INTRODUCTION
Thomas Spencer Wells was to become an acknowledged nineteenth century leader of the British surgical establishment and a notable pioneer in abdominal surgery. Born on 3 February 1818, Wells during his childhood showed an interest in the natural sciences, an interest which matured into an interest in medicine which earned him an MRCS in April 1841 [1,2]. In September 1841, after his qualification, he joined the Royal Navy and was posted to the Naval Hospital at Malta. This initiated a naval career which was to last twelve years and which served to consolidate his surgical expertise.

BRITISH NAVAL MEDICAL SERVICE
The Naval Medical Service was in 1841 at a very low ebb, with regular complaints from the assistant surgeons being published in the journals. The assistant surgeons were paid 6s 6d per day and messed in the ships’ cockpit or gunroom together with the midshipmen and warrant officers. They slept in hammocks and kept their possessions in a sea chest. The senior Naval Medical Officers and the executive Naval officers were not very sympathetic to the plight of the assistant surgeon serving on board. The living conditions were better when serving in a Naval Hospital on shore. Few qualified medical officers actually applied to join the Naval Medical Service and in 1840 the Medical Director-General Sir William Burnett responsible for the Naval Service confessed that not a single candidate had appeared for recruitment. Spencer Wells interest in a naval career may have stemmed from a wish of seeking a surgical career. Coming from humble parentage, it was difficult for a young newly qualified doctor to get a hospital appointment in London where nepotism was rife. General practice in some obscure corner of England would not have been conducive to furthering one’s career. His acquaintance with William Price, a retired naval surgeon in Leeds, may have emphasised the benefits which a young ambitious capable doctor could get from a career in the Navy. Spencer Wells’ application came to the attention of the William Burnett. In the subsequent 10 years, Burnett was to look after Spencer Wells’ career and treat him with some favouritism and tolerance [2,3,4,5].

The Maltese Islands fell under the British sphere of influence in the first decade of the nineteenth century, Britain’s possession of Malta being confirmed at the Congress of Vienna in 1815. The importance of the islands was quickly recognised, serving as an important link in the chain of Mediterranean bases between the Atlantic and Indian Oceans. The British navy, using the Malta harbour as its base, found it necessary to provide suitable shore accommodation for the sick and wounded. The necessity for a proper naval hospital was recognised very early on during the British-Malta connection, so that on the 7th November 1803 the Mediterranean Commander-in-Chief Lord Nelson wrote to the commander of the British forces on Malta Major General Villettes about a suitable site for a Naval Hospital. After a number of buildings were taken over by the British Navy to serve as hospitals for the naval personnel, a Royal Naval Hospital was built in the Grand Harbour area at Villa Bighi in 1832. The health of in the Mediterranean stations was generally very good and comparable with those prevalent in Britain, and contrasting with the mortality rates of other stations (Figure 1) [6,7].
 

SHORE POSTING 1841-1848
After joining the Naval Service in September 1841, Spencer Wells was immediately posted as Assistant Surgeon to the Malta Naval Hospital at Bighi in 1841. He reported to Haslar Naval Hospital to await passage to Malta. While awaiting passage, Spencer Wells further his education by utilising the well furnished library and museum at Haslar. His name is recorded in the visitor’s book of the library on four occasions between the 9th October and 22nd November 1841. He eventually took passage to Malta, arriving probably in December after six weeks at Haslar [2].

During his posting in Malta, Wells was mainly preoccupied with the surgical treatment of naval personnel at Bighi Naval Hospital. The cases treated at Bighi Hospital during 1842-1844 were published in The Edinburgh Medical and Surgical Journal [8,9]. The first report dealing with the cases treated in 1842 was prepared by Dr. William Martin, the Deputy-Inspector at Bighi Hospital since 1840. The paper was however reported and published in 1844 by Spencer Wells because of the demise of Dr. Martin who was shot in the back by a sentry on the 6th March 1843. During the sentry’s trial, a plea of insanity (homicidal monomania) was entered; this insanity plea was accepted by one member of the jury and thus the accused escaped capital punishment [4,10,11,12]. Spencer Wells performed Dr. Martin’s postmortem and reported that "the late head of this establishment, who was shot by a soldier on sentry, supposed to be insane……died forty minutes after the shot, the ball having passed from behind, shattering the right kidney, dividing two folds of small intestine, and passing out to the left of the umbilicus". In his short comment, Spencer Wells does not seem to be convinced of the sentry’s insanity [9]. Dr. Martin was succeeded by Dr. William Couborough Watt MD FRCS on the 25th March 1843. Watt served at Bighi Hospital until his death on the 20th August 1848 after serving with credit for over thirty years in the Royal Navy [28].

