Since gynaecological maladies, of certain types at least, follow childbirth, the history of gynaecology has always been closely associated with that of midwifery, but the specialty only moved ahead in the first half of the nineteenth century. The progress in obstetrics was dependent on the ability of man to analyze, deduce logically and profit by experience, while gynaecology was more dependent on scientific discoveries. Prior to the mid-nineteenth century, the specialty consisted of treating disorders of menstruation, displacements of the uterus, and pelvic aches and pains connected with so-called peri- and para-metritis. The treatment consisted mostly of clysters, blisters, setons, pessaries, and cervical cauterization. The term gynaecology was first used in 1847 [1].

The nineteenth century had an auspicious beginning for the specialty when Ephraim McDowell in 1809 performed successfully the first ovariotomy in Kentucky. It was not too many years after that a number of other cases were reported from around the world. In the United Kingdom, the first successful operation was performed by William Jeaffreson in 1836, but it was Charles Clay of Manchester who is credited more than anyone else for placing this operation on a sure foundation. Thomas Spencer Wells, who spent six years as a Naval Doctor in Malta, did his first ovariotomy in 1857 and by 1880 was performing his thousandth one [2]. In Malta the first ovariotomy was performed by Prof. G.B. Schembri in November 1890 [3]. The success in ovariotomy, combined with the concurrent introduction of asepsis and anaesthesia, sparked off an enthusiasm for further advances in gynaecological surgery.

Neolithic man in Malta, with his Fertility cult, was familiar with the anatomy of the external genitalia as evidence by the prominent depiction of the female external genitalia in a number of figurines and the phallic symbols representing the male organ [4]. The first evidence of gynaecological interest in Malta is the engraving depicting a vaginal speculum from a Roman period catacomb dated to the second century AD. The carving is one of a group depicting a number of surgical instruments. The vaginal speculum depicted shows a lower middle vertical ridge which denotes the screw mechanism which when turned separated the two blades of the priapiscus which thus expanded the vagina. This instrument was made of different sizes according to the age of the patient [5]. The vaginal speculum was definitely known to the Romans. Galen (130-200 AD) was the first to mention the use of the speculum, while Soranus (98-177 AD) wrote an entire chapter on the speculum in his book on gynaecology. In 1818, two specula were found in the excavations of Pompeii dated 79 AD. These were beautifully made bronze dilators, one containing three blades, the other four blades which diverged when a centrally located screw was turned [6].

Early reports of gynaecological bearing in Maltese medical history include cases of infertility and intersex. A case of infertility caused by hypospadias was reported in 1542 in a case of marriage annulment. The case appeared before the Ecclesiastical Court who appointed two doctors as court experts. Drs. J Callus and R de Bonellis examined the male partner of the marriage and confirmed that consummation was impossible owing to his genital malformation described as severe hypospadias [7]. A case of intersex resulting in a legal change of sex was recorded in 1744, when a 17 year old girl was brought before the Grand Court who appointed two medical experts. The girl was found to have a small penis with two folds on each side stimulating labia but containing testis. There was a narrow aperture between the two folds which did not allow the introduction of the small finger - a description suggesting severe hypospadias. The doctors decided that the dominant sex was male but examinee was infertile. The ruling was confirmed by a second set of seven experts [8]. In 1756, another annulment suit appeared before the Ecclesiastical Court where the husband was accused by his wife of being impotent. Four doctors were appointed as court experts. The husband had a rather thin voice for a male, but the brevity and thinness of his genitalia were more than sufficient to enable coitus [9]. Fertility was an important aspect of life in bygone days. An 1592 inventory of the Santo Spirito pharmacy included the vetch plant belonging to the bean family Cecena (cicer). The red variety of this plant was administered in the form of an electuary to stimulate coitus and sperm formation. Other preparations used to promote the onset of menses are listed. These include (1) Pille deserapin (Pililae de sagapeno) made of the gum of Sapapenum officinale, Calamus aromaticus, colocynth and aloes; (2) Antidotu emagogu (Antidoto emmenagogo) made up of fourteen constituents including cassia, black hellebore, liquorice and anise; and (3) Calamo arom. (Calamo aromatico) made up of the roots of sweet flag Acorus calamus or Caklamus aromaticus [10].

