A Maternity unit in Gozo a hundred years ago
Awarded the Medical Association of Malta Essay Prize for 1991
Published by The Author, Malta © C. Savona-Ventura, 1991
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted to any form by any means, electronic, mechanical, photocopying, recording or otherwise, without the previous permission in writing of the publisher.
Formally published in parts as: 1. Savona-Ventura C. A maternity Unit in Gozo a hundred years ago. Malt Med J, 1995, 7(1):p.10-16 2. Savona-Ventura C. Giving birth in 19th century Gozo. Storja, 2001, Malta University Historical Society, p.52-66 Also relevant to manuscript documents are the following published articles: 1. Savona-Ventura C. Nineteenth century disciplinary enquiry at Victoria Hospital, Gozo. Malt Med J, 1994, 4(2):p.44-49 2. Savona-Ventura C. Nicknames in Nineteenth century Malta. L-Imnarja: Journal of the Ghaqda Maltija tal-Folklore, 2002, 7(1):p.26-27 [republished: Folklore. Gabra ta’ Kitba minn membri ta’ l-Ghaqda Maltija tal-Folklore (ed. G. Lanfranco). Klabb Kotba Maltin, Malta, 2004, p.177-179] – see Appendix
INTRODUCTION The Maltese Islands are a group of small islands in the central Mediterranean, of which two are inhabited. In the first half of the sixteenth century the Islands were given to the Order of St John of Jerusalem, who had been ousted from Rhodes by the Turks. The Knights of St John brought with them their hospitaller traditions maintaining a high standard of medical practice influenced markedly by French medicine 1. At the turn of the nineteenth century the power struggle in the Mediterranean resulted in the Islands eventually falling under British dominion, with medical developments being influenced more and more by British standards. The control of midwifery on the Islands dates to the first quarter of the seventeenth century, when regulations were issued whereby midwives could only practice their profession after being examined and approved by the Protomedicus (equivalent to the Chief Government Medical Officer or todayâ€™s Director General) and the ecclesiastical authorities. The teaching of midwifery appears to have been by apprenticeship, since the first moves to introduce in Malta the formal teaching of the theory and practice of obstetrics to midwives were made in the late eighteenth century. These plans never materialized 2. The turn of the nineteenth century saw a major move towards the reorganization of the midwifery services in Malta and Gozo. In the mid-nineteenth century (1853) the Commissioners of Charity were still deploring the fact that "competent midwives were rapidly diminishing and that ignorant women were assuming their duties to the serious detriment of the poor population" 3. The medical profession accused midwives of being a grossly ignorant lot who either failed to call the obstetrician at the right time or else attempted to hasten delivery of the baby causing extensive perineal lacerations to the mother 4. Attempts to train midwives were hampered by the illiteracy of the students. The majority of confinements were domiciliary under the supervision of a midwife, the presence of a male doctor in the delivery room being tolerated only in cases of extreme danger 5. By 1868, it was planned that a more efficient School of Practical Midwifery would result in an adequate number of trained midwives so that one or two of them could be assigned to each police district 6. The specific midwifery staff in the Government medical service in 1896 included only an Accoucheur and Teacher of Practical Midwifery and a midwife, both with duties at the Central Hospital at Floriana in Malta. Routine obstetric work was performed by the resident medical officers in the hospitals. At Victoria Hospital in Gozo, no provision appears to have been made in the Colonial Estimates for specific midwifery staff 7. In April 1841 there was only one set of obstetric tools at the Civil Hospital, previous requests to purchase midwifery instruments for the Central Hospital (1833) and the Santo Spirito Hospital (1840) had been turned down. More midwifery instruments were obtained for the Central Hospital in 1855 8. 3
The first Maltese midwifery textbook dates to 1804 in the form of manuscript notes of lectures given to medical students by Dr F Butigiec 9. The obstetric practice being taught to midwives at the turn of the nineteenth century is outlined in three books written by the then Professors of Midwifery 10. The large majority of confinements were conducted in the home under the supervision of the midwife. The medical practitioner was only called in when abnormalities ensued 11. Hospital confinements were limited to necessitous women or difficult cases. Antiseptic techniques were introduced during this period so that whereas as late as 1883 Prof SL Pisani in his lectures recommended the smearing of fingers with oil as a lubricant when performing vaginal examinations 12, in 1896 Prof GB Schembri was recommending aseptic measures 13. Midwives were allowed to deal with cases of longitudinal presentations, whether cephalic or breech, and were advised to call the medical practitioner in abnormal presentations or cases of prolonged labour 14. The practitioner's intervention varied according to the circumstances and followed the obstetric teaching of the time resorting to internal version, and instrumental deliveries 15. Postmortem Caesarean sections are known to have been performed on a number of occasions during the late eighteenth and early nineteenth century, but the first recorded operation on a live woman in Malta was performed by Prof GB Schembri in 1891 at the Central Hospital at Floriana, though earlier practitioners had recommended the procedure to save both mother and child 16 . The birthing chair was frequently used having been recommended by Dr F Butigiec in his lectures to medical students in 1804, however both Profs Pisani and Schembri were against its use. The use of the birthing chair was made illegal in 1883 though it continued to be used up to the early twentieth century 17. By 1899 a set of 'Regulations respecting midwives' was published. These regulations laid down detailed instructions for the intrapartum and postpartum care of women 18. The island of Gozo is the second smaller island of the Maltese archipelago situated in the Central Mediterranean with an overall area of 26.974 sq miles and a total population in 1864 of 16038 individuals 19. The first woman hospital in Gozo dedicated to St. Julian dates to 1454. In 1783 a new women hospital accommodating fifty patients and receiving also unmarried pregnant women who sought refuge at the approach of labour was built. These facilities were transferred in 1838 to the Hospital of St John the Baptist situated at Rabat. This hospital changed its name to Victoria Hospital on the occasion of Her Majesty's Queen Victoria Jubilee in 1887 20.