The health of the Mediterranean Fleet was apparently quite good. The total number of patients admitted to at Bighi Hospital during 1842-44 was 1403 while a further 95 cases were carried over from 1841, an average of 468 cases annually. Bighi Hospital served a fleet of about 5000 men, though Spencer Wells points out that as a general rule the surgeons of ships sent "to hospital only such cases as from their nature or severity cannot be conveniently treated on board." The cases reported were thus not the common cases of disease, but the worst cases in the fleet. There were a total of 85 deaths reported in the hospital giving a average case fatality rate of 5.3% (Table 1). About 18.3% of cases seen at Bighi Hospital during 1842-44 were invalidated because of chronic ill-health. The average mean annual mortality rate of the fleet based on the cases admitted to the hospital in Malta approximated 17 per 1000 persons. A number of naval personnel are reported in the local press to have died prior to being admitted to hospital. The monthly admission rates showed no definite pattern though they were very much higher in the earlier period (Figure 2) [8,9].

  Table 1: Cases seen at Bighi Hospital 1842-44

The cases admitted to the hospital throughout the three year period included disease affecting the nervous system (91 cases), the respiratory organs (208 cases), the organs of the circulation (36 cases), the digestive organs (146 cases), the genitourinary organs (62 cases), organs of locomotion (49 cases), disease of the tegument and fibrous tissue (230 cases), injuries (256 cases), and specific disease (320 cases). Some minor discrepancies in the data columns given by Spencer Wells in his papers can be noted. The commonest specific cause of death was phthisis or tuberculosis accounting for 22 cases (25.9% of deaths). Other respiratory disease including pneumonia, gangrene of the lung, typhoid pneumonia, and pleuritis accounted for a further 10 cases. Cardiac related disorders accounted for 3 cases while phlebitis accounted for a further 3 cases. Central nervous disease including apoplexy, delirium tremens, cerebral effusion and abscess, cerebral or spinal injuries accounted for 9 cases. Febrile and specific infectious disease (including dysentery, liver abscess, Marsh fever, erysipelas, intermittent fever, and variola) accounted for 22 cases (32.9% of cases). A diseased kidney was the cause of death in 6 cases, while trauma to the genitourinary system accounted for a further 3 cases. Two deaths were attributed to purpura and a generally impaired health without morbid appearances respectively [8,9]. The classification used by Spencer Wells appears decidedly different from the nomenclature of disease for the Surgeon’s nosological tables required by the Naval Regulations of 1825 which were in force at the time. These requirements were altered in 1851 and by 1868 were based according to the parts of the body affected, as recommended by the Royal College of Physicians. Spencer Wells appears to have used a classification similar though not identical to that which was eventually adopted [3].

Spencer Wells performed autopsies on every patient who died, and he sent the pathological specimens to the Haslar museum, which since 1827 under the directorship of Dr. Scott was being augmented. Some of these post-mortems are described in his published reports and their accuracy and detail reflect the prize award he had received for his post-mortem reports during his undergraduate studies at St. Thomas Hospital. He also apparently attended several post-mortems performed on civilians. Thus during his first year in Malta - 1842 - he had performed 48 post-mortems on seamen and marines, while he had attended about 50 post-mortems performed on Maltese. During the period 1843-44, he reports performing 31 post-mortems on seamen. He does not appear to have performed any microscopic studies [8,9]. The performance of post-mortems in the civil population in Malta was apparently a regular feature. It is recorded that the professor of Anatomy at the University of Malta, Dr. Charles Galland (1839-58) during the year just prior to Spencer Wells arrival during December 1840 - December 1841 performed no less than 615 post-mortems on civilians dying from various causes [13,14].

