There is abundant evidence to suggest that early man did not admit the existence of disease from what we refer to as natural causes, in contradistinction to external disease. He regarded internal disease as being the result of the malevolent influence exercised by a supernatural being or by a human enemy, the disease being caused by the loss of something essential to life or by the projection of some morbid material or influence into the victim. The belief that internal disease and death were brought on by malevolent spirits or enemy accounts for the use of amulets and ex votos aimed at warding off disease or at appeasing the gods. The use of ex votos in Malta have been in vogue since prehistoric times. Excavations from a number of prehistoric sites have yielded a number of votive offerings. The use of ex votos remained ingrained in local popular folklore up to modern times, with a change from primitive superstition to a Roman Catholic flavour. This is evidenced by the large number of ex votos which can be found in various Churches in Malta and Gozo. Amulets were similarly used to ward off the evil influence which could lead to ill-health. The use of amulets was particularly prevalent during the Punic period when a number of small talismans depicting various deities were found in various tombs of the period. Talismans continued to be used throughout the ages. The ingrained belief that internal forms of disease were the result of malevolent actions led to the practice of witchcraft to attempt treat disease. These superstitious beliefs remain prevalent in present times, the best widespread example being the use of horns to protect against the evil eye [1].

The earliest evidence of internal disease on the Maltese Islands refers to infectious disease. During the Roman period c.60 AD., the evangelist Luke recorded the presence of dysentery in Malta. This bowel infection of the intestinal tract is common in warm moist countries and may be caused by the amoebic parasite Entamoeba histolytica or by the acute bacterial Shigella infestation. Therapeutic measures against dysentery in 1592 included Diascordio, an electuary composed of leaves of germander, gentian root, cassia, etc. useful for vomiting and dysentery; asqua de nenufaru o ninfea, dried roots of Nuphar luteum or Nymphaea alba drunk in wine; and Bolo di Armenia, an Armenian clay used as an astringent in dysentery and bleeding. In the seventeenth century Corallinea pulv composed of a mixture of opium, myrrh, cascarilla, cinnamon and powdered red coral was prescribed as an astringent in dysentery and to allay epigastric pains. The local medicinal plant Cynomorium coccineum found on Hagret il-General in Gozo was also associated with the treatment of dysentery. Mentioned first in 1771, the parasitic plant had a multitude of uses besides dysentery, including the control of bleeding following certain injuries, amputations, and extractions of carious teeth. It was claimed to be of use in the treatment of ulcers and gingivitis, and in the management of haemoptysis and syphilis. The therapeutic properties were still believed to be of use in 1800. During the three year period 1896-1898, there were a total of 110 deaths from Dysentery accounting for 7.28 per 1000 deaths on the Islands. The disease continued to plague the Maltese inhabitants well into the twentieth century, though the endemicity of Entamoeba was only confirmed after the 1913 epidemic. Shigella was apparently an introduced infection being first reported in 1916 among troops from Macedonia [2].

Infectious disease can be broadly divided into those infections which are endemic to the community and those that are introduced from abroad to cause epidemics. Infections which are endemic to the Islands include the acute infections such as those causing Scarlet fever, diphtheria, typhoid fever, dysentery, leishmaniasis, and rabies; and the chronic infections including, among others, leprosy, brucellosis, tuberculosis, and trachoma. Evidence of chronic endemic infections recorded in the late Medieval period include possible skeletal evidence of chronic brucellosis and syphilis. There are also literary records of a possible Scarlet fever epidemic referred to as an infection with "morbus di la gula et di la punta" which occurred in 1453-54 [3]. Scarlet Fever, like puerperal sepsis and erysipelas, are caused by the various groups of beta-haemolytic streptococcus. Erysipelas is a superficial cellulitis, whereas scarlet fever is a systemic disorder which, before the advent of antibiotics, carried a significant mortality and morbidity through chronic renal and cardiac damage. These infections occasionally took on epidemic proportions. During the greatest part of its history scarlet fever has been very often liable to be confused with diphtheria. The clinical distinction was first clearly made in 1826 by Pierre Bretonneau of Tours who gave diphtheria its present name. Diphtheria is an acute contagious disease caused by Corynebacterium diphtheriae, characterized by the formation of a fibrinous pseudomembrane in the throat and by cardiac and neural tissue damage. The first recorded death from clinically diagnosed diphtheria in Malta occurred in 1859 in a girl of 13 years. It was estimated that between that year and 1874, 1053 persons were killed by the disease in the two Islands. An anti-toxin serum was developed in 1895, but inoculation was only taken seriously in the late twentieth century. Typhoid Fever is a generalized infection caused by Salmonella typhi which causes a severe illness with a marked diarrhoea. Transmission was frequently through a contaminated water supply. Specific identification of the disease as a specific entity was only achieved after 1837, and the first recognised epidemic in Malta occurred in 1859. Leishmaniasis was identified as being endemic after its identification by Dr. A Critien in 1909. The role of the sand-fly in the transmission of the disease was only identified in 1931. Attempts to control the introduction of Rabies were made through the enforcement of quarantine laws on the importation of dogs. Canine rabies was reported to have occurred in 1725, however cases affecting dogs and humans were only reported in 1805, 1809 and 1810. A detailed description of hydrophobia in a Maltese woman occurring in 1847 was described by Sir. Thomas Spencer Wells [4].