SOURCE OF DATA From the foregoing description of maternity care practiced in Malta and Gozo in the late nineteenth century, it appears that mothers delivering at the various hospitals constituted a selected group of the population with specific sociobiological characteristics. The Register of Admissions and Discharges for Lying-in Women at Victoria Hospital for the period 29 March 1876 to 30 April 1893 (2 vols) were reviewed 21. There were a total of 396 admissions to the maternity unit, of which 358 (90.4%) delivered their infant/s. The registers included information pertaining to patient identification (name, surname, birthplace, and residence), to the patient's sociobiological characteristics (age, marital status, profession, spouses occupation, parity, religion, economic status), information about the medical and obstetric history of the patient together with notes on the present pregnancy. The Registers also noted the medical and midwifery personnel working in the hospital during the period. Further information was obtained from the correspondence books of the same hospital covering the period 9 February 1886 to 26 February 1889 22 and 6 September 1893 to 20 August 1903 23.
HOSPITAL STAFFING The Colonial Estimates for 1896 24 suggest that the staff at the Gozo Hospital included only a visiting Physician-Surgeon-Superintendent, a Resident Assistant Physician-Surgeon, a Matron Sister of Charity, a female nurse and two male nurses (one provisional and temporary), and a Chaplain, a Porter, a Cook, and a Mattress Maker-Tailor (provisional and temporary). Allowance was made for the occasional employment of Extra Medical officers and other staff. The District Medical Service in Gozo employed a further three medical officers. In 1851 there were about eighteen persons involved in the medical field in Gozo, with eight physician-surgeons, two apothecaries and eight midwives. Many worked both privately and part-time with the Government. In private practice, according to the official rates in force from 1821, a visit by day at the doctor's residence was charged £0.042, while a consultation by day £0.208. Many of the populace certainly could not afford to pay these rates, and the Government disposed of the District Medical Officers to assist the poor 25. The majority of infants were born at home. In normal births, the mother of the mother-tobe acted as midwife; if complications arose special midwives licensed by the bishop were summoned to help 26. During the period under review the post of Medical Superintendent was occupied by Dr. B. Mercieca, a post he held until 13 May 1903 when he was replaced by Dr. N. Tabone 27. In 1896 the post carried a remuneration of £130 per annum. The post was not a residential one. The Resident Medical Officer received £70 per annum, and was required to reside in 5
the Hospital at all times. The post of Resident Medical Officer was during the 16 year period occupied by four doctors in subsequent order, each of whom occupied the post for 5 - 6 years: Dr. L. Portelli (10/03/76 – 14/05/81); Dr. P. Zammit (02/07/81 – 15/04/86); Dr. N. Tabone (13/10/86 – 15/11/92) and Dr. G. Gulia (24/11/92 – 20/03/93). Dr. G. Gulia apparently filled this post at least until 21 October 1902. The interim period between Dr. P. Zammit and Dr. N. Tabone who was apparently appointed around the 1 October 1886 was solely covered by Dr. Mercieca, who on the 9 September 1886 asked the assistant Government Secretary for Gozo Mr. R. Micallef to allow the hospital to be covered by Dr. G. Debono who was the District Medical Officer for the Rabat area. There were two District Medical Officers at any one time who were referring patients to the Lying-in Unit of the Hospital. The longest referring doctor was Dr. G. Debono who referred 235 patients (59.3%) during the period 16/04/77 – 20/03/93. Other referring doctors included Dr. P. Sammut (36 patients), Dr. G. Vassallo (65 patients), Dr. N. Tabone (7 patients), Dr. B. Mercieca (4 patients), and Dr. G. Zammit (1 patient). Dr. P. Sammut who referred patients during the period 290376 - 120781 was eventually appointed a Resident Medical Officer for the period 020781 - 150486, after which he entered into private practice during which time he had no referrals to the hospital though he was involved in a case of abnormal delivery in July 1887 in association with Dr. Tabone. The District Medical officers in Gozo received £90 - 150 per annum depending on seniority 28.