Medical practitioners were apparently conversant with the current knowledge relating to gynaecology and reproductive function. Callus and de Bonellis in the mid-sixteenth century appeared to be well acquainted with medieval thought quoting in their report the views of Galen (131-200 AD), Rhazes (860-932 AD), Avenzoar (1072-1162 AD) and Avicenna (980-1037 AD) [11]. In 1740 Giorgio Locano, subsequently appointed Professor of Medicine in Malta in 1771, published his work on the physiology and anatomy of the female reproductive organs entitled Dissertatio physiologica de mechanico feminarum tributo at Montpelier in 1749 [12]. In his lectures to medical students, Dr. F Butigiec included the subject of pelvic anatomy, quoting Gabriello Fallopius (1523-1562) description of the anatomy of the Fallopian tubes, William Harvey (1578-1657) description of the anatomy of the human ovary, and Caspar Bartholin (1655-1738) description of the anatomy and function of the vaginal glands [13]. In 1843 Prof. S Arpa reviewed the clinical features of uterine fibroids and ovarian tumours particularly when these complicated pregnancy [14]. In 1860, the Department of Anatomy acquired paper mache models of different stages of the development of the human ovum, of the generative organs and of the abnormal forms of the pelvis [15]. In their lectures to midwives, Profs. S.L. Pisani in 1883 and G.B. Schembri in 1896-97 both included sections describing the anatomy of the pelvis and pelvic organs, besides an account of the physiology of menstruation [16].

There is scant information about gynaecological practices in Malta prior to the twentieth century. Venereal disease has long been a recognised problem on the Islands. A prescription list for Santo Spirito Hospital dated 1546 records the treatment for venereal disease (morbo gallico), while the accounts records of 1544 it is recorded that treatment for venereal disease was ordered for two females. A similar authorization is recorded in 1547 for four other women. The treatment recorded included various unguenta vulneria like Aegypciaco and Masticino for local lesions. Digestivi 1 2 3 4 5 contra morbo gallico were also given. These were liquid ointments made from turpentine and tincture of aloes administered to free wounds from pus. Excavations at 15th century church of Hal Millieri yielded skull remains buried before 1636 which showed erosions consistent with syphilis. The advent of the Knights of St John and the establishment of the Islands as a maritime base brought prostitution to the Islands. As early as the sixteenth century, the local physicians were familiar with the clinical manifestations of venereal disease, though they could not differentiate between gonorrhoea and syphilis. They knew that the morbus gallicus was contracted through sexual intercourse and that the enlargement of the inguinal glands could be one of its signs. By 1596 the number of affected individuals was so large that the question of providing a place for treatment was brought up. Provision for the treatment of venereal disease in hospital dates from the seventeenth century when a small building adjoining the Woman's Hospital in Valletta, known as the falanga, was set up for female patients. The falanga, expanded to care for male and female patients, was relocated to new premises in 1682. It continued to function until 1798. Another hospital - Loch Hospital - was opened in 1861. Treatment was based on the administration of mercury and hot-air baths. Keiser's pills, the composition of which remained secret, were also administered to patients. In 1762 Dr. Fortunato Antonio Cren wrote a Latin treatise on the disease entitled Tractatus physico-medicus de Americana lue, explaining its origins, describing its manifestations and method of propagation. He condemned the employment of crude mercury in its treatment because of its dangers and recommended the oral use of corrosive sublimate dissolved in spiritus frumenti to neutralize its injurious effects. The risks of acquiring syphilis by midwives during vaginal examinations was commented upon by the medical journal La Salute Publica in 1897. It advised midwives to wash their hands carefully after examinations. In 1922 cases of syphilis were made to undergo a complete course of novarsenobillon besides mercurial and potassium iodide treatment. Gonorrhoea was one of the first infections in Malta to be treated by antimicrobials in the form of Prontosil after the introduction of this drug in 1935 [17].