Endemic forms of chronic infections have also caused a marked degree of mortality and morbidity to the Maltese population throughout the ages. Leprosy or Hansen's Disease is a chronic infectious disease caused by Mycobacterium leprae, an organism with high infectivity but low pathogenicity with a predilection for skin, mucous membranes and nerves. The first recorded case of leprosy in Malta dates to 1629. The infectivity of the disease was well recognised from earlier times and the isolation of lepers to prevent dissemination had been resorted to by 1679. By 1893 leprosy had spread sufficiently as to require an Ordinance to enforce the compulsory segregation of sufferers. Effective therapy for leprosy was only identified in 1941. Tuberculosis in its acute or chronic forms is caused by Mycobacterium tuberculosis and is almost always initiated by inhalation. Pulmonary tuberculosis is the most common but the infection can disseminate to any other organ. Pulmonary tuberculosis was recognised as an infectious disease in Malta by the eighteenth century with special precautions being taken in the hospitals to prevent its spread. In the early years of the nineteenth century it was commonly believed that the Mediterranean climate was less productive of pulmonary disease, so that it became customary for consumptives to travel to the Mediterranean. During the period 1842-52, Sir Thomas Spencer Wells reported that in 12% Maltese civilian postmortems had evidence of the disease, a figure very much lower than that in sailors or soldiers. A tubercular hospital was opened in 1909, and an anti-tuberculosis drive was launched in 1946. Brucellosis or Undulant Fever was a disease which attracted little attention for a long time, partly because it was so difficult to distinguish from enteric or typho-malarial fever, and partly because of its low mortality rate. The clinical course of the disease was described by William Burnett in 1816. Further advances in the conquest of the disease were made with the organism Brucella melitensis being discovered in Malta by Col. David Bruce in 1886. In 1904 a commission of inquiry reported the findings of Sir Temi Zammit who showed that the main source of infection was the goats' milk. Civilian control of the infection was only achieved after the introduction on a national scale of pasteurization of milk in 1938 [5].

Some infections are not endemic to the Islands, and their occurrence in the Maltese population could only be attributed to the introduction of the micro-organism from abroad. This often resulted in the infection taking on epidemic proportions leaving a significant mortality. The earliest recorded form of introduced epidemic infections were those of plague which occurred in the fifteenth century. Plague infection, transmitted by the rat flea, continued to repeatedly affect the local population through the centuries. In 1348 the Black Death is known to have reached the Islands in its march across Europe, while other epidemics are recorded in 1427-28 and in 1453. Another eight epidemics occurred during the sixteenth and seventeenth centuries. Four further epidemics occurred in 1813-14 and in the twentieth century, the last epidemic occurring in 1945-46 when five cases were reported. Smallpox outbreaks were reported in the Maltese Islands since the seventeenth century, the first recorded epidemic being in 1680. Immunization by variolation was introduced in 1769, but because the results were disappointing, it was given up in 1780. Vaccination was introduced in Malta in 1800, and by 1824 free inoculation was made available. Vaccination was made compulsory in 1855, but the law was not regularly observed so that a number of epidemics continued to occur. The last cases were reported in 1946. Cholera made its first definite appearance on the Maltese Islands in 1837, though previously sporadic cases were observed among British troops stationed in Malta. The Island subsequently became notorious for epidemic outbreaks of the infection throughout the nineteenth century. The last Cholera epidemic on the Islands occurred in 1911 [6].

Man has long been subject to the effects of micro-organisms which lead to specific or non-specific infections. Some of these infections are spread from one individual to another through direct or indirect contact giving rise to epidemic spread of the micro-organism. The earliest medical problem to become the concern of more than one government was the problem of preventing infectious epidemics spreading from one country to another. At the time when epidemic disease was thought to be a punishment from the gods, little could be done to prevent its spread save prayer and sacrifices. This practice remained even after the contagion nature of the epidemic was recognised. Thus on the Maltese Islands we find that nearly all plague epidemics were followed by the institution of annual votive processions, the building of chapels or shrines and the dedication of altars to one or more saint protectors. Thus the veneration of St. Basilius, St. Sebastian, St. Nicholas, St. Roque and St. Rosalis was introduced to the Islands [7]. With the gradual realization of the fact that epidemic disease could be spread from one community to another, the first and natural reaction of a threatened community was an attempt to isolate itself against the advancing danger. The measures adopted took various forms. The crudest were the attempt of countries, communities or privileged groups which were outside the centers of infection to prevent all entry of persons or goods from the infected areas. Such attempts at a complete isolation of communities were enforced by judicial enactments and military force. To allow for some modified form of trade and yet protect the community, sanitary barriers in the form of quarantine measures were devised. The Mediterranean was the true home of the classical quarantine measures. As early as 1348, shortly after the Black Death panepidemic, Venice - then the commercial center of the Mediterranean - took steps to safeguard its population bby forming a sanitary council authorized to isolate infected ships, goods and people who arrived there. These anti-plague measures were extended and with the passage of time the Venetian system of quarantine became more and more elaborate. Eventually quarantine stations were established in all the chief Mediterranean ports [8].