GROUP PHOTOGRAPH OF DOCTORS WORKING IN GOZO AT TURN OF THE CENTURY
(photograph courtesy of the Medical Superintendant, Gozo General Hospital) left to right: sitting - Dr. N. Tabone Medical Superintendant Victoria Hospital; Dr. P. Sammut; Dr. E. Tabone D.M.O. Victoria; standing - Dr. T. Cauchi D.M.O. Xaghra; Dr. R. Mizzi R.M.O. Victoria Hospital; Dr. D. Marguerat D.M.O. Xewkija & M.O. i/c Gozo Isolation Hospital
The only midwife mentioned specifically by name for any period of time was Maria Cremona who is registered as conducting 101 deliveries during the period 11/08/81 – 15/04/86. Other midwives/nurses are mentioned by name in connection with single cases of delivery: Carmela Cordina (25/08/81), Maria Cordina (27/08/81) and Maria Camilleri (12/02/82). The latter was a hospital nurse who delivered a case of precipitate delivery. Maria Cremona also appeared on a number of occasions as the child's godmother being registered so in 56 cases over a period ranging from 16/01/80 – 01/04/87 when there were a total of 169 deliveries (3.l%). Another name which appears prior and after Maria Cremona frequently as godmother was that of Theresa Buhagiar who during the periods 07/02/77 – 28/04/79 and 11/11/87 – 28/01/93 was registered as godmother to the child on 22 occasions when there were a total of 152 deliveries (14.5%). The midwife conducting the deliveries is not named and may have been Buhagiar herself 29. There did not seem to be any provision for the regular appointment of midwifery staff at the Gozo Hospital in 1896. The regularly employed midwife in the Central Hospital in Malta received £36 per annum. A female nurse in the Gozo Hospital received £22, while a male nurse received £36 per annum 30.
Figure 1: Hospital & District Services employees
Other hospital employees mentioned in the registers included two male nurses employed respectively at the Civil Hospital and at the Ospizio, whose wives were admitted on five occasions 31. Paolo Busuttil was employed as an extra-nurse at the Civil Hospital. His birthplace and residence was at Rabat (Gozo). In 1885 he was aged 35 years. His wife was 7
aged 31 years and had had already eight previous normal pregnancies of which six children were still living. She delivered her ninth child on the 9 September 1885. A subsequent admission in 1890 showed that the couple had had another pregnancy. They had their eleventh child on 27 March 1890. A subsequent admission in 1892 showed that out of eleven pregnancies only eight children remained alive. They had their twelfth child on the 11 July 1892. Giuseppe Cefai was employed as a nurse at the Ospizio in Gozo. In 1890 he was aged 29 years. His birthplace and residence was Rabat (Gozo). His wife, aged 27 years, had had already four previous normal pregnancies with two living children. They had their fifth child on the 17 March 1890. In July 1892, she was admitted with her seventh pregnancy, when she was registered to have three living children. She discharged herself at request prior to delivery.
DEMOGRAPHY The majority of admitted patients (90%) eventually delivered their infants at the hospital. The mean annual number of admissions amounted to 23.5, with a minimum number of 13 admissions in 1876 and a maximum number of 33 in 1881 (Figure 2). The monthly admission rate varied from one month to another so that while in the month of January there were 65 total admissions in the period March 1876 to March 1893, in the month of June there were only 19 admissions. The mean number of admissions per month was 33 (Figure 2).
FIGURE 2: Annual & Monthly distribution of admissions
Thirty-eight admissions discharged themselves prior to delivery, so that there were a total of 358 deliveries during the period under review. The mean annual number of deliveries amounted to 21.1, with a minimum number of 11 in 1889 and a maximum of 29 in 1883 (Figure 3). The monthly delivery rate varied from month to month being lower in the May to August period with an overall mean number of deliveries per month of 28.1 (Figure 3). These deliveries accounted for approximately 4.4% of all the deliveries which occurred in Gozo during the period under review 32.