In 1871, the medical journal Il Barth accused some midwives of posing as doctors prescribing medicine for dysmenorrhoea and other complaints, besides pretending to correct uterine malposition. In the late nineteenth century Prof. G.B. Schembri is known to have prescribed tincture of ergot for bleeding of uterine pathology and potassium iodide for leucorrhea [18]. In his book to midwives he also advises vaginal irrigations with warm water and borax for hives and other infectious vaginal discharge, for an abundant fetid leucorrhea, and for organic disease of the womb such as cancer [19]. Contraception was apparently limited to coitus interruptus and other forms of unnatural sex. In the late eighteenth century an Augustine friar made it a point to ask his women penitents whether their husbands had unnatural intercourse with them [20], while Prof. Schembri considered this practice harmful by causing gradual and increasing congestion of the womb thus causing many ailments to the internal genitalia leading to invalidism [21]. Leaches were apparently applied to the lower abdomen to provoke menstruation, and to relieve pain and congestion. Pelvic inflammatory disease during the late nineteenth century were apparently frequently encountered problems. These were generally managed conservatively with opiates and fomentations, though faradism was introduced in the management of this condition in 1890 [22]. Gynaecological instruments in use at the turn of the nineteenth century, held at the Malta Medical School Old Instruments Collection, included a variety of vaginal speculae, metrotones, uterine sounds, and pessaries (Table 1).

GYNAECOLOGICAL INSTRUMENTS

SPECULAE - Recamier's, Madam Boivin's, Ricord's twoo-bladed, Coxeter's screw-like with obturator, Weiss three-bladed, Plum's three-bladed with obturator, Meadow's four-bladed, Meadow's three bladed, Nott's three-bladed, Cusco's Duckbill, Jobert's boxwood tubular with obturator, Vaginal bath, Marion Sims double-ended duckbill, Ferguson gum-coated glass, Ferguson metal tubular patterns.

METROTOMES - Simpson's, Greenhelgh's bilateral metrottome, Hall's uterine scarifying lancet.

PROBES/SOUNDS - Placyfair's uterine probe, Simpson uteriine sound, Jointed Simpson uterine sound, Marion Sims uterine elevator.

OTHER INSTRUMENTS - Zwancke's pessary for prolapse, uterine sponge holder, uterine caustic holder.

On the 21 November 1890 Prof. Schembri performed the first laparotomy under chloroform anaesthesia. The patient was diagnosed to have a large ovarian tumour with ascites. After rigorous asepsis and induction of anaesthesia, an infra-umbilical mid-line incision was made. A right sided mass weighing 101\2 pounds was excised, the pedicles being ligated with silk sutures. The abdomen was closed with interrupted sutures, the total operation being undertaken in 35 minutes. The postoperative course was turmulous complicated by ileus diagnosed as resulting from intestinal torsion. This was managed conservatively. The woman was discharged four weeks after surgery. The histological diagnosis was that of a cystic adenoma of the ovary [23]/.

The problem of genital prolapse received scant mention, though instructions aimed at preventing perineal lacerations during delivery had been given to medical students and presumably to midwives by Dr. Butigiec as early as 1804. These instruction were repeated by Profs. Pisani and Schembri in their lectures to midwives [24]/. Prof. Schembri in 1896 also outlines the postoperative care of women who required perineal suturing for a tear during delivery. Dry cotton wool or gauze medicated with iodoform was to be constantly applied over the sutured vagina and perineum, changing the dressing every time it gets soiled. The genitals were to be washed with boracic acid solution each time the patient opened her bowels. Repeated catheterization was advocated to avoid soiling with urine, while the lower limbs were to be kept together by a bandage tied round the knees [25]/.

After the introduction of operative gynaecology in Malta at the end of the nineteenth century, further progress was made in the specialty. Forty-five years later the number and variety of gynaecological surgery had increased. Prof. J. Ellul in papers read to the Camera Medica after 1930 presented a case of a Werthiem operation for cervical carcinoma complicated by Clostridium welchi (gas gangrene) infection. In the pre-Second World War period 1937-38 the Gynaecological Ward in the Central Hospital at Floriana consisted of a medium sized ward with 11 beds which frequently required augmentation to 16 or more. The hospital served all the gynaecological cases in Malta and some from Gozo. During these two years there were a total of 1189 admissions of which 525 were operated upon. The mortality was only 12 cases, of which only seven were postoperative [26/]/.