The observations obtained from these post-mortems were used by Spencer Wells to assess the incidence of renal disease and tuberculosis in naval personnel and compare these to that in the Maltese population. Renal disease was noted to be commoner in seamen being found in 66.7% of post-mortems performed in 1842. This incidence was very much higher than that noted among the Maltese. The morbid changes were similar to those described for Bright’s Disease, though only four cases out of 32 showed signs of albuminuria. Spencer Wells concludes that in spite of the morphological similarities, the renal disease noted in naval personnel could have been due to a disorder other than Bright’s Disease. He planned to attempt a correlation between the urine findings and the morphological state of the kidneys at time of death. His later observations for 1843-44 however decreased the noted incidence of renal disease at post-mortem to 32.3% [8,9].

The data obtained from these post-mortems and subsequent ones were in later years used by Spencer Wells to show a higher incidence of tuberculosis in seamen as compared to soldiers and the Maltese civilian population. Basing his prevalence figures on the proportion of tubercles found in post-mortems at Malta between 1842 and 1852, Wells concluded that the average number of tubercles noted in sailors was 23 a year, or 37.7% of sailors, the comparative figure for soldiers was 32% and for the Maltese civilian population 12%. He associated the high prevalence of tuberculosis in sailors to the poor ventilation in ships and made an urgent plea for improvements in ventilation through the use of Lieut. Gilmore's canvas air funnels. This plea was of little avail [15].

The clinical tools available to the mid-nineteenth century surgeon were limited to observation and examination. Spencer Wells’ description of the cases show a marked accuracy in the descriptions of the clinical progression of disease. He also effectively utilised the stethoscope for the examination of the chest and heart, and tested urine for the presence of albumin and sediment. While the Regulations of 1825 listing the instruments required by the naval surgeons did not formally include the stethoscope, Burnett had introduced this item in 1819. The pharmacopoeia used by Spencer Wells to treat the various conditions were in line with the list of medicines supplied to naval surgeons in 1825, remaining in force until 1868 [8,9,3].

Spencer Wells also reports on the efficacy of the various therapeutic regimens in use for the treatment of rheumatic disease (lumbago, sciatica, etc.) in seamen. The regimens investigated included (a) colchicum with sulphate of magnesia, (b) colchicum, sulphate of magnesia and mercury, (c) colchicum, sulphate of magnesia, mercury and opium, (d) mercury, (e) mercury, opium, and purgatives, (f) mercury and tartar emetic, (g) warm baths, (h) iodide of potassium, and (i) no medication. The results obtained with mercury, alone or in combination, were noted to be unfavourable. The most useful treatment in 1842 appeared to be the use of colchicum combined with sulphate of magnesia, while iodide of potassium, as proposed by Dr. Martin earlier, was reported to be the most useful remedy in the subsequent report. Iodide of potassium alone or combined with sarsaparilla was also found useful in the treatment of secondary syphilis. Primary syphilis was treated with mercury. Syphilis during the three year period affected a total of 126 seamen, while gonorrhoea affected 15 cases [8,9].

Medical thought at the turn of the 19th century associated several medical conditions with climate changes [16]. Spencer Wells similarly kept accurate observations on Maltese climate keeping observations on the minimum and maximum temperature and barometric monthly readings as read at mid-day with the instruments kept in a situation least exposed to local influences or changes. The prevailing winds and the number of rainy days during that month were also recorded. No relation between climate changes and the occurrence of disease states were reported, except that the death rate from phthisis was greater during or immediately after a prevalence of winds from the shores of Syria or Libya, ie the Scirocco and Liebeccio winds. It was remarked that the disease in common with all respiratory disorders ran a particularly rapid course when the Scirocco wind prevailed [8,9].