Situated on the main channels of commercial intercourse through the Mediterranean Sea, the Maltese authorities soon adapted quarantine measure to protect their community. During the late Middle Ages (at least by 1458), quarantine control was in the hands of public officials appointed by and answerable to the Mdina Municipality. Ships suspected of harbouring infection were directed to Marsamxett Harbour. Attempts to contain the infection included the burning of cargo, isolating the crew and submersing the ship. When in 1523, the ship owners refused to comply with the instructions, the municipality was compelled to set fire to the ship. During this epidemic, cases of plague broke out at Birgu and attempts were undertaken to cordon off and isolate the town from the rest of the Island with special guards [9]. With the arrival of the Knights Hospitaller of St. John of Jerusalem to the Islands in 1530, quarantine enforcement fell under their control. It has been suggested that the Knights first adopted a forty-day quarantine after their establishment on the island of Rhodes in 1306. During their stay in Rhodes the Knights developed a very comprehensive code of laws to safeguard the health of the community. These laws promulgated during the Grandmastership of Fra E. D'Amboyse (1503-1512) included detailed regulations regarding quarantine control and the notification of infectious disease. These regulations were subsequently introduced in Malta. A Health Commission composed of two knights responsible for quarantine control was set up. These formed part of the Complete Council of the Order [10]. No ship was allowed to disembark passengers, crew or goods before being granted pratique by the port sanitary authorities. Harsh punishments, including the death penalty, were meted out to anyone who infringed the regulations. All the merchandise had to be brought ashore for disinfection, while the passengers and crew had to be depurated. The isolation of persons suspected of harbouring infection was carried out at the Lazaretto. The first lazaretto was set up at Rinella Bay, but subsequently was transferred to the foreshore beneath Kordin Heights and later to the Valletta wharf. A permanent lazaretto was built on Manoel Island in 1643 by Grandmaster Jean Paul Lascaris, though the islet had been previously used on a number of occasions as a temporary lazaretto. The quarantine regulations were maintained under British rule and were only relaxed in conformity to international recommendations in the mid-twentieth century [11].

The episodic failure of the quarantine regulations are reflected by the various introduced infectious epidemics which occurred on the Islands throughout the centuries. Some introduced infections have established themselves on the Islands to become endemic. Noteworthy examples include the introduction of Cerebrospinal meningitis in 1916 and the introduction of Typhus in 1944. Previous introductions of these two infections in the late nineteenth century failed to establish themselves on the Islands. On the other hand Malaria has failed to establish itself on the Islands even though the transmitting mosquito Anophelis maculipennis has been reported to breed on the Islands. Indigenous malaria was first reported in 1904-05 when several inhabitants were infected [12].

Public Health administration concerned itself also with the control of medical and apothecary practice. Regulations aimed at controlling these practices in Malta probably date to the ordinances published by Roger II in 1140 which were later expanded by Federick II in 1224. The ordinances introduced by the Knights of St. John were similar to the earlier ones. These ordinances controlled the license to practice and teach medicine, the relationship of the physician to the apothecaries, regulated the tariff of fees, controlled apothecary practice and managed public hygiene. These were subsequently modified and amplified in line with progressive medical development into various codes and laws [13].

Apothecaries were an accepted integral part of medical practice. They were controlled by the same ordinances as the medical practitioners, and were generally responsible for the preparation of prescriptions. Evidence of apothecary practice in Malta dates to the fifteenth century, the pharmacists generally coming from Sicily. The first pharmacist recorded was Salvatore Passa who came to Malta from Palermo. He is known to have given his services in Malta during the period 1450 to 1475. The first recorded Maltese-born pharmacist was Glormu Callus who worked in 1491 and who was succeeded by his son Antoni in 1519. These pharmacists had their shop inside Mdina and were employed by the Universita`. It is reasonable to assume that the town-apothecary also served Santo Spirito Hospital. By 1580 at the latest Santo Spirito had its own resident apothecary with his own pharmacy at the hospital. The pharmacopoeia of the early sixteenth century, as evidenced by the prescription list dated 1546 of the pharmacy attached to Santo Spirito Hospital at Rabat, indicates that Maltese medicine was very much in the main-stream of the Arabo-Hellenic medical tradition flourishing on the continent at the time. This further confirms the 1542 medico-legal references to authorities such as Galen, Rhazes, Avicenna and Avenozoar [14]. The prescription list shows that generally the source for drugs was vegetable, animal and mineral sources being in the minority. A number of substances were imported, though a few were obtainable locally. A later sixteenth century inventory of the pharmacy attached to Santo Spirito dated 1592 suggests a greater proportion of imported substances probably as a result of the influence of the Knights of St. John [15].

A subsequent inventory of the same hospital drawn up in 1769 shows that there had been little progress in pharmacotherapeutics with practically all the items recorded in the previous list being included. The slow process of weeding out worthless substances can also be reflected from the prescription registers of medicaments supplied to the Jesuits at Valletta during the eighteenth century. The registers cover the period 1683 to 1768. The items included in these lists include oils, ointments, syrups, conserves, powders and emplastra. They were generally compounded of vegetable parts, but animal ingredients such as scorpions, crayfish, hart's horn and human skull are also featured. Mineral substances including lead, mercury and alum were also used in the eighteenth century. Some substances were included on the basis of their folkloric value. These included the Lapid. D. Pauli and the Linguae D. Pauli pulv. which were supposedly useful as antidotes against poison. Their therapeutic properties were was based on the belief that the apostle Paul imparted protective properties against poisoning on Malta stone, particularly that obtained from St. Paul's Grotto, and on fossil shark's teeth considered as the imprints of St. Paul's tongue. The therapeutic properties included not only the use as a remedy against the bites of poisonous animals such as snakes and scorpions, but also as a remedy against ingested poison and other illness. St. Paul's Earth was used in severe illness when other medicaments had failed, and was considered to have a cardiotonic effect. The earth was taken either mixed with wine, water or spirits, or else by drinking water or wine poured into jugs made from stone [16].

Prescription lists of the late nineteenth century shows that many of the previous pharmaceutical preparations had been discarded and substituted with useful and rational ones. The therapy was still however of a symptomatic and palliative variety. In spite of the advances in the clinical and epidemiological aspects of disease during the period, little progress had been achieved in therapeutics. It was only in the pre and post-Second World War period that major advances in therapeutics were made and introduced to the Islands [17].

