Disease has been an inseparable companion of life. A distinction has to be drawn between internal disease -often interpreted by primitive man as the result of a malevolent influence - and external disease or traumatic injuries which are commonly regarded as being surgical in nature. The art of surgery originated under the compelling influence of some immediate crisis and the first procedures were no doubt aimed at treating traumatological conditions. The archaeological skeleton remains of Neolithic man in Malta showed well healed fractures of the clavicle, tibia and metatarsals [1]. These however cannot be taken as proof of any surgical intervention since a relatively large proportion of fractures heal spontaneously with good functional results.

A developed form of surgery may have been practised around the second century AD in Malta. This is suggested by a tomb slab found in a catacomb at Rabat which shows fourteen diagrams depicting various Roman surgical instruments. The slab depicts diagrams of surgical shears, hinged surgical tongs or forceps, bleeding cups and bowl, a chisel, a vaginal speculum, a probe case, whetstones, and medicament boxes [2]. The early centuries AD were the golden age of Greco-Roman medicine when the advances in anatomical and physiological knowledge had been assimilated and had led to improved techniques for the performance of a number of operations. These techniques are best documented by the Roman author Aulus Cornelius Celsus (c 25 BC - 50 AD). In his eight books entitled De Medicina the descriptive and operative surgery can be considered to be the best contribution of Celsus to medicine. He describes a large number of surgical ailments such as the disease of bones and joints, wounds, tumours, burns, fistula, abscesses, and hernia. He also describes a number of surgical procedures including bleeding, ligation of vessels, lithotomy, castration, catheterization, enemata, and plastic surgery among others [3].

Subsequent items of surgical interest in Malta appear during the late medieval period. Medieval documents suggest that in the late fifteenth century Malta the medical profession distinguished between medical and surgical practice. Thus it appears that a number of Christian and Jewish medicus chyrurgici were practising in Malta together with a number of medicus physici. The Christian surgeon Magister Micael Ferriolu was receiving from the Universita` a regular salary in 1497, as he had been doing for the previous ten years. The Jew Xema Girbi in 1486 practised as a barber, an occupation which involved more real surgery than mere shaving or hair cutting. Other contemporary surgical practitioners included the Christian Gaspar de Monbron who practised in the 1470-80, and the barbitonsor or surgeon Magister Andreas de Avula who practised in 1497 [4]. At the turn of the sixteenth century, Santo Spirito Hospital at Rabat, Malta employed in addition to the physician, a surgeon by the name of Mastru Rayneli de Bonellis who is encountered for the first time in 1517 and was still at Santo Spirito thirty years later. He was also employed by the Universita`. By 1540 work at the hospital had increased to such an extent that one full-time surgeon alone could not cope and the town-council appointed a second Mastro Johanni Ferriolo. The arrival of the Order of St. John of Jerusalem brought an influx of medical practitioners including surgeons to the Islands. These included the Rhodian Leonardo Myriti who was granted citizenship of Mdina in 1534, Mastro Salvo Schembri who died at Mdina in 1560, and Mastro Joanni Bonellis who was found fit to practice in 1554. Two surgeons are known to have practised in Gozo in 1569 - Mastro Ferrando de Mayra and Mastro Nicolao Alizardi [5].

A prescription list for Santo Spirito patients dated 1546 indicates that the conditions treated included cases of wounding, snake-bite, a kidney ailment, a respiratory ailment and venereal disease. One case of wounding was prescribed dragon's blood, frankincense, myrrh, aloes and a mudificativum containing the same substances known from Biblical times for their cicatrizing virtues. The second case was prescribed the plaster cataplasma quinque farinarum suggesting the presence of swelling besides open wounds for which he received unguento fusco and unguento aegypciaco. Both cases received oleum rosarum and mel rosarum to induce sleep and relaxation. These prescriptions suggest that the mainline of medical thought in the early sixteenth century followed the Graeco-Arabian tradition [6].

