6, 3l. social, political, artistic and intellectual life FUantropo maUese (1860), 31st January, p. l. of Malta in the past. Any deviation from FIORINI, B., (1973). personal communication. the orthodox religious framework - even GEDDES, A., (1945). Creation and the Blessing as late as the mid-nineteenth century­ or the Curse Upon Fruitfulness, Man, 1945, called forth the intransigent opposition of Nov.-Dec., p. 123. the Maltese ecclesiastical hierarchy who Guida di MaUa (Muscat) (1855), p. 23. suspected implications of the most danger­ n messaggiere popolare (1860), 9th February, p. 3. ous kind even in the universal and harm­ n portafogUo maUese (1849), 29th March, p. 4918. less emblem of a professional association. Ibidem (1860a), 1st February, p. 3 & 4th February, Indeed they saw the disrupting enemy in p.3. all shapes and on every front not only in Ibidem (1860b), 15th February, p. 3. the artistic manifestations of classical Ibidem (1874) 28th July, p. 2. culture and in the flow of foreign influences LAFERLA, A.V., (1938). British Malta, Vol. I, among the laity, but even within their own Malta, pp. 229, 271 & 244. ranks. LAFERLA, G., (1855). Sun'uso deUa gomma The episode, however, has its redeem­ resina d'asafoetida adoperata per prevenire ing aspects; for by their stand our past col­ la morte del feto neUe gravidanze morbose leagues brought into sharp relief their cor­ agravate da inerzia deU'utero, Malta. porate sense of honour and set us an Uarte. (1864)" 22nd August, p. 4. example of courageous resistance against Ibidem (1865), 7th September, p. 6. what they felt to be the unreasonable Libr. Ad. 53, n.p. Royal Malta Library. demands of others. Although their efforts Uindipendente (1860), 11th February, p. 3 & 18th were not completely successful we cannot February, p. 4. but look with pride on the resolute manner La rivista medica, (1890), 31st July, p. 8. with which they met the challenge and on Uordine (1856), 3rd October, p. 4797. their dignified endeavours to save from Ibidem (1857), 2nd October, p. 5006. oblivion a unique landmark of our Ibidem (1859), 2nd September, p. 164; 9th Sep- medical heritage. tember, p. 167 & 16th September, p. 172. Ibidem (1860a), 29th June, p. 4. Acknowledgements Ibidem (1860b), 18th May, p. 3. Ibidem (1864), 12th August, p. 4. I am deeply grateful to His Grace the Ms. 491, n.p. Royal Malta Library. Archbishop for allowing me access to the Ms. 1404, n.p. Royal Malta Library. Archiepiscopal Archives and to Rev. Fr. B. Pace Forno, G., (1860). Correspondence. Archie­ Fiorini O.F.M. Conv., for indicating and piscopal Curia, Valletta. helping me to use sources in the archives Pronostku malti (1960), Malta, p. 6l. of the Minor Conventuals at Valletta and Ricorsi e lettere del Dr. G. La Ferla e di Sir E. also to Rev. Fr. A. Bonnici of the same Stuart Baynes, (1854), Malta. Order for other assistance. SAMMUT, A., (1860). Un fatto notabUe, Malta. 166

SCHOUTEN, J., (1967a). The Rod and Serpent of Ibidem (1845b), pp. 85, 101, 190, 202, 242 & 257. Asklepios, Amsterdam, p. 87, 88 & 227. Suppliche (1741,61), Vo1. 7 Part 2, fo1. 786, Archie­ Ibidem (1967b), pp. 194, 201 & 224. piscopal Curia, Valletta. Ibidem (1967c), p. 98. The MaLta Government Gazette (1856), 29th Ibidem (1967d), p. 204. August, p. 271. Statuto della societa medica d'incoraggiamento The Malta Observer (1865), 11th September, p. 2. (1843), Malta, frontispiece. The Messenger 9f St. Anthony (1969), September Storia della societa medica d'incoraggiamento Number, p. 15. (1845a), pp. xxiii, xxiv, xxvi, xxvii, xxxiii, & xxxviii.

A NOTE ON THE ECONOMICS OF MEDICAL PRACTICE IN EIGHTEENTH CENTURY MALTA

PAUL CASSAR S.B.SU., M.D., B.Sc., D.P.M., F.R.Hist.S

Hon. Fellow of the Roya:! University of Ma!.ta

The medical man is traditionally three hitherto unpublished manuscript regarded as being dedicated to the relief of volumes bearing the title Minutario dell' human suffering and motivated by a senti­ audienza (Arch. 675, 676 & 677). mental compassion for the needy sick. The applicants are of all kinds - gold­ Because of this dignified calling he is held smiths, tailors, coalsellers, manufacturers in high esteem by the community which he of gloves and stockings, notaries and even serves. This image of the doctor's apostol­ the compgnia dei comici (theatrical com­ ate, however, tends to blur the fact that pany) which sought payment for the hiring there is also an economics of medicine of boxes at the Manoel Theatre. Among since a practitioner adopts the medical pro­ this motley band of creditors figure our fession as a career and, therefore, expects ancestral colleagues - the physicians and to make a rewarding livelihood from :it. surgeons - and their auxiliaries i.e. the This paper deals with this facet of the prac­ aromatario (pharmacist), the maestro di tice of medicine in Malta in so far as the fisica (physic master), the pnattico (assistant financial aspects of the care and treatment surgeon), the barberotto (barber-surgeon) of opulent and highly placed members of and the cQJvasangue (phlebotomist or the Order of St. John during part of the bleeder). eighteenth century were concerned. Except in occasional instances, tile' When a knight died his creditors requests for payment are written in a uni­ applied to obtain their due from his spaglia form stereotyped manner Here are two Le. the effects existing at the time of his typical speciments (translated from the demise. Their names for the second half of original Italian): "Dr. Carlo Perdon the eighteenth century are recorded in demands to be paid from the spoglio of the 167 late Commandeur Menos for services forming bleedings and cuppings; gIvmg rendered during fourteen months' treat­ steam-baths; "twenty-three introductions ment of his chronic illness" (26th March of the catheter" (langaria) and operative 1759) and "The pharmacist Agostino treatment the nature of which is not stated Schembri requests to be paid from the Arch. 675, Arch. 676c, Arch. 677b). above named spogUo the sum of two scudi The pharmacist at times carried out being the price of the medicaments sup­ surgical treatment. Although as a rule the plied to him during his last illness" (15th two "arts" of the surgeon and of the phar­ Jnauary 1759) (Arch. 675). (A scudo was th8 macist were mutually exclusive, pharma­ equivalent of about 8 cents, the tari about cists who lived in the countryside, where 6 mils and a grana about 0.4 mils). the services of a surgeon were not easily Very often more than one practitioner available, were allowed to carry out "base attended the same patient. Usually the surgery", i.e. cupping, extraction of teeth medical team consisted of a physIcian, a and bloodletting, by permisSion of the surgeon, a barber-surgeon and a pharmacist Grand Master (Arch. 1195). Thus in 1758 but sometimes it was more numerous; thus the pharmacist Alessandro Farregiani the Venerable Bali B. Martino Plata was claimed remuneration for "bleedings in looked after by the protomedico (physician­ various ways, clysters almost daily; fomen­ in-chief) Lorenzo Thei, Dr. Michel' Angelo tations, vesicants, mortifications and every­ Grima, surgeon Saverio Micallef, assistant thing else that was needed". surgeon Gius6ppe MaIlia, barber-surgeon Physicians and surgeons were entitled Giuseppe Grech and pharmacist Gaetano to be paid extra for the distance travelled MaIlia- while Grand Master Emmanuel to see the patient. In fact we come across Marie de Rohan was attended by the such specifications as "from the city to same protomedico, Dr. Giuseppe Maria Floriana" or "two consultations one of Grech, physician and surgeon Aurelio which in Birkirkara" or "twice daily out­ Badat, surgeon Angelo Ventura and the side the city" or "three months from morn­ two pharmacists Gio Maria Grech and ing to night at Attard" (1758). Antonio Gatt (Arch. 677a). Some medical practitioners like Dr. The fees of the physician, surgeon and Gaetano Azzopardi, made use of their own physic-master were assessed according to carriage (the caZesse) to visit patients and (a) the duration of professional attendance then claimed an extra sum to cover the in dftys, months and even years; ih one travelling expenses. In other instances instance the period covered was as long as transport was provided and paid for by the tw'enty-two years, the patient having suf­ patient himself. In fact it is on record that fered from "an inveterate and incurable in 1767 a certain Angela Gatt submitted disease of the urinary bladder" (1759) a bill of 6 scuidi and 10 tari for the hire of (Arch. 675); or (b) the number of consulta­ caZessi for the conveyance ot the doctors t~ons and day and night visits the latter dis­ and the surgeons who attended on Com­ tinction being necessary because night visits mandeur de Cloyach during his "long ill­ were assessed at a higher rate; thus we come ness" (Arch. 676d). across references to "three visits a day"; Occasionally the physican hints that eight entire nights "without undreSSing"; he was forced to visit a sick knight and to '·twenty-e1ght visits and four days of con­ stay with him even though he had to tinuous attendance"; six hundred and abandon all his other patients. Thus Dr. E. ninety-three visits, fifty-seven of which at Maggi stated that he was "obliged by night; nine hundred and three visits over a superior orders to leave his own patients" period of two years; and even a figure of to visit the Ven. Bali of Chambray in Gozo, two thousand one hundred and ninety while Dr. Giovanni Bruno wrote that he had visits spread over three years (Arch. 676a); to attend to. the Ven. Bali de Bocage "at and (c) some special type of procedure such eight o'clock at night with serious incon­ as "the administration for two months of venience and was detained by him for more mercurial treatment" (Arch. 676b); the than an hour in accordance with the com­ application of leeches and vesicants; per- mand of the said Bali". 168