The theory and practice of medicine remained in the Arabo-Hellenic tradition well into the Modern Period. This was primarily based on the teachings of Claudius Galen of Pergamus (131-200 AD). Galen's physiology followed that of his predecessors in the theory of pneuma as the essence of life. It was his concept that the pneuma consisted of animal, vital and natural spirits. The animal spirits originated in the brain, the vital spirits mixing in the heart, and the natural spirits being developed from the blood via the liver. The heart was considered to be the canter for the movement of blood and heat regulation, while the liver was considered to be the center for nutrition and metabolism, and the brain for sensation and movement. While he knew nothing of the concepts of the circulation of blood, he wrote a number of treatises on the pulse. He believed that the two sides of the heart were connected by invisible pores. Galen's treatments were medical and surgical, the basic concept of his medical therapy being that of contrary measures. He applied heat for disease that came cold, and heat for those that came from heat. He ordered evacuations in cases of plethoric conditions. He utilized diets, drugs, exercises, massage and climatotherapy. Bleeding held an important part of his therapeutics. The number of drugs, mainly vegetable and animal, used by Galen was very large, recognising as many as 600 plants as having therapeutic properties. He rejected all metallic remedies [18].

During the Renaissance period, medical thought changed rapidly as a result of free, critical and individualistic studies, a process that was consolidated during the seventeenth century. The eighteenth century was the Age of Enlightenment. During this century various individuals made careful observations of disease and studied various methods of treatment in an age that was very conscious of its intellectual emancipation and intent upon applying new ideas in practice. A number of Maltese eighteenth century physicians contributed various physiological and medical thesis to obtain their medical doctorate from French and Italian Universities. The earliest medical thesis by a Maltese physician was published in 1636 by Dr. Joseph Cossaeus. His thesis Suprema Apollinaris Laurea seu Doctoratus Quaestiones Quatuor Cardinales consists of four short essays dealing with the casting of spells, the necessity of sexual expression, the role of neurotomy to treat dental pain, and the current effectiveness of used medicaments. Giorgio Imbert in 1723 described the clinical pictures and management of depression in his work De Morbus animi, while Giuseppe Demarco in 1744 submitted a thesis on the physiology of respiration Dissertatio phisiologica de respiratione. Dr. Salvatore Bernard in 1749 published his treatise Trattato filosofico-medico dell'uomo e sue principali operazioni which dealt with the nature and basis of nervous and mental phenomena as it was understood in his time. In 1762 Dr. Fortunato Antonio Creni wrote a treatise on venereal disease entitled Tractatus physico-medicus de Americana lue [19].

A university incorporating the faculties of Theology, Law and Medicine was established in 1771 by Grandmaster Em. Pinto de Foneca. Until and after the establishment of the local University, young men continued to seek to improve their medical knowledge in Italian medical schools such as those at Salerno, Rome and Florence as well as the foremost French universities of Paris, Montpellier and Aix-en-Provence. It is to be presumed that besides a good knowledge of Latin, Maltese medical men could also speak Italian and/or French. The first Professor of Medicine in the University of Malta was Giorgio Locano who held the Chair until 1797. The University was abolished by Napoleon in 1798, but was later re-instituted by Sir Alexander Ball in 1800. Dr. Ludovico Abela was appointed as Professor of Medicine. The Collegio medico was however only formally set up in 1839 and in the early decades of the nineteenth century medicine was often thought by private tutors including Dr. Agostino Naudi and Dr. Gavino Patrizio Portelli. Clinical wards or Istituto Clinico were founded in 1823 in the Civil Hospital by Dr. S. Grillet, then Professor of Physiology, Pathology and Medicine (1815-1831). The clinical wards were open from October to June and were managed by the University Professors of Medicine [20].

The nineteenth century saw the development of the modern basic sciences and the various specialties of medicine and the development of the cellular theory and the science of bacteriology. The primary advance was however that of the development of clinical method of diagnosis which removed a physical diagnosis, particularly in cardiac and pulmonary disease, from the realm of speculation to the field of demonstrated fact. This move started with the discovery of percussion by the Austrian Leopold Auenbrugger in 1761. This was however initially ignored until it was popularized forty-seven years later by the French physician Jean Corvisart. The discovery of auscultation by French physician Rene Theophile Laennec in 1816 further gave an impetus to physical examination. The pleximeter was invented in 1826 by the French physician Pierre Adolphe Piorry for the practice of mediate percussion. The use of the stethoscope and pleximeter for the examination of the chest was being advocated in Malta in 1838. The thermometer was first described in Venice by Santorio Santorio in 1625, but the universal employment of the thermometer for diagnostic purposes was only introduced after 1870. Detailed instructions about the use of the thermometer were given to midwives by Prof. S.L. Pisani in 1883. Attempts to amplify the pulse and detect occult abnormalities were made with the development of the sphygmograph which was introduced in 1863 by the French physician E.J. Marey. In Malta the sphygmograph was employed by 1888. An important diagnostic aid in modern medicine in the ophthalmoscope which was invented by the German physician Prof. Hermann Ludwig Helmholtz. The Maltese profession were soon introduced to the instrument by Dr. Giuseppe Clinquent by a lecture given to the Societa` Medica d'Incoraggiamento in 1843. Chemistry was also made subservient to the diagnosis of medical conditions by the examination of urine and blood. Microscopic examination of urine was recommended in Malta as early as 1838, while its use to study blood and sputum was well familiar by 1872. The spectroscope was similarly in common use to study blood stains. Microscopy of organs was being performed at least by 1860, while bacteriological analysis was well established by 1887 when David Bruce with the help of the government analyst Dr. G. Caruana Scicluna was able to examine bacteriologically the splenic tissue of soldiers dying from brucellosis. The discovery of X-rays in medicine by Wilhelm Konrad Roentgen in 1895 added further precision in the diagnosis of various disease. The discovery was soon introduced in Malta by notices in the newspaper Daily Malta Chronicle. The first experiments with the procedure were made by Prof. Temi Zammit in August 1896 when x-ray photographs of inanimate objects were taken. X-ray photographs of the hand were taken in September 1896. X-ray apparatus was ordered from England in 1899, but radiology was only introduced in the Central Hospital in 1908 [21]