One remedy used from primitive to contemporary times to treat a wide variety of conditions was blood-letting or venesection. This procedure was generally performed by the barber or barber-surgeon, since the performance of venesection was not becoming of a physician. In the late eighteenth century blood-letting in small but repeated amounts was a routine procedure after traumatic injuries. It was performed with the intention of preventing an unduly violent inflammation of the wound and of promoting the absorption of extravasated blood. The jugular and brachial veins were generally used, followed by lower limb veins. The actual quantity of blood removed depended upon the constitution and temperament of the patient. Sanguine type individuals were bled liberally, while less copious bleeding was applied to the bilious individual. Those with a melancholic disposition were not bled at all. Blood-letting was the standard treatment for fevers. In the early nineteenth century, Dr. William Burnett reported that on occasions of fever, he sometimes removed up to 90 oz of blood from the temporal artery in six hours and even up to 15 lbs of blood over a period of eight days. Another form of bleeding was through the use of leeches. These similarly formed the bed-rock of practice to allay pain in swollen parts, to diminish congestion in inflamed regions and to provoke menstruation by applying them to the lower abdomen. Since haematophagous leeches are not endemic to Malta, these animals (probably Hirudo medicinalis) were imported from Tunis and Bone. Leeches were still being routinely used in 1883 when Prof. S.L. Pisani described their use in his published lecture notes to midwives. Their use continued in popular medicine well into the 1930's and isolated instances have been recorded even in the 1960's. From three to twelve of the animals were applied generally to the abdomen, until they engorged themselves and fell off. To ensure a continuous flow of blood, a cupping glass was applied over the orifices made by the animals. After use they were washed in fresh water and a pinch of salt placed on their mouths. They were then placed in woodash until they digested the blood. Blood-letting was in 1804 reportedly used also in pregnant women to prevent the development of eclampsia, and in 1842-43 leeches were used to manage cases of puerperal sepsis and intra-abdominal bleeding [7].

Other Maltese late medieval-early modern period surgical disease recorded in the archaeological record included healed fractures, metastatic lesion of a malignant tumour, and spina bifida. A case of hypospadias glandis was reported in a medico-legal report dated 1542 when two medical witnesses, including the surgeon Rayneri de Bonellis, were appointed by the court. These medical witnesses referred to the Graeco-Arabian works of Galen (c.131-200 AD.), Rhazes (860-932 AD.), Avicenna (980-1037 AD.), and Avenzoar (1072-1162 AD.). Galen contributed more to physiology and anatomy that he did to surgery. He mentions in an operative view trepanning, wound treatment with warm water and oil, and disease of bones. He detailed the subject of bleeding and bandaging. Rhazes, in contrast, showed considerable knowledge in the operative branches of surgery and ophthalmology, including the treatment of fractures and dislocations by machines; the treatment of abscesses, burns, necrosis, caries, hare-lip, and fistula; ophthalmic surgery for trichiasis, ectropion and entropion and cataract extraction. He also described tracheotomy, tonsillectomy, and venesection. Avicenna's work was the textbook and law of the healing art even as late as the first century of modern times. Avenzoar practised surgery with distinction and performed experimental operations on animals [8].

In the early seventeenth century a number of confraternities bearing the name of a tutelary saint came into fore in Malta. The medical practitioners and surgeons were organised in a confraternity dedicated to the Arabian twin brothers Cosmos and Damian on the 10 October 1635. The confraternity was also known as the Universitas barbitonsorum. The saint brothers practised medicine and performed many marvelous cures before being martyred in 303 AD. because they would not forswear their faith. The confraternity included physicians, surgeons and barbers, since the latter were considered ancillary assistants to doctors and surgeons being entrusted with the application of leeches, blood-letting and tooth extractions. This formal association between physicians and barbers in a common confraternity continued until 3 June 1797 when by their own request the barbers were separated from the physicians and surgeons and formed their own confraternity under the tutelary saint Ludovicus of France. The barbers continued to perform their medical functions well into the nineteenth century. It was only in 1921 that they were removed from the list of medical practitioners [9].