In some instances the practitioner di Malta, the body of laws preva]ing in even stayed the night with the patient Malta at the time (Dritto municipale di sleeping at his house to be at h:s beck and Malta, 1843). The same legal code laid down call. Thus the pharmacist Giacomo Gatt that the assessment of the doctor's fees and presented a bill of scudi 124 in June 1756 the price of medicaments supplied by phar­ for the drugs supplied to the Ven. Bali de macists pertained to the protomedico and Chambray and also for "the assiduous that payment was to be mad2 at the end of assistance given him for a term of twenty­ treatment (Arch. 652) four days visiting him seven or eight times Although the eighteenth century a day besides sleeping on the premises for practitioner treated poor patients gratis eight days". Surgeon Domenico Pace had he did not hesitate to charge a fee to highly slept for twelve nights in the mansiOIl of placed personages even when these hap­ Com. Fra Baldassare Torres. Surgeon pened to be a grand master or a bishop. Claudio Camilleri, in December 1758, while In 1769 Dr. Gaetano Azzopardi requested treating Bishop Fra Paolo Alpheran stayed payment for treating Mgr. Bishop Barto­ at the Bishop's Palace at Mdina "during the lomeo Rull during "the course of four course of the illness, both by day and by years and three months". Dr. Gaetano night, without leaving the Palace during all Azzopardi and the barber-surgeon Fran­ this time" while Dr. Salvatore Bernard, cesco Mamo did the same while the phar­ who was treating the same personage, had macist Gi9como Gatt submitted his bill of to live at the Palace for seven whole days 234 scudi for medicaments supplied by him to minister to his needs by day and by night (Arch. 676e). .... having abandoned his private patients When Grand Master Emmanuel Pinto to whom he found it imposs!ble to attend" died in 1773 his medical attendants Drs. The quantum of the fees due to Gio. Domenko Biagio, Gaetano Azzopardi, physicians and surgeons is not recorded in Gaetano Azzopardino and Michel' Angeln their requests for the settlement of their Grima asked for their honorar:fa (Arch. accounts. We know, however, that the legal 676f). In 1776 it was the turn of the phys~­ code of Grand Master Antonio Manoel de cians Giorgio Imbert, Gaetano Azzopardi, Vilhena of 1724 fixed a rate of one tari for Gio. Domenico Biagio, Antonio Cren, Sur­ a day visit and four tari for a night call, geon Antonio Cabany and phlebotom·st the fees to be collected at the end of treat­ Giorgio Tonna to claim remuneration for ment (Cassar, 1965a). There was only one treating Grand Master Francesco Ximenes instance where a surgeon stated his fee - during his last illness (Arch. 676g). "an hono/iQirium of one hundred scudi and Apart from visits, doctors sometimes another hundred sCUidi by way of gratifi­ performed other services which entitled cation" (Arch. 677c). them to some reward. Dr. Giuseppe The pharmacist, on the other hand, Demarco, in 1767, asked for the sum of 231 always declared the sum due to him for scudi 3 tari and 9gmni to meet the expenses drugs supplied to the patient, occasionally incurred by him for the publication of "a also specifying them such as "three gallons medical work" dedicated to the Ven. Bali of orange flowers water" (1761). To ensure J oseph de Duenas the cost of which this that his fees should be forthcoming, the knight had promised to defray (Arch. 676h). pharmacist sometimes made it a point to The book referrred to is entitled De Lana obtain a written declaration from the published in Malta in 1759. patient testifying to the medicaments Requests for payments for writing caS2 bought and also took care to retain the histories also figure in the Minutario. On prescriptions which had to bear the name the 2nd April 1770 Dr. Biagio Consoli asked of the patient, the date and the signature to be paid for "an extensive report in writ­ of the prescribing physician to constitute ing to be sent abroad" describing the ill­ a valid proof, in a court of law, that the ness of his patient (Arch. 676i). Dr. Lorenzo med!caments were actually sold to the Thei made a similar submission on the 12th patient. This was in accordance with the July of the same year for "three reports in provision contained in the Dritto municipale writing sent to Naples" (Arch. 676j). 169