It appears that whereas during the Medieval and Modern periods, the management and control of epidemic infections were the primary concern of Maltese medical practitioners and authorities, other medical conditions also affected the local population. The earliest evidence of a metabolic disorder in the Maltese population dates to the prehistoric period. The outstanding feature of the various statues and statuettes found in the various Neolithic temples is the gross obesity depicted by both the male and female figures. These have very prominent abdomens, often with creases representing folds of fat sometimes extending to the hips. The buttocks are large of a broad type and bulge backwards. The statuettes have abnormally fat forearms, hips and legs. It has been suggested that these figurines were idealized representations of the human form as understood by Neolithic man. The disturbance of the balance of metabolism has been known since time immemorial, and in certain cultures was regarded as a sign of wealth and beauty. The thick deposits of fat on the hips, thighs and buttocks are said to be to a certain extent a racial characteristic in women. Opinions are still divergent as regards the mechanism for the development of obesity, and as to whether endocrine, constitutional, hereditary or physical factors are most important or whether the disorder is simply as result of a faulty diet. That the Mediterranean races are inclined to obesity is considered to be due to an earlier mixing with Negro blood. Obesity remains one of the major non-communicable medical problems of the Maltese population. It has been shown that in 1984 14% of men and 15% of women between the ages of 25 to 35 years were obese, the proportions increasing to 28% and 54% respectively by the time they reach 55 to 64 years [22].

Another common metabolic problem in the Maltese population, also related to the excessive body weight, is Diabetes Mellitus and other degrees of impairment of glucose metabolism. The type of abnormality which is most prevalent in the Islands usually appears in mid-life and is common among overweight or obese individuals. The National Diabetes Program in Malta in 1981 showed that 7.7% of the population was diabetic while a further 5.6% had minor forms of impairment. The earliest evidence concerning interest in diabetes in Malta dates to 1698, this evidenced by the presence of the work by the Dutch physician Martin Lister belonging to a Victorius Grech. Other books published in the eighteenth century and which deal with diabetes form part of the National Malta Library holdings. Increasing recognition of the importance of the disease is reflected in the early nineteenth century with the delivery of a series of lectures on diabetes being given by the Professor of Medicine in 1826. From the 1830's onwards, British, Italian and French ideas influenced the management of the disease in Malta, with diet being the anchor of treatment. By 1872 carbuncles, vision loss, and lower limb gangrene were recognised as complications of the disease. Insulin therapy, discovered by Frederick Banting and Charles H. Best in 1921, was introduced in Malta in 1922-23. Awareness that the disease was a major health problem in Malta was manifested in 1952 and efforts were made in the 1960's to assess and control the problem. The earliest survey to estimate the incidence of diabetes in Malta was carried out by Prof. J.V. Zammit Maempel in 1964-65 [23].

The opposite end of the spectrum of nutritional disease are conditions caused by nutritional deficiencies, including disorders such as anaemia, rickets and scurvy. Scurvy is an acute or chronic disease caused by a deficiency of vitamin C and is characterized by haemorrhagic manifestations and connective tissue abnormalities. The role of vitamin C in the production of the disease was only demonstrated in the twentieth century, though the first controlled experiment in the management of the disease was made by Dr. James Lind in 1753. The disease was a major problem of naval personnel when fresh fruit could not be supplied for a prolonged period of time. The first recorded case of scurvy in Malta dates to 1781. This deals with the case of nun of the Monastery of St. Mary Magdalene in Valletta who during the period from 1775 to 1781 was diagnosed as suffering from scurvy. The disease was attributed to the "salty air that prevails in the Island". It was recommended that she should proceed to Sicily for a change of air and for taking the baths at Catania. The naval preoccupation with the supply of citrus fruit, even in the Mediterranean, was subsequently evident in the early nineteenth century when the Physician to the Royal Navy Mediterranean Fleet Dr. John Snipe chose Villa Bighi as an idea site for a Royal Navy Hospital. In his letter to Nelson in 1803 he commented that Villa Bighi had "sufficient ground belonging to it, in a high state of cultivation, to produce abundance of vegetables for the use of the sick, and if lemon and orange trees were planted, the Fleet, on this station, might be amply supplied with those antiscorbutic fruit" [24].

The commonest form of disease of the blood-forming organs are the various forms of anaemia. The Maltese population is known to suffer both from nutritional anaemias and from congenital haemolytic anaemias including thalassaemia. Several studies conducted on the Maltese population over the last thirty years indicate that nutritional anaemia in Malta occurs at rates comparable with other developed European countries, while thalassaemia trait occurs in about 4% of the population. Anaemia accounted for 28 deaths (1.1 per 1000 total deaths) during the five-year period 1896-1900. Pernicious anaemia caused by folic acid or vitamin B deficiency was common in the early twentieth century with seven cases being reported in pregnant women in 1937. These were managed with strong doses of iron and hepatex-ventriculin. In 1952 the Chief Government Medical Officer Dr. J. Galea commented that "It is to be regretted that as an effect of commercial propaganda the public has had its attention focused on the importance of vitamins and calcium (which seem to be the least common deficiencies), while little, if any, attention is paid to iron requirements, which mineral is too often very badly needed by our multiparous women and their numerous offspring" [25]. Dr. Galea was also concerned about calcium and vitamin D deficiency causing rickets, commenting that "The high calcium content of the local water supply supplements a considerable degree any possible calcium deficiencies of the foodstuffs....Rickets, although mild, is frequent enough to justify enquiry why it should happen at all in a country enjoying several hours of clear sunshine for days and weeks all the year round. There is not much to suggest a cause in the milk and food given......suggest that much of the rickets is the effect (rather than a cause) of progressive illness, but other factors as obsolete houses, excessive or unsuitable clothing, prejudice against exposure of infants to sunshine etc., do probably come in. This may be supported by the observations that the incidence of rickets in villages is apparently equal to, if not higher than, that in towns, and that rickets is getting less common with the better education of mothers which is going on at present." At the turn of the nineteenth century (1896-1900), rickets accounted for a total of 62 deaths or 2.5 per 1000 total deaths [26].