It appears that during the medieval period there were no provisions for the training of medical practitioners in Malta. The local government ensured that competent medical and surgical care was available to the Island's population with doctors being appointed from Sicily. These worked alongside Maltese medical practitioners trained in institutions overseas. The arrival of the Knights of St. John allowed the arrival of foreign practitioners and the further expansion of hospital services which allowed for the introduction of basic surgical training on the Islands. The School of Anatomy and Surgery in Malta was established in 1676 by GrandMaster Fra Nicolas Cottoner with the first teacher being Dr. Fra Giuseppe Zammit. The School acquired great renown in Europe during the eighteenth century. During the eighteenth century, the surgeon's training generally started in a barber's shop where he underwent a period of apprenticeship as a barber-surgeon at the Holy Infirmary, enriching his experience on the battlefield or in the naval service. He subsequently qualified as a junior surgeon when he started treating wounds, extracting bullets and foreign bodies, setting fractures and performing amputations. With experience he would attempt more serious operations such as skull trepanning and lithotomy. Before qualifying as surgeons, students had to pass a practical test in the subject. During the period 1750-1798 there were a total of 11 barber-surgeons recorded as having attended sick knights of the Order, in addition to 38 surgeons and two assistant surgeons. The School of Anatomy and Surgery was the prelude to the Faculty of Medicine at the University of Malta. The three faculties of Theology, Law and Medicine were established in 1771 by GrandMaster Em. Pinto de Fonceca after the expulsion of the Jesuits. The Chair of Anatomy and Surgery were incorporated in the new institution. The Chair of Surgery was separated from Anatomy for the first time in 1858 [10].

An important eighteenth Maltese surgeon was Michel'Angelo Grima. Grima was born in Valletta in 1731 and started his apprenticeship at the Infirmary at the age of twelve years. After nineteen years he joined the medical school of Santa Maria Nuovo Hospital in Florence and subsequently obtained his doctorate in philosophy and medicine from the University of Pisa in 1745. He continued his work in Florence conducting experiments on methods of intestinal sutures. In 1758 he went to Paris to continue his studies and later joined the French forces as surgeon during the Seven Years War. In 1763, Grima was recalled to Malta and was appointed Chief Surgeon at the Holy Infirmary and appointed to the Chair of Anatomy and Surgery in 1765. He died in 1798. During his career, Michel'Angelo Grima wrote a total of fifteen medical contributions, seven of which during his stay in Florence and Paris during 1750-1763. These works record the results of the experimental animal surgery undertaken by Grima in the operations of splenectomy and intestinal anastomosis, physiological experiments on tendons, and cadaveric experiments on lithotomy. He published also surgical works relating to the surgical cases of intra-abdominal abscesses and on the surgical excision of a breast lump, the management of popliteal aneurysms, and a major work on traumatic surgery. He also wrote anatomical works [11].

Grima's work on traumatological surgery gives a detailed representation of the concepts of surgery prevalent during the eighteenth century. Firearm wounds at this time were washed with a solution of water and alcohol after exploring the wound to remove all extraneous material. The wound was then packed with threads, covered with clean linen, and carefully bandaged. Suppuration and pus collection was managed by surgical drainage and irrigations with tepid water or a decoction of quinine. Excessive granulation was cauterized with silver nitrate. Grima advocated suturing of the edges in clean cut wounds, in contradistinction to previous practice where suppuration was promoted. Active haemorrhage was managed by compression and ligature, though the tourniquet was sometimes used in an emergency. The management of head injuries depended on the severity and ranged from conservative to surgical intervention including trephining and elevation of depressed skull fractures. Limb fractures were reduced and splinted, while in the case of a badly comminuted fracture the loose fragments were removed to allow fusion of the larger bones. Amputation or disarticulation was resorted to in badly crushed bones or in the presence of gangrene, caries or osteomyelitis of the long bones, or popliteal artery aneurysms. Perforating chest injuries were actively managed, while drainage operations of empyema or haemothorax were undertaken. Injuries to the abdominal viscera were rarely actively treated, though musket balls impacted in the kidneys or the liver were extracted. Traumatic lesions of the bladder were managed by catheterisation. Surgical procedures described during the late eighteenth century included perineal lithotomy, ano-rectal operations to treat fistula-in-ano and remove foreign bodies, and the removal of new-growths from the male genitalia, female breasts and other external parts of the body. A case of Meckel's diverticulum complicated by a worm infestation managed by suturing of the intestines has been described. This however ended fatally [12].