In 1758 Dr. P.P. Azzopardi claimed re­ reward. (Arch. 676p). muneration "for assistance rendered in the In 1798 surgeon Stanislao Sammut embalming of the cadaver" of Mgr. Bishop applied :to the Commissari degli sp.ogli to Fra Paolo Alpheran (Arch. 675). In 1769 remove to their office all the furniture and the physician and surgeon Michel' Angelo other effects of the late Commandeur Gri.ma asked for "the usual honorarium Romagnoli to ensure the payment of the and all the customary allowances that are fees due to him. (Arch. 677e), given to rohe maestro d'ana,tomia for the Apart from the difficulty in recovering embalming of the corpse" of Mgr. Bishop their fees, medical practitioners complained D. Bartolomeo Rull (Arch. 676k). about the inadequacy of the standard fees In October 1776 the surgeon Antonio which did not correspond to the value of Cabany applied for "the usual honoraria the services rendered; so much so that on for himself and for five of his colleagues for the 2nd April 1770 they submitted a plea the embalming of the corpse of Grand "for an increase in their remuneration for Master Francesco Ximenes as had been done the treatment given to the Yen. Grand on the occasions of the deaths" of Grand Crosses, Knights and other members of the Masters Antonio Zondadari, An. Manoel Sacred Religion, in accordance with the de Vilhena and Raimondo Despuig. Apart nature of their services and in proportion from his fees, Cab any also received "a to the high cost of living of the time". Their quantity of clothes" so much so that when demand was only partially acceded to, the Dr. Michel'Angelo Grima came to know of Camera dei conti agreeing "to provide ~n this he asked "to be granted all the cloth­ extraordinary cases and (in the case of ing which he had soiled during the embalm­ visits) to (members living) in the country­ ing of Bishop ;Rull" or its value in money side" (Arch. 676q). (Arch. 6761). In 1797 surgeon Aurelio Badatt claimed payment for embalming the Comment last grand master to die in Malta - The three manuscripts surveyed above Emmanuel Made de Rohan (Arch. 677d). throw light on the relations of practitioners 'l'here is evidence that the prac­ with their wealthy and aristocratic patients. titioner's demands for his fees were not They also give an insight into the social always settled promptly and to his satis­ scene ofjeigh~genth century Malta as it faction. Thus in 1775 the surgeon Domenico affected the financial s~de of medical prac­ Pace was only paid 5 sCUJdi for "fifty-two tice and provide us with the names of the days of attendance" (Arch. 676m). In the "successful" medical men and pharmacists following year Dr. Gaetano Azzopardi of the time who had reached the front line demanded the sum of 75 scudi which had of their profession from 1750 to 1798 - not yet been pa:idi for services rendered the last year of the Order'S domination over over a period of six months. He was also Malta (Appendix). asking for "some special remuneration for These past colleagues, while offering visiting the patient - Yen. Bali de Tencin their services free to the sick poor, lived - at Casal Lia over a period of thirty-six in a "strictly business" age when it was days" (Arch. 676n). In 1767 Dr. Giuseppe accepted that a medical practitioner was D~marco repeatedly complained that for 631 fully entitled to make a living from his calls, two consultations, three night visits profession so much so that. as we have and a night spent at the patient's residence already seen, not even bishops and grand (Commandeur de Cloyach) he only received masters were exempt from the onus of one instalment of 25 scudi "for so much paying for treatment received. The settling labour" (Arch. 6760). In the same year Dr. of accounts, however, at the patient's Gius,eppe Bigeni appJied to the Camera dei demise \had. ,serious drawbacl~3 especially conti for some kind of 'compensation from if the patient suffered from an illness of the spoglioof the Bali Fra Lucio Cresci­ long duration which meant that the medi­ lllanni. He had not only treated this knight cal man had to wait many months and during the previous five years but also all perhaps even years before he received his his domestic staff without ever getting any feeR. 170

We come across only one incidental APPENDIX reference to the performance of an opera­ tion but we are left in the dark as to its Chronological list of Physicians, Surgeons, nature and outcome. Although some forms Pharmacists and Medical Auxiliaries who of minor surglcal procedures are specified attended sick knights between (such as bleedmgs, cuppmg, etc.), no men­ 1750 and 1798. tion is made of the therap8utIc measures used by physicians. Physicians We do not know how opulent these 1 Giuseppe Parnis 1746-1753 "fashionable" medical men became for the 2 Vittorio Grech 1750-1751 manuscripts exammed are silent on this 3 Enrico Maggi 1750-1759 point but other dpcuments leave no doubt 4 Pietro Paolo Azzopardi 1750-1756 that some of these practitioners did not 5 Carlo Perdon 1750-1778 derive sufficient material rewards from 6 Giorgio Imbert 1751-1778 th(:~ir profession to ensure their economic 7 Giovanni Bruno 1751-1761 survival after their retirement from prac­ 8 Gio. Domenico Biaggio 1752-1779 tice. It is on record that at least two of 9 Giuseppe Vella 1752 them were so penurlOus in their last years 10 Antonio Cren (Creni) 1755-1780 of life that they were in debt. Thus in 1791 11 Salvatore Bernard 1759-1766 Dr. G. Locano and surgeon Michele Grillet 12 Gio Batta Borgia 1758 declared that they did not have the means 13 Gaetano Azzopardi 1758-1780 to pay their rent which they owed to the 14 Gio. Basilio Zammit 1760 government treasury (Cassar, 1965b). 15 Giorgio Locano 1761 The passage of two centuries has 16 Filippo Zammit 1761 brought some notable changes in the struc­ 17 Lorenzo Thei 1762-1798 ture of the medical hierarchy. The physi­ 18 Giacomo Bruno 1763 cian, the surgeon and the pharmacist 19 Filiberto Gatt 1764 remain but ,the barberotto, prattico, maes­ 20 Giuseppe Bigeni 1764-1769 tro di fisica and cavasangue ha;ve disap­ 21 Michel' Angelo Grima 1765-1794 peared from the professional stage. There 22 Giuseppe Demarco 1767-1778 are two aspects, however, which retain a 23 Salvatore Vella 1768 modern ring:- (a) most of the physicians 24 Gaetano Azzopardino 1770-1775 and surgeons who attended members of high 25 Marc' Antonio Mallia 1771 rank in the Order had gained prestige on 26 Pietro Famuncelli 1774 account of their appointment to the staff of 27 Vincenzo La Rosa 1775-1777 the Holy Infirmary; in our own days, too, 28 Andrea Seychel 1775-1780 ambitious medical men who aspire to 29 Giuseppe Aquilina 1775 achieve pre-eminence as leaders.. of the pro­ 30 Leopoldo Bernard 1777 fession and to boost their private practice 31 Giuseppe Maria Grech 1780-1797 realize the importance of occupying a post 32 Giovanni Agius 1794-1796 on the staff of the main hospital of the 33 Ludovico Abela 1794 Island; and (b) the grievance that our medi­ 34 Gaetano Pisani 1794 cal charges do not always represent c.. 35 Francesco Borg 1794 reasonable remuneration for services 36 Francesco Dimech 1795 rendered and that fees tend to lag behind 37 Giuseppe Ciaja 1795 an ever increasing cost of living is but a 38 Gaetano Saydon 1795 perennial echo from the past. 39 Francesco Gravagna 1797

Surgeo~s 1 Giuseppe Calleja 1750 2 Domenico Pace 1751-1780 3 Gio. Batta Lhoste 1751 4 Onorato Auduard 1752·1767 171

5 Vincenzo Checcoli 1753 17 Giuseppe Felici 1761 6 Fabrizio Gauci 1753 18 Vincenzo Farrugia 1761 7 Antonio Brincat 1755 19 Fra Luciano Lupp5na 1762 8 Giuseppe Reboul 1756 20 Emanuele Fenech 1763 9 AloislO Rapinett 1756-1767 21 Gio. Francesco Magri 1765-1780 10 Claudio Camilleri 1758 22 Gioacchino Delicata 1765-1779 11 Sigismondo Cousin 1759 23 Michel' Angelo Agius 1765-1778 12 Antonio FarrUgla 1759 24 Giovanni Pace 1766 13 Felice Camilleri 1759-1767 25 Paolo Zammit (also a 14 Giorgio Tonna 1759-1793 barber- surgeon) 1771-1777 15 Michele Grillet 1759-1779 26 Antonio Zammit 1772 16 Paolo Celestri 1760 27 Antonio Gatt 1772-1797 17 Francesco Mamo 1761-1794 28 Pietro Balzan 1774 18 Francesco Grech 1762-1775 29 Fortunato Vella 1775-1780 19 Michel' Angelo Magri 1763-1776 30 Aloisio Gatt 1777-1780 20 Giuseppe Farrugia 1764-1771 31 Gaetano Salvaloco 1777 21 Gaetano Zarb 1765 32 Vincenzo Camilleri 1793 22 Giuseppe Micallef 1765-1775 33 Gio. Maria Grech 1794-1797 23 Andrea Cousin (Cousi) 1767-1775 34 Ignazio Apap 1794 24 Fedele Sammut 1767 25 Alessandro Faregiani 1768 Barber Surgeons 26 Giorgio Teuma 1769 27 Lorenzo La Speranza 1769 1 Antonio Farrugia 1765 28 Antonio Cab any (Cabani) 1770-1779 2 Carlo Zammit 1765 29 Giovanni Andreotti 1794 3 Fedele Sammut 1767-1775 30 Felice Debono 1794 4 Francesco Mamo (referred 31 Antonio Abela 1794 to also as surgeon) 1768-1773 32 Salvatore Micallef 1794 5 Paolo Zammit (he was also 33 Angelo Ventura 1794 a pharmacist) 1771 34 Giuseppe Speranza 1796 6 Domenico Pace (referred to 35 Giovanni Briffa 1797 as surgeon) 1772-1774 36 Aurelio Badatt 1797 7 Gaetano Sammut 1772 37 Stefano Borg 1798 8 Antonio Delicata (referred to 38 Stanislao Sammut 1798 also as Physic Master) 1774-1779 9 Giorgio Tonna (referred to Pharmacists also as surgeon) 1774 10 Michele Pimpinella 1778 1 Agostino Graner 1745-1750 11 Giuseppe Grech 1794 2 Giacomo Gatt 1745-1769 3 Filiberto Gatt 1750 Assistant Surgeons (already dead) 4 Andrea Farrugi~ 1750 1 Giuseppe Falzon 1766 5 Antonio Zahra 1750-1760 2 Giuseppe Mallia 1794 6 Agostino Schembri 1751-1759 Physic Masters 7 Salvatore Cutajar 1751-1765 1 Michele Farrugia 1751-1762 8 Franc:Rco Mallia 1751-1754 2 Antonio Delicata (referred to 9 Giuseppe N avarro 1752 also as barber surgeon 1795-1795 10 Guglielmo Buhagiar 1753 11 Giuseppe Alfano 1758 References 12 Gaetano Mallia 1758-1797 13 ? Piott 1758 Arch. 652, fo1. 203, Royal Malta Library (RML). 14 Alessandro Farregiani (sic) 1758 Arch. 675, no pagination, RML. 15 Giacomo Zerafa 1759 Arch. 676a, fols. 131 & 154, RML. 16 Vincenzo Belan 1759-1779 676b, fo1. 213. 172