Another partially related bone disorder which affects the Maltese population is bone disease in the elderly caused by osteoporosis. Environmental factors, including diet, could affect both the accumulation and loss of bone mass. Physical activity and a good dietary calcium have both been cited as important throughout life. Osteoporosis in commoner in the menopausal woman. The earliest evidence of osteoporosis in Malta comes from the skeletal remains of a female buried at the late medieval church St. Gregory Church. It has been shown in recent times that the incidence of osteoporotic hip fractures in Malta was similar to that seen in other Mediterranean countries being about a third the incidence in Northern European countries. The osteoporotic process accelerates with the female gonadal deficiency that occurs after the menopause. One of the first experimental demonstrations of the existence of ovarian hormones was given by the Austrian gynaecologist Emil Knauer in 1896 who showed that the sexual characters developed in castrated animals when the ovaries were transplanted. Oestrone was isolated in 1929. The hormonal role of the ovaries to prevent menopausal symptoms was recognised in Malta at least by 1938. Prof. J. Ellul reported that after radical gynaecological surgery auto-innestation of the ovary in the vulva was performed in young women. In some cases recourse had to be had to injections of hormone preparations (Aestroform B) [27].

The roman and medieval skeleton record from the Maltese Islands has yielded evidence of skeletal joint disease in the form of chronic osteoarthritis. Osteoarthritis is perhaps the best documented disease in palaeopathology. In a general way, it can be ascribed to the inevitable trauma to the various joints which accumulates over the course of many years. Chronic strain contributes to the onset of the disease but the aging process appears to the related to its progression. Another joint disease which affected the Maltese population during the medieval period was gout. The first evidence that this recurrent acute arthritis occurred in Malta is given in a certificate dated 1583. The Knight Gianbattista Calerari was certified to be unfit to travel because he was suffering from severe pain resulting from gout. The condition, which lasted from forty to sixty days, was attributed to gout. Gout results from the deposition urate crystals in the peripheral joints. Gout without doubt is a very ancient disease and its metabolic aetiology was first postulated by the Swiss physician Paracelsus (1493-1541). All the beliefs and therapeutic methods, prior to the present times, had their origin in Greek times and were passed down virtually unchanged until the opening of the nineteenth century. The 1592 Santo Spirito Pharmacy inventory list a large number of medicaments which are known to have been used in the treatment of gout. These included the Electuarium episcopi seu elescoph solidum, a mixture of cloves, cinnamon, ginger and nutmeg useful against colic and the pains of gout; Pillole fetide, made of coloquinth, aloes, cinnamon, scammony and euphorbia used to purge the body of cold humours and allay gout pains; Pilulae de hermodactylus made of colchicum, aloes, saffron and dried preputial beaver follicles useful for gout and other joint pains; Pilulae de sagapeno made of the gum of Sagapenum officinale, Calamus aromatiocus, colocynth and aloes used in gout and to promote menstruation; Coloquintida which consisted of the dried fruit of Citrullus colocynthis; and Aristolochia made from the roots of A. rotunda used against fevers and gout. During the nineteenth century the mainstays of treatment were salicylic acid and Extractum colchici, together with a number of external applications to reduce inflammation and pain [28].

Only in very rare cases is it possible to mark the early occurrence of nervous and mental disease. A disease with very old roots is epilepsy or morbus sacer, the holy disease. Hippocrates believed that there was no difference between the morbus sacer and any other disease. A early case of a Maltese woman suffering from epilepsy dates to the late fifteenth century (c.1593-1602). The woman, reported to have previously suffered from epilepsy, was found dead in her room. Three medical experts were called to assess the cause of death. They wrongly concluded that she had died from suffocation during an epileptic fit. She had in fact been murdered by her servants. Insanity similarly is as old as history and there are several references to madness in Homer. Man's mental condition was conceived as being in the hands of the gods, those whom they wish to destroy they first drive mad. Asylums for the insane were in existence from about the thirteenth century, but they were far from being hospitals in which the patient's mental condition was treated. While the first suggestion for the humane treatment of the mentally sick was made by the Spanish scholar Juan Luis Vives (1492-1540), it was only in 1793 that this was implemented by the Parisian physician Philippe Pinel. In sixteenth century Malta, the insane were recognised as not being legally responsible for his action. In 1535, the knight Fra George Aylmer was charged before the Council of the Order imputed with "certain crimes". The Commissioners concluded "that he was not completely of a sound mind" and Fra Aylmer was to live "in a suitable place". The concept that the insane offender was not legally responsible for his acts persisted up to present times. In 1725, mental patients were admitted to the Holy Infirmary at Valletta and looked after by an attendant in a room reserved for madmen. The patients were confined to beds through the use of personal restraint. When violent, they were kept in the basement of the hospital secured to the walls by chains or pinioning. When the patients were declared incurable they were transferred to the Ospizio at Floriana where they were kept in small rooms chained to the walls. The mental patients were frequently beaten since they were considered to possess the devil. Female patients were cared for at the Hospital for Incurable Women at Valletta. The inhumane treatment of mental patients continued to the third decade of the nineteenth century. In 1837 the mental patients were transferred from the Ospizio to a mansion at Floriana, previously the residence of the knight Fra Fabrizio Franconi. The new mental hospital was put under the directorship of Dr. Thomas Chetcuti (1797-1863). After his appointment, Dr Chetcuti proceeded to the continent to visit mental asylums there, where the humane treatment of the insane was being introduced. On his return, he undertook measures to free patients from their chains and abolished the use of the stick to subdue excited patients. The treatment in vogue at the time involved both physical and psychological measures. Physical measures were aimed in the hope of relieving cerebral irritation and allay excitement, using cold applications to the head, tepid baths, administration of laxatives, and blood-letting. Psychotherapy was considered the mainstay of treatment where the removal of the patient from a stressful environment helped the patient to shift his attention from the morbid thoughts to other interests. Occupational therapy was considered useful to attain this end. Villa Franconi soon became unsuitable as a result of overcrowding. In 1861 the mental patients were moved to a new lunatic asylum at Attard. Hydrotherapy, work and psychological measures remained to therapy for mental patients until the therapeutic advances of the early twentieth century [29].