A common affliction until the early years of the twentieth century was bladder stone. The operation for its removal is one of the oldest in Surgery and was one of the few elective operations performed in pre-anesthetic days. The surgical approach to the bladder was the perineal approach, the operation being termed Perineal Lithotomy. In 1761, Michel'Angelo Grima described in detail the operation performed by him on the cadaver with the double gorgeret, an instrument invented by William Bromfeild senior (1713-1792) for the extraction of vesical stones by the lateral approach. Grima favourably compares this method to other operation procedures he had seen, including those performed by the Maltese lithotomist Michele Grillet who was appointed surgeon to the slave prison in 1755 and retired in 1791. Attempts had been previously made to treat this ailment with drugs which were supposed to dissolve the stone inside the bladder. The 1592 hospital pharmacy included the roots of Nardus indica and seeds of Panicum miliaceum taken to dissolve renal and vesical stones. Decoctions of the horsetail plant, the wall-pellitory and of Spergularia rubis remain popular folk remedies to help expel urinary gravel and stones [13].

Another common affliction which occupied the attention of surgical practitioners was hernae. These were managed by the barber-surgeon or bragherista who manufactured the hernia trusses under the direction of the Principal Surgeon whom he accompanied on the morning and afternoon ward rounds. The bragherista was always on call for any adjustments needed to the trusses of hospital patients. He was in the early years of the nineteenth century paid six tari for every truss after the appliance was examined and approved by the principal Surgeon or his assistant. The common incidence of hernae in the Mediterranean fleet was ascribed by Dr. William Turnbull in 1806 to the excessive consumption of oil and the hot weather prevailing in the region. In the 1840's, herniorrhaphies were being performed at the Civil Hospital and the Gozo Hospital. A century later, Prof. P.P. Debono engaged his attention to the frequent incidence of inguinal hernia on the Island. He ascribed this to the wearing of a sash round the waist by manual workers and to adiposity. He devised a special fascia carrier in 1929 for use in the McArthur hernia repair technique. The instrument was made for him by Down Brothers of London [14].

Ophthalmic problems similarly occupied the attention of medical practitioners. The 1592 pharmacy inventory included the preparation Pilutae sine quious compounded of aloe, rhubarb, agaric, scammony, etc. which was believed to be efficacious in cataract, earache and melanchony. In the eighteenth century purulent conditions of the eyeball were known to occur as complications of fractures of the orbit produced by fire-arms. The primary treatment included the application of leeches to the temple to reduce the inflammation. If the infection persisted, the purulent matter was evacuated by a cruciate incision to the eyeball to prevent the condition of sympathetic panophthalmitis and damage to the opposite eye. The removal of cataracts was the most frequent ophthalmic operation carried out. Lachrymal fistulae were also operated. An important Maltese practitioner who made a made a name for himself in ophthalmology abroad was Prof. Joseph Barth born in Valletta in 1745. He studied at the Holy Infirmary and subsequently made his way to Vienna to practice ophthalmology. Here he successfully treated the son of Empress Maria Theresa and was rewarded with the Professorship of Anatomy, Physiology and Ophthalmology, the Chair being specifically created for him in 1773. He died in Vienna in 1818. It appears that in the early nineteenth century ophthalmic surgery was not very frequently undertaken by local surgeons and Malta became a fertile field for foreign oculists. Dr. Giuseppe Camenzuli is known to have operated for hare-lip, new-growths and cataracts between 1823-1847. In 1840 Dr. Charles Galland operated for squint. Squint surgery featured in the early experimental efforts of Sir T. Spencer Wells on the use of ether anaesthesia. The first Chair of Ophthalmology was set up in Malta in 1880 being occupied by Prof. Lawrence Manche`. [15]