676c, fo1s. 77, 154 & 225. 676p, fo1. 35. 676d, fo1s. 34 & 213. 676q, fo1s. 118 & 129. 676e, fo1s. 96, 119 & 130. Arch. 677a, fo1s. 27 & 122, RML. 676f, fo1s. 186 & 260. 677b, fo1. 12. 676g, fo1s. 268 & 274. 677c, fo1. 45. 676h, fo1. 47. 677d, fo1. 124. 676i, fo1. 118. 677e, fo1. 153. 676j, fo1. 13!. Arch. 1195, fo1. 69, RML. 676k, fo1. 108. CASSAR, P. (1965a), Medical History of Ma~ta, 6761, fo1s. 280 & 325. London, p. 494. 676m, fo1. 9. CASSAR, P. (1965b), loco cit., p. 490. 676n, fo1. 22. Dritto municipale di Malta, Malta, 1843, p. 258. 6760, fo1s. 34 & 59.

HOSPITAL SERVICES IN GOZO AT THE TIME OF THE KNIGHTS JOSEPH BORG K.M., Ph.C., L.P., F.R.S.H,. F.Inst. Pet.

Senior Customs Analyst

In the main town of Gozo, then now in the Medical Superintendent's Office. known as Rabat, Grand Master De Vilhena, Vilhena also made the necessary endow­ who had built so much for the Order and ment to provide funds for the celebration for Malta, saw to the erection of the ho>:­ of Holy Masses on Sundays and on Days of pital at St. Francis's Square, providing it Obligation, on the feast days of St. with its two main large entrances leading Anthony, St. John the Baptist, St. Co srn as to tbe male and female sections. Thp. and st. Damian, St. Theresa of Avila and architect was Michael Cachia (1760-1859) on all the feast days of Our Lady. This the son of the more renowned Dominic great benefactor also procured for h:s (1710-1790) from Zejtun; Michael, inciden­ hosp~tal the services of two medical men tally, had been the leader of the Zejtun (one of whom as Senior), two Surgeons inhabitants dur~ng the insurrection against (one of whom provided with free living the French in 1798. The Grand Master quarters attached to the hosp'tal), a clerk, dedicated the men's section to the Blessed an accountant (in whose office was later Virgin Mary with St. John the Baptist and placed a large canvas showing St. Thomas St. Anthony of Padua and tbe women's from Villanova, distributing alms to the section to the two Brother Doctor Martyrs, poor), a cook (for whom the Chancellor of Saints Cosmas and Damian and he pre­ the Order Fra Louis Belardes prov:ded a s:mted two paintings for the wards (the first more spacious kitchen complete with the one commonly referred to as "St. necessary utensils), two servants and a Anthony"), which complete with his coat­ gate-keeper. of-arms, are a perenn:al reminder of the The first Senior Physician was Dr. princely interest. These paintings are Leonard Dalli, from Gozo, who was fol- 173 lowed in 1739 by Dr. Fra Angelo Bonnici, ag" of 77, together with his servant also from Gozo, a worthy pupil of the Thcresa de Azzopard aged 40 years, on the famous Dr. Fra JOSE-ph Zammit, from c.~th August 1723 at his abode in the Citadel Balzan, who in 1676 at the request of the (wh~:r~ the Gozo National Museum is now Spanish Grand Master Fra N:cholas housed, formerly called "Casa Bondi" from Cotoner (1663-J680) had founded the its l2St owners). School of Medicine and Sureery. Grand Master De Vilhena donated The Gozitan Dr. Bonnici, was a great about 1,000 "scudi" to have the works friend of the Rsverend Thomas Saliba, who ccmpleted. The hospital b8gan to be used had built the rural, beneficial "Church of for m:m patients in June 1728, but soon the Valley" on the approach, from Rabat b~came fully operative for both sexes as on the Zebbug road, to the village of from st. John's Day 1729. It was soon Ghasri. had dedicated it to the "Patronage endowed with the property of the Gozitan of Our Lady" and in 1739 obtained from Jurat Joseph Cassar confiscated by order the Va1:can the authority for removing it of the Criminal Court of 16th August 1729 from the parochial jurisdiction of zebbug and thus disposed of at the wish of Grand and annexing it to St. John Lateran's Major Master De Vilhena as per Act of Notary Basilica in Rome, obtaining thereby for it Bartholomew Paschali of 28th October the honorific title of Minor Basilica, just as 1729, bringing the income of the hospital their friend Dri. Baltlhasar Debono, M.D. to 1,060 scudi per year. (1666 - 28.12.1746) of zebbug-Malta had Before this hospital there had been obtained for his church of the "Addolorata" consecutively in Gozo two very small hos­ somewhat previously in 1720. pitals or more properly asylums, both Dr. Fra Bonnici was followed as Senior originally dedicated to St. Julian, as the Physician in Gozo by Dr. George Locano, oldest hospital known in the world, that at M.D., on 8th February 1754 on the recom­ Rome erected in 755 by the noble Cesarini mendation of the "Protomedicus" Dr. family, with its adjacent church had been Gabriel Henin, ("an expert in Medicine. dedicated. St. Julian, a saint who was a Surgery and Histology, from 1723 teacher diplomat and a med!cal-man himself, was of Anatomy, Physiology and Pathology" credited with having provided an asylum who diad shortly afterwards aged 56 years for poor pilgrims and sick people. on 15th October 1754), and confirmed by The first one of these asylums, at first his successor Dr. Peter-Paul Azzopardi. Dr. catering for only two sick women and for Locano was followed by Dr. Gregory some tired-out poor female pilgrims but Bajada, on 20th February 1796 (cf. R.M.L. later for a few more female patients, had Arch. 1198, pages 85/96), a pupil of the been instituted on 22nd February 1454, as famnus Dr. Michael-Angelo Grima, (1731- per Act of Notary Andrew de Ben,iamin, 1798). by the Gozitan philanthropist Francis The bulk of the funds for the building Bonnici in the two store-rooms adiacent to of this hospitaL originally intended for use St. Barbara's chapel under the "Matrice" of men patients, had been given a few in the Citadel, where, incidentally, the years previously, (with the approval of the famous, church- and. tower-architect Victor Order's Venerable Council given on 21st Cassar (1550-1607), Donat of the Order and June 1719 and registered in the Order's son of the equally famous, Jerome (1520- Chancellery on 12th December 1729 as 1586), from Gudja, was buried, as a well as in the Acts of Notary Blaise Zammit memorial tablet therein records and there­ of 22nd December 1718. 16th June 1719 fore not. as r.ommonly believed and and 13th July 1721) by the Very Reverend repeated, at St. Barbara'schurch in Kings­ Canon John-Mary CamillerL born at Gozo way-Valletta. In the Gozo chapel burial for in 1646. Parlsh Priest of Vittoriosa from the general public was stopped in 1899 and 1676. the first Parish Pripst of Gharb-Gozo for Canons and Priests as from 25th June (15.9.1679 - August 1712) and subse­ 1934. Franc;(3 Bonnici on his doath-bed quentlv Canon of the "Matr'ce". Canon disposed that this hospital should be man­ Camilleri was wickedly assassinated at the aged by his sons John and Andrew and that, 174 if these died without issue, then it should definitely closed down in 1838 when its few become the property of the clergy of this patients were transferred to the larger Mother Church and be provided for by near one. Each section of the latter was them from a vineyard and some building purposely provisionally provided with a land which he bequeathed for the purpose. main ward altar, though the administration It was visited by the Apostolic Visitor of the sacraments to the patients was still Monsignor Peter Dusina in 1575. In time, carried out from the Parish Church of st. however, its income proved to be too little George. Soon, however, in the following for its proper running. Indeed its medical­ year 1839 the present common chapel was man, who gave his services there free of bu:lt and dedicated to "Our Lady and St. charge, Dr. Joseph Siricha, M.D., from John". An altar painting, showing "Our Gozo had to pass his last days as a pauper Lady and Holy Child and St. John the Bap­ at the "Sacra Infermeria" where he made t:st" was presented by the then Archbishop­ his last will on 18th January 1666 (cf. Bishop of our Islands Monsignor Francis­ R.M.L. Arch. 1758, page 87v) at the time of Xavier Caruana, from zebbug-Malta (1831- th!" "Protomedicus" Dr. Archangelo Grech, 1847), who direCted that the Holy Eucha­ M.D. This asylum was later named after St. rist for the use of the patients and th? John the Evangelist by the Gozitan clergy. staff should be kept therein. It was some­ Fortunately, towards the end of that cen­ what enlarged in 1893 when it was tury it obtained help from another legacy. rc-dedicated to the "Sacred Heart of Jesus" The second small hospital, or rather by the then Bishop of Gozo Monsignor Fr. a successor to the one mentioned, under John-Mary Camilleri. The old altar canvas better auspices, naturally also for women, is now at the Medical Superintendent's with 12 beds and on occasions even with office; and was consecrated by the late more, was established in 1732 at the place Bishop of Gozo Monsignor Joseph.Pace, on of the present local Seminary (in amicable 23rd November, 1954. In this hospital there rivalry with the other new larger hospit!ll), are also to be found the following can­ by the French Archbishop-Bishop Fra Paul vasses: "Our Lady and the Holy Child" (now Alpheran de Bussan (1728-1757)~ using for in the old Females' section). "Our Lady its set-up the proceeds of the original one of Sorrows" (now in the chapel) and "St. of St. Julian in the Citadel. De Bussan Theresa of the Child Jesus" (which had named it after this saint, but then changed been in the hospital named after her at the name to St. Co srn as and St. Damian. His "tal-Ibrag" and is now in the Medical Super­ uncle Fra Melchior Alpheran de Bussan, intendent'fl office). Grand Prior of St. John's Conventual This Gozo hosp:tal is now mostly Church (1713-1734), who had just given referred to as "Victoria Hospital", while 5.000 "skuti" to the "Casa dellOl Caritll" at its Geriatric or so-called Incurable section Malta, donated, as per Acts of Notaries s:tuated at the lower-level apartments, J oseph Callej a of 25th November 1732 and opened in 1851 and now provided with 172 Charles Cauchi of 30th September 1734, beds, is usually 'called teSt. John the Baptist the sum of 1,600 "skuti" so that from their Hospital" in memory of the Order. The annual interest Holy Masses should be per­ Gozo hospital was never meant to cater for petually said for the sick inmates there on all the sick in Gozo and we know from all Sundays and other Days of Obligation. testamentary records that many died at the This second small hospital was Holy Infirmary in Malta. 