In 1843 Spencer Wells published two articles on plague and quarantine. In 1847 Spencer Wells published a sequel to his earlier articles, analysing and criticising the contemporary report of the French Committee. In this article, Spencer Wells conformed with the belief that the contagion of plague was quite consistent with reduction of quarantine measures, and that public health could be maintained simply by imposing restrictions upon vessels arriving from ports when plague was actually present. Being ignorant of the true aetiology of plague and believing this to be due to "miasma", Spencer Wells believed that the recurrent outbreaks of plague in Egypt were the result of the method of sepulture in that country. He thus proposed that the dead in Egypt should be buried in lime or soda to neutralise the miasma or pernicious exhalations which caused the disease. He also advocated better hygiene, sanitation and nutrition as useful general measures to control the disease. He continued to regard burial of the dead adversely. In 1874, Spencer Wells, as a member of the Medical Society of London, was co-signitory to a declaration drawn up by Sir Henry Thompson which stated "We, the undersigned, disapprove the present custom of burying the dead and we desire to substitute some mode which shall rapidly resolve the body into its component elements, by a process which cannot offend the living and shall render the remains perfectly innocuous. Until some better method is devised we desire to adapt that usually known as Cremation" [17,18].

During his stay on the Island, he was elected Fellow of the Royal College of Surgeons of England (1844). This election was made possible by the new charter of 1843 which permitted the College Council to elect a block of 300 further fellows. Spencer Wells was the youngest service officer selected through the intervention of Sir William Burnett, then Medical Commissioner to the Royal Navy. In Malta, Spencer Wells frequented the local medical circles and on the 28th April 1845 was enrolled a member of the Societa' Medica d'Incorraggiamento, the local medical association [3,19]. He was apparently also consulted to treat the local population, particularly ophthalmology and obstetrics. Wells was thus reported in 1847 to have operated on a least three cases of squint on Maltese inhabitants referred to him by local practitioners including Dr. Adami who practised in one of the towns around the Grand Harbour. The regard for his surgical expertise by the local medical community is reflected by the fact that one of the patients was in fact the daughter of a local practitioner (Dr. C. Vassallo). He was also one of the naval doctors called in consultation in a case of hydrophobia [20].

During his short stay in Malta, Spencer Wells was one of the practitioners responsible for the introduction of surgical anaesthesia on the Island. Sulphuric ether was first used as a surgical anaesthetic on the 30th September 1846. Ether anaesthesia spread to Europe and news of the discovery did not take long to reach Malta [21]. The use of ether to induce surgical anaesthesia was quickly taken up by Spencer Wells and two other British practitioners working in Malta. On the 9th March 1847, The Malta Times reported that experiments with ether had been previously undertaken by Mr. Wells and Dr. A.J. Burmester. These doctors initially prepared an apparatus to enable them administer ether. The first operation they attempted with this apparatus - one of amputation of the hand - was only partially successful because of imperfections in the locally produced apparatus which allowed the admixture of air with ether. The failure was subsequently attributed by Burmester to the impurity of the ether used [22,23]. Spencer Wells subsequently sent for a Hooper's inhaler from England which arrived on HMS Oriental. The apparatus was used for the first time successfully at Bighi Naval Hospital on a naval officer for an operation requiring large deep incisions only two days after its arrival. The operation was performed by the Deputy Inspector at Bighi Dr. William Couborough Watt, while the anaesthetic was administered by Spencer Wells. Two further surgical operations had subsequently also been performed painlessly [22].