Early nineteenth century surgery was mainly a continuation of the surgery of the previous century. In the absence of anaesthesia and antisepsis, abdominal and pelvic surgery remained outside the realms of the surgeon, while any surgical intervention required great courage and fortitude of patient and surgeon alike. In the pre-anaesthetic days operations were rushed through at lightning speed and under conditions of appalling difficulty. The most hardened surgeons had to steel themselves to perform operations which they knew would cause agony to their patients. Speed in carrying out the operation was an extremely important factor, and a surgeon's ability was measured by the time he took to operate. Michel'Angelo Grima, for instance, was renowned for his rapidity in performing lithotomy and mastectomy which he performed in 21/2 and 3 minutes respectively. Surgeon Gabriele Henin is reported to have removed a sarcoma from the back in only two minutes [16].

Attempts to dull the pain of surgery with potions date to early times. The earliest reference to surgical anaesthesia dates to the first century, where in his herbal Diocorides (40 - 90 AD.) recommended the use of mandrake to induce a deep sleep in patients undergoing surgery. The use of soporific potions continued throughout the ages with the use of opium and later morphine. The use of opium to allay pain and induce sleep was recorded in use during the sixteenth century in Malta in the form on Pille cenaglossa and Filoniu romano. The use of morphine as an analgesic for intrauterine obstetric manipulations was recorded in Malta in 1890. Morphine was also reportedly used in 1843 to manage cases of severe puerperal sepsis, while opium extract was described as useful in 1871 in cases of eclampsia. After its introduction in 1847, chloroform was used to induce anaesthesia in cases of eclamptic convulsions in 1871 and those requiring intra-uterine obstetric manipulations in 1890 [17]. One method of producing analgesia that seems to have been used intermittently from quite early times was compression using a tourniquet. Loss of consciousness prior to surgery was achieved by the hammer-stroke. This consisted of encasing the patient's head in a helmet on which the surgeon delivered a good blow with a wooden hammer. Another method was to compress the carotid arteries to cause syncope [18].

Surgical anaesthesia by means of ether and chloroform did not come into use until 1846 and 1847 respectively. News of the discovery did not take long to reach Malta. On the 22nd December 1846, the local newspaper Malta Times carried a report from its Boston correspondent about the use of ether by William Thomas Green Morton as an anaesthetic in "about two hundred times with almost uniform success". A month later the same newspaper reported news of painfree operations performed at Addenbrook's Hospital in Cambridge and elsewhere [19]. On the 9th March 1847, the Malta Times reported that a few days previously, a successful operation under ether requiring deep incisions had been performed at the Bighi Naval Hospital by Dr. William C. Watt, the anaesthetic being administered by Mr. (later Sir) Thomas Spencer Wells. Two other painfree operations had been performed since. The newspaper reported that experiments with ether and a locally prepared apparatus had been previously undertaken by Mr. Wells and Dr. A.J. Burmester. The initial operation - one of partial amputation of the hand - was only partly successful because of imperfections in the apparatus. Mr. Wells had then arranged to bring a Hooper's inhaler from England. A description of the Hooper's inhaler and directions for its use were published in the Malta Times anonymously (Dr. A.J. Burmester ?), while Mr. Wells demonstrated the inhaler to local practitioners in a meeting of the Societa` Medica d'Incorraggiamento held on the 16th March. The initial experiments with ether were soon taken up by other practitioners, and chloroform was taken up soon after its description in Edinburgh. The first anaesthetic fatality in Malta occurred on the 20th April 1855 in a patient undergoing amputation of the finger [20].

By the middle of the nineteenth century pain had been banished from surgical operations, but one grave danger still faced every patient submitting himself to the surgeon's knife. This was the ever-present risk of sepsis. Michel'Angelo Grima wrote that the most common complications and sequelae of wounds were erysipelas, metastatic abscesses, fistulae and sinuses, gangrene and exhaustion from prolonged suppuration. Tetanus was also an observed complication of surgery [21]. That these disease were due to some form of contagion had long been suspected, but the general view was that whatever was responsible for the contagion or infection was generated spontaneously in wounds. Alternatively it was thought that air itself was the agent responsible for suppuration and many attempts were made to exclude the air from wounds by means of elaborate dressings. A number of medical men had postulated the existence of minute particles which carried contagion. The work of the pioneers in the concept of sepsis had no immediate repercussions on surgical practice. Simple methods of disinfection were sometimes effective but the problem was still obscure and the antiseptic system still lacked a proper scientific basis. This state of affairs continued until the elucidation of the true nature of infection by Louis Pasteur (1822-1895) and the application of Pasteur's discoveries to surgical practice by Joseph Lister published in 1867.