175 A NOTE ON SUICIDE cuss proposals for a nomenclature and definitions of terms used in the field of A good friend of ours, Mr. Joseph chronic lung diseases; (b) to define three Galea, formerly of the Royal Malta categories of terms, i.e. clinical resp:ratory Library and well known as a historian, has, physiology, clinical pathology of the lung, in connection with the paper on suicide in and card:orespiratory syndromes; (c) to Malta in our last issue, let us read a list make proposals for a glossary of terms of suicides in Malta between 1800 and which could serve as a basis for future 1900, which forms part of his impressive activities in this field. collection of Melitensia. This list, with Professor S. Halter, Secretary-General some details about each case, refers to 64 of the Ministry of Public Health, Family cases (54 men and 10 women) and reflects Welfare and the Environment, opened the the circumstances of its times. There were meeting on behalf of the Belgian Govern­ 39 Maltese, 24 Britons and Irish and an ment. The Working Group was attended by Italian. Suicide was by leaping off high nine temporary advisers, three observers places (mainly bastions) in 19, by drowning from the European Society for Clinical in 16, by shooting in 12, by use of razors Respiratory Physiology, one staff member in 10 and by hanging in 5 cases. One person from WHO Headquarters, and one from the stabbed himself and one killed himself with WHO Regional Office for Europe. Professor morphine. The proportionately large num­ H. Denolin, Belgium, was elected Chairman ber of unhappy Britons was mainly made and Professor H. Matthys, Federal Republic up of service men at a time when the gar­ of Germany, Rapporteur. Dr. M. Arhirii, risons in Malta were large and when, un­ WHO Regional Office for Europe, acted as fortunately, drunkenness was common; Secretary. The Working Group was organ­ such persons also had firearms handy. iZ2d to follow up the' meeting of the SEPCR Suicide by jumping off high places (still in Milan, 10-11 November 1973, con­ the commonest way in present times) may vened in order to examine the need for and have something to do with living in a to make preparations for the suggested walled town. Meilak, Cassar and Grech in nomenclature. their paper gave the number of suicIdes between 1955 and 1972 as 171, so had Mr. Topics discussed Galea's list been complete the increase The Working Group stressed the would have been enormous but this is necessity of expressing diagnoses in the almost certainly not the case. It does field of chronic lung diseases in identical appear, however, that matters have not and generally recognized terms and, h~nce, improved over the years and society which the need for a nomenclature and definiEons can claim so many advances. has still a bad of such terms. record in this special problem. The blame As decided at the meeting in Milan, can hardly be laid on medicine (including provisional definitions for the three cate­ psychiatry) but medicine evidently must gories of terms had been prepared by Dr. exert itself further to improve this macabre J.E. Cotes (United Kingdom) for clinical situation. respiratory physiology; by Dr. A. de Coster (Belgium) for clinical pathology, and by THE NOMENCLATURE FOR Professor H. Denolin (Belgium) for cardio­ respiratory syndromes. FOR CHRONIC LUNG OISEASES Thel Working Group reviewed the pro­ posals and prepared revised drafts of the The Regional Office for Europe of the definitions and terms. Three examples are World Health Organization, in collaboration given below to illustrate the phrasing and with the Government of Belgium and the contents of the terms. European Society for Clinical Respiratory Phys:ology (SEPCR), convened a Working Clinical respiratory physiology Group in Brussels from 1st to 3rd July 1974. The Working Group reviewed the The purpose of the meeting was: (a) to dis- proposals and prepared revised drafts of 176 the definitions and terms. Three examples request that any comments they may have are given below to illustrate the phrasing on the terms and definifons be submitted and contents of the terms. before publications in a WHO final report. Translation of the terms into French Clinical Respiratory Physiology: and German will be done by specialists of ALVEOLAR VOLUME: Volume alveo­ French and German mother tongue resp~c­ laire (F). Volume of the lung distal to the tively. anatomical dead space. Comment: The vol­ The meeting represented an impor­ ume is usually measured by the dilution tants step forward in collaboration between in the lung of a single breath of test gas. the SEPCR and the WHO Regional Office Thsi volume may be less than that obtained for Europe. Its posWve outcome encour­ by other methods. ages even closer co-operation on problems which fall within the scope of the two Clinical pathology of the lung: organizations. CHRONIC BRONCHITIS: Bronchite chronique (F). Increased bronchial secre­ MEDICAL NEWS tion resulting in productive cough at some time of the day for at least three months We congratUlate, belatedly but heartily, of two consecutive years. Comment: Cigar­ Dr. Paul L. Bernard on his appointment as ette smoking, more tahn pollution, plays a Chief Government Medical Officer. This very important role in the pathogenesis. climaxes his long career in the Health Sputum may be mucous (as, for example, in Department and has led him to occupy smoker's cough), mucopurulent or purul­ the post which his late father, Professor ent; no breathlessness. Pulmonary function Albert V. Bernard had occupied with such normal or sub-normal. distinction. We do not doubt the family tradition is in safe hands. Our congratula­ Cardiorespiratory syndromes: tions also to Dr. Paul Vassallo-Agius on his ACUTE COR PULMONALE: Coeur appointment to the post of paed;atrician at pulmonaire aigu (F). Acute right ventri­ St. Luke's. He is now also the Civilian 'Con­ cular strain caused by a sudden marked sultant in paediatrics to the Royal Navy in increase in the work demanded of the right Malta. ventricle, left heart insufficiency being Our congratulations to Dr. Frank excluded. Comment: Although the tmos Portelli for obtaining the Fellowship of the common cause of acute cor pulmonale is Royal College of Surgeons of Edinburgh; pulmonary embolism, the two terms are not we also congratulate most heartily Dr. interchangeable. Emanuel Vella, the son of Colonel E.E. In reviewing the terms, due regard Vella, on qualifying M.B., B.Ch. at the was paid to the work already done in this University of Birmingham last June. field by the Council for International Or­ Dr. Robert Karachi is now work;ng in ganizations of Medical Sciences -(CIOMS). the Pathology Department of the Western Further, a glossary of terms with clas­ Infirmary in Glasgow; Dr. Charles Gauci is sifications of chronic lung d:seases was in Wales doing Anaesthesia;. Dr. Albert discussed by the Working Group, which Cilia Vincenti, after working at the Mars­ decided to refer final details to the next den, the Roya,! Free and St. George's Hos­ meeting when comments on the draft defi­ pitals in London, was recently appointed to nitions have been received. a lectureship in Histopathology at the Charing Cross Hospital Medical School. Conclusions and recommendations At a meeting of the Medical Research The draft definitions as revised by the Society, held at King's Hospital Medical Working Group will be distributed to the School, in London, on the 17th. May Dr. R. Member States of the WHO European Ellul-Micallef read a paper by himself and Region and the national branches of the Professor F. Fenech on- "Clinical Pharma­ SEPCR, as well as other international cological studies on corticosteroid adminis­ associations and organizations, with the tration to chronic asthmatic patients." 177 Under the auspices of the Malta Branch In October the Welsh Surgical Travel­ of the B.M.A. the St. Luke's Day lecture ling Club came to Malta and had various was this year given at the Medical School meetings, at some of which our surgical by Dr. Emanuel Agius. colleagues played hosts. Various interesting The International Academy of Legal papers were read, by the visitors and by and Social Medicine met in Malta for its the members of our hospital surgery International meeting between the 4th and department .. the 7th. December. We are glad to print, in this issue, a Under the auspices of "The Associa­ historical sketch by Mr. Michael Galea. tion of Surgeons and Physicians of Malta" Admittedly the medical flavour is not very a seminar was held, on the 3rd. December strong, but even doctors are entitled to on "The Management of Renal Failure", enjoy what is a pleasant historical divertis­ Professor S. Giovanetti, visiting from sement, depicting a time when Malta, under Italy, being the leading speaker. On the British rule, was a happy country free from panel were Dr. J. Rizzo Naudi, Mr. R. fear. Mr. Galea has pubEshed two books of Parnis and Dr. P. Vassallo-Agius. Prof. historical sketches and one on the smaller F. Fenech was chairman. On the 4th. Pro­ churches in Valletta. fessor Giovannetti lectured for the universi­ tyon ·'Uraemia". The lecture was ,excellent BOOK REVIEW but the occasion reminded us once more of the necessity for better projection of Adalberto Pazzini. Dell'arte sanitaria, slides; as it is the resulting picture is two volumes, Edizioni Minerva Medica, minute and even those in the front seats Turin, 1973, pp 1767. find it difficult to read figures which are The author of this work has achievei generally not enlarged enough. A public a very high standard in the presentation of address system is also essential. a subject that has made very rapid advances during this century; indeed he has A Malta Association of Physiotherapists succeeded in keeping pace not only with was formed and formally launched at a the accumulated results of the research general meeting on the 26th, June, under work done up to date in the field of medi­ the patronage of Mr. V. Amato and at the cal history but also with its critical evalua­ initiativE' of Mrs. D.A. Camilleri M.C.S.P. tion. A working committee was formed consisting Professor A. Pazzini, who until very of Dr. L. Vassallo as president, Mrs. C. recent times was Professor of Medical His­ Marryat M.C.S.P. as Chairman and Mrs. tory at the University of Rome and Camilleri as Honorary Secretary and Director of the Scuola di perfezionamento Treasurer. in StJoria d'ella Medicina of Rome enjoys a The Oration on Foundation Day was world wide reputation as an authoritative this year given, at the Church of the Uni­ medical historian and an experienced versity by Professor Frederick Fenech. He researcher. spoke on "Medicine and Society in Malta" The Storia dell'arte sanitaria is not a and almost everybody was in agreement mere account of the developments in the with almost all he said, including his pro­ art and science of healing but is also a his­ posal that lectures on the history of tory of the ideas behind