The Hooper's inhaler was demonstrated to local practitioners by Mr. Spencer Wells during a meeting of the Societa' Medica d'Incorraggiamento held on the 16th March 1847. The apparatus was described as consisting "of two glass globes communicating with each other and both containing a sponge. In the upper the ether is formed and gradually drops through the sponge into the lower, from which the tube passes and carries the vapour of the ether and the air charged with it to the patient's mouth. The end of this tube is attached to a mouth piece, and is furnished with a stop-cork and two valves. One of valves prevents the air expired from re-entering the inhaler, the other allows it to escape, so that it can never again be taken into the lungs." Wells, presenting his address in Italian, reported that a number of operations, including two cases of squint, had been performed successfully under the influence of ether at the Naval Hospital and elsewhere. He observed that generally weak delicate individuals or those worn out by sickness were very speedily affected by ether within about two minutes, whereas strong stout persons and those accustomed to alcohol required a longer inhalation period, even up to eight minutes. Wells concluded that none of his ether-anaesthetised patients had suffered from any ill-effect and believed that the reported ill-effects of ether were accounted for by impurity in the ether, defections in the apparatus or carelessness in application, or previous disease in the patient. During the meeting two local medical practitioners (Drs. FL Gravagna and Luigi Calleja) inhaled ether to try its effects [24]. A commission of three practitioners, including Wells, was proposed to study the effects of ether on animals and humans and report to the Society during its subsequent meeting a month later. No further mention can be found regarding the work of this commission, but two years later a new commission was re-proposed to study the effects of ether and chloroform since Dr. Wells and another member of the original commission were away from the Island [19]. A detailed description of the Hooper's inhaler and directions for its use were subsequently published anonymously by Dr. Burmester, signing himself as a Member of the Royal College of Surgeons. The surgeon further described his experiences with self administration of ether during a demonstration in the presence of Mr Wells and Dr. Chetcuti. During this experiment, a decayed tooth was painlessly removed by Mr. Wells. He cautions against the indiscriminate use of the drug and suggests that local practitioners should investigate the subject. He subsequently invited medical men and other scientific persons to view this apparatus at Valletta [23].

Dr. A.J. Burmester was a British civilian practitioner practising in Valletta where he held consultations in all cases connected with medicine, surgery, ophthalmic surgery and midwifery. He was member of the Royal College of Surgeons of England and a Fellow of the Royal Medical and Chirurgical Society of London. His career came to an untimely end on the 29th May 1848 when he accidentally shot himself. He was buried in the Floriana Cemetery [28]. Credit is given by the local press to Spencer Wells for the introduction of ether anaesthesia saying that "credit is due to Mr. Wells, whose superior scientific attainments are well known here, as being the first to introduce to Malta, at rather considerable personal expense, the Ether apparatus" [22]. Burmester on the other hand wrote that he had instituted the initial experiments with ether [23].

The reading public in Malta was kept informed of the developments in the use of ether and several dental and surgical operations under ether anaesthesia soon made marked headway in the local scene. Spencer Wells and his colleagues were reported in the local press to have performed a series of operations in 1847, including (1) circa January: partial amputation of the hand - operated and ether administered by Burmester and Wells; (2) March: deep incisions - operated by Watt and ether administered by Wells; (3) March: deep cuts in a very sensitive part of the body - operated by Wells; (4) 9th March: removal of nail; (5) 15th March: two corrections of squint, one on a boy aged 13 and the other a lady aged 17 years - operated by Wells; (6) March: removal of a carried tooth - operation performed on Dr. Burmester by Wells; (7) April: squint operation performed by Wells; (8) July: correction of stabismus of the daughter of Dr. C. Vassallo by Wells [22,23,24,25]. In June 1847, Wells published 54 cases in which he had given ether with complete success [2]. Spencer Wells retained his experimental interest in anaesthesia. He was the first in 1867 to clinically use bichloride of methylene, a mechanical mixture of chloroform and methyl alcohol introduced by Benjamin W. Richardson in 1867. He continued to administering this mixture using the Junker's inhaler in abdominal surgery for more than twenty years [26].

Spencer Wells also attempted to extend the use of ether anaesthesia to the management of severe convulsions. The use of ether to control fits was apparently a standard therapeutic regimen well known to Spencer Wells. A case of a seaman undergoing fits in 1842 was successfully administered ether by Wells to produce unconsciousness, while the 1825 list of medicines supplied to naval surgeons included "Spiritus Aether Nitr." [3,8]. Ether anaesthesia was described by Dr. Burmester as a "novel application of an old remedy" [23]. In June 1847 Wells, together with other naval medical officers, was called in consultation to see a Maltese woman residing in one of the cities around the Grand Harbour who was bit by a rabid cat. The woman developed hydrophobia and notwithstanding the efforts of the medical practitioners died a few days later. This was reported to be the first case of Hydrophobia which has ever been known in Malta, though previous cases reported in the eighteenth and early nineteenth century had elicited the interest of medical practitioners [27,28]. Spencer Wells subsequently published in the local press a detailed clinical account of the case including the attempts at treatment with ether vapour and belladonna. He request information about the use of Indian hemp or the scutellaria in the management of hydrophobia in human subjects [29]. Mr Spencer Wells in later years (1859) reported the use of curare in the management of three cases suffering convulsions from tetanus [30].