The first surgical condition that was recognized to be caused as a result of infection was puerperal fever. Efforts to reduce the incidence of puerperal sepsis in Malta were made in the 1890s. Dr. G.F. Inglott in 1890 advised the use of antiseptic vaseline when carrying out podalic version and further prescribed antiseptic irrigation of the uterus following these procedure. Prof. G.B. Schembri advised midwives to wash their hands and instruments with the antiseptic solution 5% Boracic acid of Condy's Fluid. These suggestions were included in the official Regulations for midwifery practice. Strict aseptic measure are recorded to have been observed during the first laparotomy performed by Schembri in 1890. Prof. P.P. Debono during the Second World War commented that he was "old fashioned enough to follow Lister's rules and to use boric acid and iodoform dressings and the sulpha drugs when these were available". Sulphanilimide (prontosil) was first tried in Malta in 1935 with encouraging results in infections caused by haemolytic streptococcus. It did not, however come into general use until 1937 when it was tried also in the treatment of gonorrhea and other infections. Sulphapyridine appeared in 1938-39. Penicillin was known to Maltese doctors in 1943 but supplies were still not available for civilian use. Penicillin was first used in surgical practice by Prof. P.P. Debono on the 31 January 1945. Surgical operating theatres were non-existent in the eighteenth century, the operations taking place in an ordinary room with the patient being laid and bound on a wooden table with a leather-covered top. An operating room was definitely in existence in the Civil Hospital in 1822, though in 1840 operations were performed in the Anatomical Amphitheatre. In 1850 the Central Hospital was equipped with an operating room and was furnished with an "operating table and stool, four circular high-backed benches and glass cases for preparations and instruments". Surgical instruments were likewise in short supply during the eighteenth and early nineteenth century. It is recorded that surgical instruments had been acquired in 1716, but these had become non-existent by 1761 when a further set of instruments were bought from Paris. By 1827 the instruments in use at the General Hospital had become unserviceable and a new case of instruments was obtained. This case included instruments for injecting hydrocoele, a case of lithotomy and ophthalmic instruments, two cases of scalpels and an aneurysm needle. The hospital remained with one set of capital instruments until 1834. In the nineteenth century surgical instruments were generally obtained from London, though a few were occasionally manufactured by Maltese silversmiths [22].

The introduction of anaesthesia and antisepsis enabled surgeons to carry out procedures that had formerly been quite beyond them, including long operations within the head, thorax, abdomen and pelvis. The first elective laparotomy was performed by Prof. G.B. Schembri in 1890 at the Civil Hospital in Malta. The first operation involved the excision of a large ovarian tumour weighing 101/2 lbs which histology showed to be a cystic adenoma. The operation was performed under chloroform anaesthesia, while aseptic measures were rigorous. The intra-operative period was complicated by syncope which was managed by subcutaneous injection of ether and ammonia. The postoperative period was complicated by intestinal ileus which resolved with conservative measures. A second laparotomy was subsequently performed with the excision of a large abdominal wall tumour [23]. By the mid-1930s a large number of surgical operations were being performed. The number continued to increase significantly by the mid-1950s (Table 1) [24].
 