medical events medicine should form part of the curricu­ from the time when medicine formed part lum. We were somewhat alarmed at his of priestcraft in primitive communities to mentioning som0 special reference should the position it commands to-day when the be made to the history of medicine in Malta. most advanced technical equipment is This, we were assured, would not be over­ b8ing placed at the service of humanity to done since Malta's contribution in this field cure its ills and alleviate its sufferings. All has been relatively m;nute. Professor these wide ranging contributions to the Fenech is too intelligent a person to be advance of medicine through a wide diver­ caught up in the prevalent nationalistic sity of cultures and national settings are frenzy. fully covered in the two volumes of Paz- 178 zini's work. Vol. I deals with the prehistoric Medicine and Social Medicine, Malta.) period, the old civilizations of Greece, ELLUL-MICALLEF, R (with BORTH­ Rome, the Near East, India and China, the WICK, RC. and McHARDY, G.J.R) 1974. Middle Ages and the Renaissance; Vol. II The time-Course of Response to Predni­ extends from the seventeenth century to solone in Chronic Bronchial Asthma. Clini­ the present day. As every medical his­ cal Science and Molecular Medicine, 47, torian knows it is a matter of the greatest 105-117. difficulty for a writer, in dealing with such VELLA, E.E. 1974. Rabies. J. Roy. a mass of material, to decide upon what Army med. Cps., 120, 80 - 98. ought to be recorded and what should be ZAMMIT-MAEMPEL, J.V. 1974. Cor­ left out without loss to the general con­ ticosteroids in Ventricular Tachycardia. ception of the work. Pazzini has struck a Israel J. of Medical Sciences, 10, No. 9, balance with signal success for, while lay­ 1126 - 1132. ing before us a broad panorama of the sub­ ject, he has not omitted the important details; in fact this excellent work con­ OBITUARY NOTES trives to be both a source book and an exhaustive narrative of medical events so that it is an essential item for the medical Prof. J.E. Debono historian and for the cultured practising doctor alike. Professor Joseph Edward Debono was The subject matter is described in a born in Valletta on thelst May 1903. -He clear and concise style. The volumes are belonged to a family with a heavy artistically presented and fully illustrated. "medical" loading. His father was Prof. Indices of names and of subjects are pro­ Francesco Debono, holder of the Chairs of vided. The addition of a list of references Natural History and of Forensic Medicine. or a bibliography would greatly enhance His brothers were Prof. P.P. Debono, a the value of a future edition of this work professor of Surgery and Dr. Salvino which promises to become a classic and Debono, a specialist in otorhinolaryngology. which stands as an eloquent testimony to Three of Prof. J.E. Debono's sons the scholarly and objective mind of its Edward, David, and Anthony - are author. medical men. Paul Cassar. After studying at the Lyceum lie entered the University in 1918. He was first in his course obtaining the B.Sc. in PUBLICATIONS LIST 1921 and the M.D. in 1925. On qualifying he used the Government Scholarship to The following are recent publications pursue post-graduate studies at st. Bartho­ by members of our medical faculty: lomew's Hospital in London. He was one BUGEJA, T.J. (with Aquilina, J.N.) of the first Maltese doctors to obtain the 1974. Primary malignant lymphoma of the L.RC.P., and M.R.C.S. (1926). At that time bladder; case report and review of litera­ tuberculosis was still very widespread and ture. J. Urol., 112, 64-65. he went to Davos in Switzerland to study BUSUTTIL, A., PACE, J.B., and jts treatment by artificial preumothorax MUSCAT, J. 1974. Traditional treatment of which he introduced in Malta on his return. 194 cases of Tetanus. Brit. J. Surg., 61, Another disease that absorbed much of No. 9, 731 - 734. his time and energy was Undulant Fever CASSAR, P. (1974). A medico-legal which was common among the civilian report of the sixteenth century from Malta. population of the Maltese Islands. He Medical History, 18, 354-359. worked with Sir Themistocles Zammit in CASSAR, P. (1974). Landmarks in the an endeavour to prepare a vaccine against development of Forensic Medicine in the the disease in goats and to rear brucella­ Maltese Islands. (Presented at the meeting free herds. By 1930 Zammit and Debono of the International Academy of Legal had not succeeded in achieving "complete 179 and effective immunity" but they consid­ In 1946 Prof. Debono was rais~d to the ered that they were justified in continuing Chair of Medicine from which he retired their experiments as vaccination did in on the 1st May 1963 on reaching the age fact confer a certain measure of protection of sixty. As a teacher he stressed the need in goats (The Lancet, 1930, p. 1343). These of investigating not only the clinical and attempts were given up in the late thirties pathological aspects of disease but also the when government introduced the pas­ psychological, social and environmental teurisation of goats' milk in 1937. factors on the grounds that "every patient Prof. Debono, however, continued to must be considered individually, as a per­ study the disease in humans and after the son." He warned of the danger that in Second World War he was the first in becoming more scientifically trained, doc­ Europe to treat Undulant Fever success­ tors run the risk of becoming "more fully with the new antibiotic aureomycin interested in the disease than in the a sample of which had been sent to him patient" (The Chest-piece, 1948, 1, 13) from America (1949). The high infantile mortality that pre­ His wide knowledge and experience Of vailed in the Maltese Islands up to 1943 this disease are apparent in his contributwn (fluctuating between 190 and 310 deaths to LF. Huddelson's book on Brucellosis in per 1000 live-births) became the target of Men and Animals (1939). His description of his therapeutic attacks. By prescribing a this illness became a standard text on the treatment consisting of the administration disease in the English language. of a sulphonamide (Dagenan) and a glucose­ He gained the M.R.C.P. in 1935 and in salt-and-water mixture for enteritis, he con­ the following year became Professor of tributed to the lowering of the fatality rate Pharmacology and Materia Medica. His to a considerable extent; so much so that appointment coincided with the dawn of a by 1952 it had dropped to quQlsi-European new era with the development of chemo­ standards. therapy ranging from the sulphonamides He was the first Maltese doctor to be to the antibiotics. elected a Fellow of the Royal College of During the Second World War he wal:> Physicians' (1948). "For medical services in in charge of the Medical Wards of the Malta" he was made Commander of the emergency hospitals set up in various parts Order of the British Empire (C.B.E.) in of Malta - Sacred Heart Convent at St. January 1956. Julian's; the Blue Sisters Hospital, where In 1953 he represented the University he was also Blood Transfusion Officer; at the First International Congress of Bugeja Institute at Hamrun and st. Aloy­ Medical Education in London where he sius College at Birkirkara. The greatest read a paper on "The Place of the Text challenge that he had to face at this period Book in the Teaching of Medicine". He also was the poliomyelItis epidemic of 1942 at attended the Fourth International Congress a time when neither prophylactic immunis­ of Mediterranean Medicine and Hygiene at ation nor effective therapy were yet avail­ Barcelona where he contributed a paper able. The first cases in children were on "The Present State of Undulant Fever admitted to St. Luke's Hospital which then in Malta". functioned as an Isolation Hospital and In the early years of his career ne where I had the privilege of being his showed a particular interest in the manage­ assistant. He insisted on the performance ment of diabetes about which he published of lumbar puncture in acute cases. The a booklet in 1927 to help diabetics to un­ mode of transmission of the virus and its derstand the nature of their illness and portal of entry into the body were then a thus cooperate in its treatment with their matter of doubt and speculation and I still physicians. He returned to a deep study of vividly recall the days of anxiety we went this disorder in the later years of his life; through after I accidentally pricked one of so much so that after his retirement he my fingers with a lumbar puncture needle was chosen in 1963 to run the first out­ on withdrawing it from the spine of a rest­ patient clinic for the treatment of diabetes less and wriggling child. at St. Luke's Hospital, a post which he 180 occupied until 1972. He died on the 18tt 11. Full Freedom of Scholarly Enquiry August 1974. He is survived by his wife and Expression and the Rlght of Man­ Mrs. Josephine Burns Debono and four kind to Knowledge and Free Use sons. Thereof, Scientia, 1957, 23, 55. 12. Treatment of Undulant Fever with Publications: Novobiocin, Lancet, 15th March 1958, p.585. 1. What Every Diabetic Should Know, 13. Brucellosis Simulating Acute Anterior Malta, 1927. Poliomyeltis, Lancet, 23rd May 1964, 2. Immunisation of the Maltese Goat by p. 1132. means of Cutaneous Vaccination, Paul Cassar. Lancet, 21st June 1930, p. 1343. 3. Treatment of Brucella melitens;s In­ fection with Prontosil. British Medical Prof. Salvatore Vella Journal, 1939, 1, 326. 4. Acute Anterior Poliomyeltis (with Professor Salvatore Vella died on the Debor~), P.P. Coleiro, C., & Agius, E.), 19th. September last, his passing being Malta, 1943. regretted by all who knew him. Professor 5. The Treatment of Diarrhoea in In­ Vella dedicated most of his working life to fancy, Malta, 1944. Ear, Nose and Throat surgery, having been 6. Part Ill, Section IV in Huddleson, I.F. Lecturer on that subject to the University Brucellosis in Man and Animals, New and Senior E.N.T. Surgeon at St. Luke's and York, 1939. Director of the CI~nic there between 1950 7. Kala Azar in Infants, Proceedings oj and 1963. Professor Vella qualified B.sc. the Royal Society of Medicine, 1947, in 1924 and M.D. in 1928 in Malta and 40, 155. D.L.O. in London. He was a Demonstrator 8. The Psychosomatic Approach in Medi­ in Anatomy between 1930 and 1934 and was cine, The CheSlt-piece, 1948, 1, 13. Professor of Biology from, 1934 to 1950. 9. Aureomycin in Undulant Fever, Professor Vella is survived by his wife LQJncet, 29th August 1949, p. 326. Gemma nee Cauchi, his daughter EIsa, a 10. The Treatment of Diarrhoea in In­ doctor, marr~ed to Dr. Luis Vassallo and his fancy, The Chest-piece, 1952, 1, 3. son Patr2ck Vella LL.D.