The medical spectrum of the disease in Malta has changed throughout the ages, particularly in the last century. Whereas formerly the major medical disorders centered around infectious conditions, the development of effective prophylaxis and therapy of infections, coupled with a betterment in the medical and social conditions of the population have led to a decrease in the incidence and case-fatality rates from infectious disease. As a result other disorders caused by non-communicable disease have come into the fore. There is irrefutable evidence that lifestyles, particularly nutritional habits, have a strong bearing on health, and in particular on the chances of our developing cardiovascular, metabolic or malignant disease in later years. The medical profession must now address this field for the betterment of the health on the Maltese population.

1. T. Zammit and C. Singer: Neolithic representations of the human form from the Islands of Malta and Gozo. J Royal Anthrop Inst, 1924, 54:p.67-100; T.C. Gouder: Some amulets from Phoenician Malta. Heritage, 1978, 1:311-315; A. Bonnici: Maltin u l-Inkizizzjoni f'nofs is-seklu sbatax. Klabb Kotba Maltin, Malta, 1977, p.71-121; J. Cassar Pullicino: Studies in Maltese Folklore. Malta University Press, Malta, 1991, p.191

2. Luke: Acts of the Apostles, 28:1-10; P. Cassar: Inventory of a sixteenth century pharmacy in Malta. St. Luke's Hospital Gazette, 1976, 11(1):p.26-34; P. Cassar: Two centuries of medical prescribing in Malta. St. Luke's Hospital Gazette, 1969, 4(2):.p.107-112; C.J. Boffa: Hagret il-General - A Reminder of a Medicinal Plant. Maltese Medical Journal, 1980, 1(2):p.17; S.L. Pisani: Malta Government Gazette supplement, 27 November 1897, no.3959 +18p.; S.L. Pisani: Public Health Department: Reports for 1897-1898. Chronicle Offices, Malta, 1898-1899, 2 vols.; P. Cassar: Professor Peter Paul Debono (19th June 1890 - 3rd June 1958). The Man and his times. SSt. Luke's Hospital Gazette, 1975, 11(2):p.129-130

3. P. Cassar: Medical History of Malta. Wellcome Hist Med Libr, London, 1964, p.164-209, 251-258; S. Ramaswamy & J.L. Pace: The Medieval Skeletal remains from St. Gregory's Church at Zejtun (Malta): part I. Paleopathological Studies. Arch Ital Anat Embriol, 1979, lxxxiv(1):p.43-53; J.L. Pace & 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, & A.T. Luttrell. Malta Univ Press, Malta, 1990, p.84-95

4. P. Cassar, 1964: ibid, p.248-250, 262-270; L. Vassallo: Epidemiological aspects of typhoid fever in the Maltese Islands. Malta University Press, Malta, 1973, +29p.; A. Critien: Infantile Leishmaniasis (Marda tal Biccia) in Malta. Annals of Tropical Medicine and Parasitology, 1911, 5:p.37; T. Spencer Wells: Case of hydrophobia following the bite of a cat. Employment of ether vapour and belladonna. Malta Times, 24 August 1847, p.3

5. P. Cassar, 1964: ibid, p.210-223, 240-247; J. Bugeja: Leprosy in Malta. Reports on the workings of Government Departments during the financial year 1930-31. Government Printing Office, Malta, 1932, sec.R, p.17-30; C. Savona-Ventura: Malta and the British Navy: the medical connection during the nineteenth century. Part III: Medical and other problems. J Royal Naval Med Serv, 1993, 79:p.100-105; D.J. Vassallo: The Corps Disease: Brucellosis and its historical association with the Royal Army Medical Corps J Royal Army Med Corps, 1992, 138:p.140-150

6. C. Savona-Ventura, 1993: ibid

7. P. Cassar, 1964: op. cit. note 3 above, p.421-425

8. N.M. Goodman: International Health Organizations and their work. Churchill Livingstone, Edinburgh, 1971, p.23-52

9. P. Cassar, 1964: op. cit. note 3 above, p.11-13, 164-165

10. N.M. Goodman: op. cit. note 8 above, p.31; P. Cassar, 1964: ibid, p.273; L. De Boisgelin: Ancient and Modern Malta, London, 1805, vol.1, p.275

11. P. Cassar, 1964: ibid, p.283-308

12. C. Savona-Ventura, 1993: op. cit. note 5 above; C. Savona-Ventura: An outbreak of Cerebrospinal Fever in a 19th century British Mediterranean Naval Base. J Royal Army Med Corps, in press