The introduction of anaesthesia, antisepsis and blood transfusion made possible the great accomplishments and triumphs of present day surgery. Every surgeon and every patient owes an incalculable debt to those masters of the more distant past who laid the foundations of the art and science of surgery. The leading surgeon of the fourteenth century Guy de Chauliac, in his surgical textbook acknowledged the debt he owed his predecessors saying "We are like children standing on the shoulders of a giant, for we can see all that the giant can see, and a little more". On the local scene, one must pay tribute to the pioneer eighteenth and nineteenth century surgeons and anaesthetists such as Michel'Angelo Grima, Thomas Spencer Wells, Dr. William C. Watt, Dr. A.J. Burmester, and Prof. G. B. Schembri who with their expertise and innovations enabled the early introduction of surgical developments on the Islands.

1. L.J. Pace: The anatomical features of prehistoric man in Malta. Royal University of Malta, Malta, 1972, p.14-15

2. P. Cassar: Surgical Instruments on a tomb slab in Roman Malta. Medical History, 1974, 18:89-93

3. J.H. Bass: Outlines of the History of Medicine and the medical profession. R.E. Krieger Publ., Huntington, 1971, vol.1, p.161-163

4. G. Wettinger: The Jews of Malta in the late Middle Ages. Midsea Book Ltd, Malta, 1985, p.18, 138

5. S. Fiorini: Santo Spirito Hospital at Rabat, Malta: The early years to 1575. Department of Information, Malta, 1989, p.59-64

6. S. Fiorini: A prescription list of 1546. Maltese Medical Journal, 1(1):p.19-31

7. M.A. Grima: Della medicina traumatica altrimenti detta vulneraria. Firenze, 1773, +240p; W. Burnett: A practical account of the Mediterranean Fever as it appeared in the Ships and Hospitals of His Majesty's Fleet in that Station during the years 1808, 1811 and 1813 and of the Gibraltar and Carthagena Fever. Callow, London, 1816; P. Cassar: Teaching of midwifery in Malta at the beginning of the 19th century. St Luke's Hospital Gazette, 1973, 892):p.91-111; Considerazioni teorico-pratiche sulle febbri puerperali. Il Filocano, 15 February 1842, 2(2):p.17-23; S. Arpa: Di un caso particolare di gravidanza extra-uterina. G. Camilleri & Co, Malta, 1843, p.7; S.L. Pisani: Ktieb il Qabla. P. Debono & Co, Malta, 1883, p.86-88; P.J. Schembri: A note on non-marine leeches (Annelida: Hirudinea) from the Maltese Islands. Central Mediterranean Naturalist, 1986, 1(4):p.81-83

8. J.H. Bass: op. cit. note 3 above, p.168-176, 227-232; S. Ramaswamy and J.L. Pace: The Medieval Skeletal remains from St. Gregory Church at Zejtun (Malta): Part 1. Paleopathological Studies. Arch Ital Anat Embriol, 1979, lxxxiv(1):p.43-53; J.L. Pace and S. Ramaswamy: Skeletal Remains: Excavations at Hal Millieri, Malta: a report of the 1977 campaign conducted on behalf of the National Museum of Malta and the University of Malta. eds T.F.C. Blagg, A. Bonanno, and A.T. Luttrell. Malta University Press, Malta, 1990, p.84-95; P. Cassar: A Medico-legal report of the sixteenth century from Malta. Medical History, 1974, 18:p.354-359

9. P. Cagliola: Almae siciliensis provinciae Ordinis Minorum Conventualium S. Francisci. Venice, 1664, p.121; P. Cassar: Medical History of Malta. Wellcome Histr Med Libr, London, 1964, p.485-486; Second Sanitary Law. Malta Government Gazette supplement, 13 May 1921, p.126

10. P. Cassar, 1964: ibid, p.437-448, 484; R. Ellul-Micallef: The Maltese Medical Tradition. Overseas contacts that have influenced its development. Malta: A Case Study in International Cross-Currents. eds. S. Fiorini and V. Mallia-Milanes, Malta University Publications, Malta, 1991, p.187-198; P. Cassar: A note on the economics of medical practice in eighteenth century Malta. St. Luke's Hospital Gazette, 1974, 9(2):166-172.