NOTICE This periodical is published b!annuaHy in June and in Decem­ ber. Contributions for the June number are to reach the Editor by the 1st May. 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 valuable support. IN'DEX TO VOLUME IX About Ourselves (Editorial)... 103 Aesculapius, the serpent of, the confraternity of SS. Cosmas and Damian and the Bishop of Malta. (Cassar, P.) 156 Agius, E. An hour for my thoughts. 138 Agius-Ferrante T.J. Obituary notice. 100 Air embolism, Traumatic (Azzopardi, N.) 119 Anatomical Errors in the Lapidary of st. John's (Cassar, P.) ... 13 An Hour for my Thoughts. (Agius, E.) 138 Attard, R. Medico-Iegal aspects of Surgical Practice. 43 Azzopardi, N. Traumatic Air Embolism. 119 Blood, Occult, Urinary in Exudative Tonsillitis (Zammit, L.) 75 Boffa, G.M. A method for reducing theatre contamination by exhaled anaesthetic drugs. 67 Borg, J. Hospital Services in Gozo at the time of the Knights. 172 Cancer,Early diagnosis of. (Sultana, H.M. 64 Cancer, Multiple of the. Colon. (Sammut Tagliaferro, J. and Parnis, R.O.) 85 Cancer, Oral in Malta. (Sultana, H.M. and Portelli, J.M.) 60 Cassar, P. Anatomical Errors in the Lapidary of St. John's. 13 Cassar, P. Dell' Arte Sanitaria. Book review 177 Cassar, P. Economics of Medical Practice in Eighteenth Century Malta. 166 Cassar, P. TheSerpent of Aesculapius, the Confraternity of SS. Cosmas and Damian and the Bishop of Malta ... 156 Cassar, P. (with Meilak, J.A. and Grech, J.L.) Suicide in Malta. 53 Cassar, P. The works of Michel' Angelo Grima. 3 Coleiro, J.A. Light Coagulation in Diabetic Retinopathy 72 Coleiro, J.A. Ocular Onchocerciasis. 127 Crime an War, Florence N!ghtingale and Malta. (Galea, M.) 148 Damato, F.J. A case ofOculo-Auriculo-Ver~ebral Dysplasia. 70 Damato, F.J. Haemangioma of the Orb_tral Bones. ... 122 Darnato, P.J. (with Pace-Balzan, J.) Parapharyngeal Chordoma. 116 Debono, J oseph E. Obituary Notice. Diverticulum, Solitary Caecal, A case Report. (Podesta. M.T. and Pace, J.L.) ... 81 Dermatology and Surgery (Parnis, R.O.) 114 Diverticula of the Large Intestine, Anatomical Distribution. (Pace, J.L. and Podesta, M.T.) 138 Economics of Medical Practice in Eighteenth Century Malta. (Cassar, P.) 116 Ellis, H. Surgery and Advanced Abdominal Malignancy. 105 Ellis, H. Royal Operations. 144 Ellul-Micallef, R. (with Galdes, A. and Fen~ch, F.F.). Determination of serum zinc levels in normal Maltese adults. 128 Fenech, F.F. (with Ellul-Micallef, R. and Galdes, A.) Determination of serum zinc levels in normal Maltese adults. 128 Felice, A.E. (with Grech, J.L.) Assessment of a laboratory method for the evaluation of hyperilipo-proteinaemia. 92 Galdes, A; (with Ellul-Micallef, R. and Fenech, F.F.) Determination of serum zinc lenls in normal Maltese adults. 128 Galea, M. Malta, Florence Nightingale and the Crime an War. ... 155 Gozo, Hospital Services in at the time of the Knights. (Borg, J.) ... 172 Grech, J.L. (and Felice, A.E.) Assessment of a laboatory method for the evaluation of hyperlipoproteinaemia. 92 Grech, J.L. Medical Testimony and the Medical Witness. 39 Grech, J.L. (with Meilak, J.A. and Cassar,P.) Suicide in Malta. 53 182