13. J.H. Bass: Outlines of the history of medicine and the medical profession. Krieger Publ Co., Huntington, 1971, vol.1, p.274-276; National Malta Library: De medici physicis et chirurgis: pragmaticae Rhodie, ms. 153, fol.42t, 71, 73t; NML ms. 740, fol.36-39; Leggi e costituzioni prammaticali, Malta, 1724; Del dritto municipale di Malta, Malta, 1784

14. S. Fiorini: Kura u Servizzi tas-Sahha f'Malta sa nofs is-seklu XVI. Oqsma tal-Kultura Maltija. ed. T. Cortis, Ministry of Education and Internal affairs, Malta, 1991, p.238-239; S. Fiorini: A prescriptions list of 1546. Maltese Medical Journal, 1988/89, 1(1):p.19-31; P. Cassar: A medico-legal report of the sixteenth century from Malta. Medical History, 1974, 18:p.354-359

15. S. Fiorini, 1988/89, ibid; P. Cassar, 1976: op. cit. note 3 above; P. Cassar, 1969: op. cit. note 3 above

16. L. Farigiani: Taxa Recens Pretii Omnium Pharmacorum..ad usum Hospitalis...Sancti Spiritus. Malta, 1769; P. Cassar, 1969: ibid; C. Savona-Ventura: Maltese Medical Folklore - Man and the Herpetofauna in Malta: A Review. Maltese Medical Journal, 1990, 2(1):p.41-43

17. P. Cassar, 1969: ibid; P. Cassar: Clinical teaching in Malta fifty years ago. A personal view. Mediscope, 1987, 11:p.24-29

18. J.H. Bass: op. cit. note 13 above, p.168-176

19. P. Cassar: French Influence on Medical Developments in Malta. Ministry of Education, Malta, 1987, p.5-14

20. P. Cassar, 1987: ibid; 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 & V. Mallia-Milanes. Malta University Publications, Malta, 1991, p.187-198

21. P. Cassar, 1964: op. cit. note 3 above, p.529-530; J.H. Bass: op. cit. note 13 above, vol.2, p. 1010-1026; S.L. Pisani: Ktieb il Qabla. P. Debono & Co, Malta, 1883, p.89-91; P. Cassar: The first 75 years of radiology in Malta. St. Luke's Hospital Gazette, 1972, 7:p.108; P. Cassar: Some early x-rays photographs taken in Malta - a postscript. Mediscope, 1983, 4:p.14-16; P. Cassar, 1975: op. cit. note 2 above, p.131-133.

22. F. Henschen: The history of diseases. Longmans, London, 1962, p.205; T. Zammit and C. Singer: op. cit. note 1 above, p.74-76; M. Bellizi, H. Agius Muscat, and G. Galea (eds.): Food and Health in Malta. A situation analysis and proposals for action. Department of Health, Malta, 1993, p.19-25

23. G. Katona, I Aganovic, V. Vuscan, and Z. Scrabalo: The National Diabetes Programme in Malta. Final Report Phases I and II. W.H.O., Geneva, NCD/OND/DIAB/83.2, 1983; P. Cassar: Historical development of the concept of diabetes in Malta. Ministry of Health, Malta, 1982, +27p.; J.V. Zammit Maempel: Diabetes in Malta. A pilot Survey. The Lancet, 11 December 1965, p.1197-1200

24. National Malta Library: Arch.1189, fols.70, 110, 113-114; P. Cassar: Landmarks in the development of forensic medicine in the Maltese Islands. M.U.p., Malta, 1974, p.7; C. Lloyd and J.L.S. Coulter: Medicine and the Navy 1200-1900. E&S Livingstone Ltd, England, 1963, vol.4 (1815-1900) p.247-252

25. C. Savona-Ventura: Anaemia in the Maltese Islands. Contribution to the Malta Case Study for the International Conference on Nutrition in Malta. Department of Health, Malta, 1992; S.L. Pisani, 1897: op. cit. note 2 above; S.L. Pisani, 1898-99: op. cit. note 2 above; S.L. Pisani: Public Health Department. Report for 1899-1900. G. Muscat, Malta, 1900-1901; 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; J. Galea: 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.8

26. J. Galea: ibid, p.8; S.L. Pisani, 1897: ibid; S.L. Pisani, 1898-99: ibid; S.L. Pisani, 1900-1901: ibid

27. S. Ramaswamy and J.L. Pace, 1979: op. cit. note 3 above; J. Ellul: Report on the Maternity and Gynaecological Departments, Central Hospital. 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. 29 December 1939, no.154, Appendix MA, p.112, 116; Y. Muscat Baron and M. Brincat: The epidemiology of post-menopausal osteoporotic fractures in the Maltese Islands. Contribution to the Malta Case Study for the International Conference on Nutrition in Malta. Department of Health, Malta, 1992.

28. P. Cassar, 1974: op. cit. note 24 above, p.5; P. Falcone: La nunziatura di Malta nell'Archivio Segreto della Santa Sede. Rome, 1936, p.59; P. Cassar, 1976: op. cit. note 2 above; P. Cassar, 1969: op. cit. note 2 above

29. P. Parisi: Aggiunta agli avvenimenti sopra la pesta. Palermo, 1602, p.189; P. Cassar, 1974: ibid, p.11, 14-19; C. Singer and E. Ashworth Underwood: A short history of Medicine. Clarendon Press, Oxford, 1962, p.494-512; National Malta Library: Arch.1720, fols.2; P. Cassar: The Institutional treatment of the Insane in Malta. Malta, 1949