In October 1847, Spencer Wells was appointed to HMS Hibernia [31]. He was promoted to full surgeon in 1848 even though he had not fulfilled the regulation of serving a year on a sea-going commission. By 1848, Wells had earned some leave and was granted six months. In July 1848 he requested permission to proceed to Paris to study war injury pathology under Malgeigne, Dupuytren and Claude Bernard. Later he studied under Stokes and Graves in Dublin and Travers in London. His leave was further extended and he went on half-pay until September 1851 [1,2].

SEA-GOING COMMISSION 1851-1853
In September 1851, Wells was appointed to HMS Modeste, a small sloop with a complement of 150 seamen. There was also an assistant surgeon Mr. Pearce on board. The Modeste cruised the Mediterranean ports, proceeding from Sheerness to Sardinia, then Malta, Corfu and Constantinople. After a visit to Genoa and Leghorn, the ship returned to Malta. During his sea-going commission, Wells occupied his time writing accounts of his experiences in Malta, besides meticulously keeping the doctor's journal which includes an 1852 account of the Ionian Isles. In his journal, Wells also commented on lack of ventilation in ships which he considered was the cause of the high incidence of tuberculosis in sailors, and recommended the use of Lieut. Gilmore's canvas air funnels. He did very little surgery, though he was asked to perform a post-mortem on a fatal cases of smallpox and a major operation while in Corfu [2,15]. The practice of encouraging naval surgeons who found themselves in out of the way places to describe their medical topography, climate, products, prevalent diseases and the local drugs used was only formalised by the Regulations of 1868. The journal was then sent to the Naval Medical Department at the end of each year. While formalised in 1868, intelligent surgeons had already availed themselves of such opportunities and had written essays of considerable historical interest [3].

After the 1844 Shipping Act was passed Sir William Burnett was asked to prepare a scale of medicines to be carried by law on all merchant ships, together with a handbook on first-aid. This duty devolved upon Wells after the passing of the 1850 Act (7 Vict., c.112), which was known as the Mercantile Marine Act; this handbook - "The Scale of Medicines with which Merchant Vessels are to be furnished....with observations on preserving the Health and increasing the comforts of Seamen" published first by Orr of London in 1851 passed through innumerable editions. Wells was then a renowned naval surgeon and the author of a treatise on gunshot wounds [3].

SUBSEQUENT CAREER
In 1853, on the grounds of a chronic chest ailment, Wells applied for sick leave and returned to London to be appointed to the Samaritan Free Hospital for Women. During the Crimean War, even though still on sick leave from the Navy, Wells joined the Army in 1855 as an army surgeon, serving in the British Civil Hospital in Smyrna and later at Renkiol. This interlude with the Army Medical Corps resulted in conflict with the Naval administration, since 1855 under the direction of Sir John Liddell who had succeeded Burnett. Liddell had made his name in his preparations for the Battle of Navarino (1827) which gained him the Glibert Blane Medal in 1832. He had attended Sir Walter Scott at Malta on his last voyage in quest of health (1831) and served in Malta until 1844 when he was transferred from Malta to Haslar and later to Greenwich [3]. The overlap between Liddell’s tour of duty in Malta with that of Spencer Wells ensured a previous acquaintance between the two men.