The abdominal operations recorded during these two years included subtotal and total hysterectomies with/out salpingo-oophorectomies, Werthiem's radical hysterectomies, myomectomies, ovariotomies, and shortening of the round ligaments. These were undertaken for a variety of indications generally uterine fibroids, ovarian tumours or other pathology, cervical malignancy, fibrosis uteri, and rarely pelvic inflammatory disease. When both ovaries were removed in young patients auto-innestation of the ovary in the vulva was done and in some cases hormone preparation injections were given in attempts to prevent osteoporosis. Genital prolapse was generally managed with an anterior and posterior colpoperrinorraphy combined with Collin's operation for ventrosuspension. The surgery was performed in two stages, the first whenever possible being performed under local anaesthesia, the latter under general anaesthesia. Le Fort operation was performed in very old women. Uterine malposition were advised ventrosuspension or a Hodge pessary was introduced after digital correction. Vaginal panhysterectomy was performed for a case of uterine malignancy. Other surgery recorded included plastic surgery for genital fistulae, dilatation and curettage for abnormal uterine haemorrhage, cervical trachelorrhaphy, torsion of uterine polyps, and excision of vulval tumours [27].

Malignant tumours were generally seen at a late stage. Management was very often in these cases palliative against sepsis and haemorrhage with strong fulgurization, strong antiseptic solutions and cupric salts injections. Radium treatment and deep roentgen therapy was still unavailable in Malta, this being only introduced in 1970 at Boffa Hospital at Floriana with patients previous to this being referred abroad. Cervical erosion were managed by three to five applications of thermocoagulation. Cases with pelvic inflammatory disease were managed with antiphlogistic treatment followed by Nauheim baths, medical diathermy and strong iodine treatment. Surgery was undertaken to incise and drain abscess, radical surgery being rarely undertaken [28].

The post-war period saw major advances in surgical practice increasing the safety of surgical procedure through the introduction of safer anaesthesia, blood transfusion, effective antimicrobials, and advances in hormone influencing preparations. In recent years advances in investigative techniques using ultrasonography, computerized axial tomography, and endoscopy have allowed accurate definition of pathology enabling better planned procedures. Screening facilities, particularly for cervical dysplasia, have allowed for the detection of pre-cancerous lesions enabling early effective therapy.

1. J.M.N. Kerr, R.W. Johnstone and M.H. Phillips: Historical review of British Obstetrics and Gynaecology 1800-1950. Livingstone, Edinburgh, 1954, p.358

2. J.M.N. Kerr et al: ibid, p.359

3. V. Vella: Laparotomia in Malta. Rivista di Ostetricia e Ginecologia. (reprint), 1891, +3p.

4. T. Zammit and C. Singer: Neolithic representations of the human form from the islands of Malta and Gozo. J Royal Anthropol Instit, 1924, p.92-97

5. P. Cassar: Surgical instruments on a slab in Roman Malta. Medical History, 1974, 18:p.89-93

6. T. Cianfrani: A short history of obstetrics and gynecology. C.C. Thomas, USA, 1960, p.331

7. P. Cassar: A Medico-legal report of the sixteenth century from Malta. Medical History, 1974, 18:p.354-359

8. P. Cassar: Change of sex sanctioned by a maltese law court in the eighteenth century. British Medical Journal, 1954, 2:p.1413

9. Archiepiscopal Archives Melitensis - Super Divortio Inter Alicunda Vella e Alessio Vella, unclassified documents; F. Ciappara: Marriage in Malta in the late eighteenth century. Assoc News Ltd, Malta, 1988, p.69