11. J.V. Psaila: The 18th Century Surgeon. Chestpiece, May 1972, p.29-41; P. Cassar: The works of Michel'Angelo Grima (1731-1798). A bibliography with summaries and notes. St. Luke's Hospital Gazette, 1974, 9(1):p.3-20

12. M.A. Grima: op. cit. note 7 above; P. Cassar, 1964: op. cit. note 9 above, p.132-143; G. Henin: Observatio chirurgo-anathomica. Messina, 1749; G. Azzopardi and G. Bruno: Lettera apologetica contro la dissertazione intitolata nuovo e sicuro di cucire l'intestini. Messina, 1762, p.12-22

13. P. Cassar, 1964: ibid, p.432; P. Cassar, 1974: op. cit. note 11 above; V.G. Griffiths: Cutting for stone. Maltese Medical Journal, 1989, 1(2):p.12-16; M.A. Grima: Reflexions sur la memoire sur la taille lateral de Bromfield. Journal de medicine, chirurgie et pharmacie, 1761, 14:p.161-171; P. Cassar: Inventory of a sixteenth century pharmacy in Malta. St. Luke's Hospital Gazette, 1976, 11(1)p:26-34

14. P. Cassar, 1964: ibid, p.537; P. Cassar: Medicine in Malta in 1800-1810. Contrasts, Concepts and personalities. St Luke's Hospital Gazette, 1971, 6(1):p.4; C. Savona-Ventura: Malta and the British Navy: the medical connection during the nineteenth century. Part III. Medical and other problems. J Royal Naval Medical Service, 1993, 79:100-105; P. Cassar: Professor Peter Paul Debono (19th June 1890 - 3rd June 1958). The Man and his times. St Luke's Hospital Gazette, 1975, 11(2):p.135-137

15. P. Cassar, 1964: ibid, p.139, 442, 458-459, 535-536; P. Cassar, 1976: op. cit. note 13 above, p.32; M.G. Grima: op. cit. note 7 above, p.57; National Malta Library ms.14, fol.206; NML Archives 1191, fols46, 201; Societa` Medica d'Incoraggiamento - Etherization. The Malta Times, 23 Marchh 1847, p.2

16. P. Cassar, 1964: ibid, p.132-143

17. P. Cassar, 1976: op. cit. note 13 above; G.F. Inglott: Distocia. La Rivista Medica, 15 April 1890, Anno I(3):p.6; S. Arpa: Di un caso particolare di gravidanza extra-uterina. G. Camilleri & Co., Malta, 1843, p.16-17; G. Gulia: Ostetricia. Sulle convulsioni puerperali. Il Barth, 16 October 1871, Anno I(3):p.45-48

18. P. Cassar: Psychological and medical aspects of the Siege of 1565. Melita Historica, 1955, 1:p.199

19. The Malta Times, 22 December 1846, p.3; The Malta Times, 26 January 1847; The Malta Times, 9 February 1847

20. Painless surgical operations. The Malta Times, 9 March 1847 p.2; Anon. (Burmester A.J. ?): Insensibility to pain produced by inhaling the vapour of sulphuric ether. The Malta Times, 23 March 1847, p.2-3; The Malta Times, 30 March 1847, p.3; Societa` Medica d'Incoraggiamento -Etherization. The Malta Times, 23 March 1847, p.2; The Malta Times, 4 January 1848, p.2; The Filologo, 4 March 1848; The Malta Mail, 24 April 1855, p.4

21. M.A. Grima: op. cit. note 12 above, p.62

22. C. Savona-Ventura: Reproductive performance on the Maltese Islands during the Second World War. Medical History, 1990, 34:p.173; P. Cassar, 1964: op. cit. note 9 above, p.132-133, 530-531

23. V. Vella: Laparotomia in Malta. Due casi di sezione addominale seguiti da guarigione. Rivista di Osteticia e Ginecologia, 1891, +3p. (reprint)

24. Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1937. Government Printing Office, Malta, 1938, p.cxiv-cxviii; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1952. Government Printing Office, Malta, 1954, p.84: Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1953. Government Printing Office, Malta, 1954, p.85-86

25. P. Cassar, 1975: op. cit. note 14 above, p.138; C. Savona-Ventura: op. cit. note 22 above, p.174