Grech Hardie, Charles. Obituary Notice. ... 102 Grima 'Michel'Angelo, Works of. (Cassar, P.) 3 Haemangioma of the Orbital Bones. (Damato, F.J.) 122 History and Medicine (Editorial) . . . 1 Hyperlipoproteinaemia, assessment of a laboratory method for the evaluation of. (Grech, J.L. and Felice, A.E.) ... 92 Insanity as a defence in Criminal Law (pullicino, J.) 47 International Academy of Legal Medicine and Social Medicine 96 International Gathering (Editorial 102 Intersex -:- case report (Psaila, A.J.) 87 Malta, Florence Nightingale and the Crimean War. (Galea, M.) 152 Medical News. 99, Meilak, J.A. (with Cassar, P. and Grech, J.L.) Suicide in Malta. 53 Nightingale Florence, Malta and the Crimean War. (Galea, M.) 155 Oculo-Auriculo-Vertebral Dysplasia, A case of. (Damato F.J.) ... 70 Onchocerciasis, Ocular. (Coleiro, (J.A.) 127 Pace, J.L. (with Podesta, M.T.) Solitary Caecal Diverticulum, A case Report. 81 Pace-Balzan, J. (with Damato, P.J.) Para pharyngeal Chordoma...... 116 Parapharyngeal Chordoma. (Damato, P.J. and Pace-Balzan, J.) 116 Parnis, R.O. Dermatology and Surgery 114 Parnis, R.O. (with Sammut Tagliaferro, J.) Multiple Cancer of the Colon. 85 Podesta, M.T. (with Pace, J.L.) Anatomical Distribution of Diverticula of the Large Intestine. 133 Podesta, M.T. (with Pace, J.L.). Solitary Caecal Diverticulum, A case Report. 81 Portelli, J .M. (with Sultana, H.M.) Oral Cancer in Malta 60 Psaila, A.J. Intersex - case report. 87 Publication List 100, 178 Pullicino, J. Insanity as a defence in Criminal Law. 47 Retinopathy, Diabetic,. Light .Coagulation in. (Coleiro, J.A.) 72 Royal Operations, (Ellis, H.) ... 144 Samut Tagliaferro, J. (with Parnis, R.O.). Multiple Cancer of the Colon. 85 Scicluna, Nicholas, Obituary Notice. 102 Serum Zinc Levels. Determination of, in normal Maltese adults. (Ellul-Micallef, R., Galdes, A. and Fenech, F.F.) ... 128 Suicide in Malta .. (Meilak, J.A., Cassar, P. and Grech, J.L.) 53 Suicide, a Note on. (Editorial( 1 Sultana, H.M. Early Diagnosis of Cancer. 64 Sultana, H.M. (with Portelli, J.M.) Oral Cancer in Malta 60 Surgery and Advanced Abdominal Malignancy. (E llis , H.). 105 Surgical Practice, Medico-Iegal Aspects of. (Attard. R) . . . 43 Testimony, Medical and the Medical Witness (Grech, J.L.) 39 Theatre Contamination by Exhaled AnaestheEc Drugs. A method for Reducing. (Boffa, G.M.) ... 67 Vella, E.E. Weil-Felix Test for the Rickettsioses. 20 Weever Fish Stings, More About. (Zammit, L.) 108 Weil Felix Test for the Rickettsioses. (Vella, E.E.) 20 Zammit, L. More about Weever Fish and their Toxic Stings. 108 Zammit, L. Occult Urinary Blood in Exudative Tonsillitis. 75