When in January 1856, Spencer Wells wrote requesting a renewal of leave, Liddel replied testily and refused the request. When Spencer Wells’ presence in the Army in the East became known, Liddell ordered Spencer Wells home and appointed him to the HMS Highflyer in August 1856. Pleading ill-health from his lung condition, his commission was terminated. Thus Spencer Wells career with the Royal Navy came to an end, having served for about six years in Bighi Naval hospital in Malta (1841-47), subsequently being transferred to the HMS Hibernia (1848) and Modeste (1851-53). Spencer Wells returned to his practice in London and forwarded his career to become president of the Royal College of Surgeons in 1883 when the title of baronet was also conferred on him. He died on 31 January 1897 [1].

1. R.A. Leonardo: Lives of master surgeons. Froben Press, New York, 1948, p.448-450.

2. J.A. Shepherd: Spencer Wells - Surgeon RN. Proc Roy Soc Med 1970; 63:306-308

3. C. Lloyd and J.L.S. Coulter: Medicine and the Navy 1200-1900. vol iv 1815-1900. E&S Livingstone Ltd, Edinburgh, 1963

4. C. Savona-Ventura: Malta and the British Navy: the medical connection during the nineteenth century. Part II. Some medical practitioners of note. J roy nav med Serv 1993; 79:33-36

5. Burnett W: 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

6. C. Savona-Ventura: Malta and the British Navy: the medical connection during the nineteenth century. Part I. The establishment of the Naval Hospital at Bighi. J roy nav med Serv 1992; 78:171-176

7. Leffin J: Surgeons in the field. J.M. Dent, London, 1970, p.113-114

8. W. Martin, T. Spencer Wells: Report of Cases treated in the Royal Naval Hospital, Malta. Edinburgh Medical Surgical Journal 1844; 61:350-390

9. T. Spencer Wells: Report of Cases treated in the Royal Naval Hospital, Malta, in 1843 and 1844. Edinburgh Medical Surgical Journal 1846; 65:1-24

10. The Malta Mail, 7th April 1843, p.2; 15th April 1843, p.1,3

11. Il Portafoglio Maltese, 3rd April 1843, p.2174; 10th April 1843, p.2183

12. The Malta Times, 10th March 1843, p.4

13. Davy J: Notes and Observations on the Ionian Islands and Malta. Smith Eldar and Co., London, 1842, 436p.

14. Cassar P: Physiological and Pathological Research at the General Military Hospital of Valletta, Malta, in the early Nineteenth Century. Medi-Scope 1986; 9:p.18-33

15. Public Record Office: Adm. 101 (Medical Journals/109). In: C. Lloyd and J.L.S. Coulter, 1963, p.203

16. Chetcuti D, Buhagiar A, Schembri PJ, Ventura F: The Climate of the Maltese Islands: A review. University Press, Malta, 1992, 108p.

17. The Malta Times, 20th July 1847, p.2

18. E. Jepson: The Society's influence on Medicine and the Community. In: T. Hunt (ed): The Medical Society of London 1773-1973. Heinemann, London, 1972, p.53-58

19. Storia della Societa` Medica d'Incoraggiamento. Malta, 1845, p.16,121,260,265,269

20. The Malta Times, 6th July 1847, p.3; 23rd March 1847, p.2; 15th June 1847, p.3.

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

22. Painless Surgical Operations. The Malta Times, 9 March 1847, p.2; 30th March 1847, p.3

23. MRCS (?Burmester AJ): Insensibility to pain produced by inhaling the vapour of sulphuric ether. The Malta Times, 23rd March 1847, p.2-3

24. Societa' Medica d'Incoraggiamento - Etherization. The Malta Times, 23 March 1847, p.2

25. The Malta Times, 13th April 1847, p.3; 6th July 1847, p.3

26. British Medical Journal, 1888, 1:1211

27. Case of hydrophobia following the bite of a cat. The Malta Times, 15 June 1847, p.3; 12 September 1848, p.3

28. Cassar P: Medical History of Malta. Wellcome Hist Med Libr, London, 1964, p.248, 544-551

29. Spencer Wells T: Case of hydrophobia following the bite of a cat. Employment of ether vapour and belladonna. The Malta Times, 24 August 1847, p.3

30. Spencer Wells T: Three cases of tetanus in which "woorara" was used. Proc Roy Med Chir Soc London 1859; 3:142-157

31. The Malta Times, 12 October 1847