10. P. Cassar: Inventory of a sixteenth century pharmacy in Malta. St Luke's Hospital Gazette, 1976, 11(1):p.26-34

11. P. Cassar, 1974: op. cit. note 7 above

12. G. Locano: Dissertatio physiologica de mechanico feminarum tributo. Montpelier, 1749; P. Cassar: French influence on medical developments in Malta. Ministry of Education, Malta, 1987, p.8

13. F. Butigiec: Trattato dell'arte ostetrica dettato e spiegato del Perille Signor Dr Francesco Butigiec nello studio publico del Grand Ospedale Nazionale de'Maltesi. Principiato li 18 Ottobre 1804, manuscript, +250fols. In P. Cassar: Teaching of midwifery in Malta at the beginning of the nineteenth century. St. Luke's Hospital Gazette, 1973, 8(2):p.91-111

14. S. Arpa: Di un caso particulare di gravidanza extra-uterina. G Camilleri & Co, Malta, 1843, +41p.

15. J.L. Pace: The history of the School of Anatomy in Malta. Royal University of Malta, Malta, 1974, p.16

16. S.L. Pisani: Ktieb il Qabla, P Debono & Co, Malta, 1883, p.5-18,A-E; G.B. Schembri: The Midwife's Guide book. Government Printing Office, Malta, 1896, p.1-20; G.B. Schembri: Taghlim ghal istudenti ta l-iscola tal kwiebel ta l-Isptar Centrali. Government Printing Office, Malta, 1897, p.1-28

17. S. Fiorini: A prescription list of 1546. Maltese Medical Journal, 1988-89, 1(1):p.19-31; J.L. Pace and S. Ramaswany: The Finds: Skeletal remains. In: T.F.C. Blagg, A. Bonanno and A.T. Luttrell: 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. Malta University Press, Malta, 1990, p.84-95; P. Cassar: Medical History of Malta. Wellcome Hist Med Libr., London, 1964, p.224-234; Le Levatrice. La Salute Publica, 10 November 1897, 1(15):p.3-4; A. Galea: Office of the Charitable Institutions. Reports on the working of Government Departments during the financial year 1922-23. Government Printing Office, Malta, 1925,sec.Q p.2; Annual 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

18. Sulle levatrice. Il Barth 22 March 1973, Anno II(13): p.260-261; P. Cassar: Two centuries of medical prescription in Malta 1683-1882. St Luke's Hospital Gazette, 1969, 4(2):p.111

19. G.B. Schembri, 1896: op. cit. note 16 above, p.106-108

20. Archivum Inquisitionis Melitensis - processi 131A, fol.155r-207r; F. Ciappara: op. cit. note 9 above, p.90

21. G.B. Schembri, 1896: op. cit. note 16 above, p.104

22. P. Cassar, 1964: op. cit. note 17 above, p.528-529; C. Mifsud: Casi di Salpingo-ovarite curati colla ellettricita`. La Rivista Medica, 31 March 1890, Anno I(2):4-5; C. Mifsud: Ascesso dell'utero. La Rivista Medica, 30 April 1890, Anno I(4):p.4-5

23. V. Vella: op. cit. note 3 above; T. Zammit: Adenoma dell'ovario sinistro. Laparotomia-guarigione. Sarcoma fusocellulare intraaddominale. Laparotomia-guarigione. La Rivista Medica, 15 June 1891, Anno I(21):p.1-2

24. P. Cassar, 1987: op. cit. note 12 above; S.L. Pisani: op. cit. note 16 above, p.79-80 ; G.B. Schembri, 1896: op. cit. note 16 above, p.68-69

25. G.B. Schembri, 1896: ibid, p.108

26. J. Ellul: Application of Joseph Ellul B.Sc. M.D. Junior accoucher and Gynaecologist - Central Civil Hospital. Malta, 1930; Annual report.......1937: op. cit. note 17 above, p.119-126; Annual report on the health conditions of the Maltese islands and on the work of the Medical and Health Department for the year 1938. Malta Government Gazette suppl. 1939, 154:p.106-127

27. Annual Report......1937, ibid; Annual Report.......1938, ibid

28. Annual Report......1937, ibid; Annual Report. .....1938, ibid