FIGURE 3: Annual & Monthly distribution of deliveries
(* excludes Jan - Mar deliveries)
A large proportion of patients resided at Rabat/Victoria (n = 174, 43.9%), while patients from Xewkija accounted for 14.9% (n = 59). Other catchment areas included Caccia (n = 28), Qala (16), Zebbug (17), Gharb (15), Kercem (17), Sannat (12), Nadur (12) and Ghajnsielem (11). The illegitimate pregnancies came from Rabat (10), Nadur (5), Caccia (4), Ghajnsielem (4), Sannat (2), Xewkija (1), Qala (1) and Gharb (1). Six mothers came from Malta (Valletta 2, Qormi 1, Mosta 1, Notabile 1, Sliema 1 ). Marriages between couples from the same village were frequent accounting for 262 admissions (66.2%). All except ten resided in the village where they were born (Table 1). This observation is similar to that made for the late 18th century when in Xewkija and Gharb, marriage between couples from the same village accounted for 53.1 and 70.2% respectively, in contrast to the trends in many villages in Malta 33. Couples marrying from different villages often resided in either the wife's (26: 19.4%) or the spouse's (71: 53.0%) birthplace. Ten husbands were registered as residing in a separate place to their wives, either in Malta (4 cases) or abroad (6 cases). Married couples living separately without permission was considered a reserved sin without special penalties, so that it is likely that 9
the separate residence of these couples reflected the high migration rate to Malta or elsewhere forced on by economic difficulties 34. Village à Rabat à Nadur à Xewkija à Sannat à Qala à Zebbug à Gharb à Ghajnsielem à Kercem à Caccia (?) TOTAL
no of marriages 129 8 42 9 13 12 12 5 10 22 263
TABLE 1: Marriages between couples from same village
SOCIOBIOLOGICAL CHARACTERISTICS The mean maternal age of the women admitted to the hospital during the period under review was 32.26 s.d. 6.9 years with the youngest mother being aged 15 years and the oldest three patients aged 46 years (Table 2). Eleven women (2.8%) were aged less than twenty years, five of whom were unmarried. Age at marriage is an important demographic parameter about the past since the number of children born is particularly dependant on the age of the bride. A number of sporadic literary non-statistical references are responsible for the commonly held opinion that the Maltese in past times married young 35. However statistical analysis of age at marriage in the late eighteenth century in a town in Malta have shown the mean age at marriage was 22.6 years 36. In Gozo during the first half of the nineteenth century, the trend appears to be marriage at the age of twenty for the bride, and twenty-two for the bridegroom 37. The mean age of primigravid mothers in this present series (n = 59) accounting for 15.2% of the study population was 23.9 years, while if only legitimate pregnancies (n = 38) are considered then the mean age of primigravid married mothers was 24.9 years. The mean paternal age was 36.32 s.d. 10.1 years with the youngest father being 18 years and the oldest 83 years. There were six spouses (1.7%) aged under 20 years, while eleven were aged more than sixty; four were under 65 years, a further four were under 70 years, while three were aged more than 70 years. The paternalmaternal age difference was very variable with a mean of 3.8 s.d. 8.7 years with a marked tendency towards an older husband (59.7%). In only 27.6% was the woman older than her spouse. The maximum age difference was of 53 years in two instances: husband aged 80 10
years wife 27 years, and husband 83 years wife 30 years. A reversed difference with an older wife only reached a maximum of 16 years with the husband aged 24 years and the wife 40 years. The mean paternal age of cases having their first pregnancy was 27.5 years. Similar observations were made in various towns and villages in Malta for the late 18th century 38. Thus in Balzan bridegrooms were noted to be about three years older than their brides with a mean age of 25.8 years. An older woman than her spouse accounted for 20.9 - 27.1% of all marriages in various towns and villages in Malta. AGE
mean+sd à à à à à à à à à à
under 20 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 over 60 TOTAL
MATERNAL AGE no % 32.26+6.9 11 2.8 55 13.9 58 14.7 105 26.5 83 21.0 78 19.7 6 1.5 0 0 0 0 0 0 396 0
PATERNAL AGE no % 36.32+10.1 6 1.7 34 9.4 45 12.4 74 20.4 60 16.6 78 21.5 25 6.9 22 6.1 7 1.9 11 3.0 362 34
TABLE 2: Age distribution - maternal & paternal
Grand multiparity appeared to have been a common feature in the late nineteenth century so that 35.9% of patients had had 5 - 9 previous pregnancies, while a further 8.9% had had ten or more previous pregnancies (Table 3). The mean previous gravidity excluding the index pregnancy was 4.4 pregnancies including abortions. no of children nil 1-4 5-9 10 - 14 over 15 unknown (4+) TOTAL mean
PREVIOUS PREGNANCIES no % 59 15.2 159 40.2 142 35.9 32 8.1 3 0.9 1 0.3 396 4.4
TOTAL LIVING CHILDREN no % 69 17.4 241 60.9 84 21.2 1 0.3 1 0.3 0 0 396 2.7
TABLE 3: Previous parity of all admissions
The fetal-child wastage appeared to be very high reaching 39.3%, so that the mean number of living children at the time of admission was 2.7 children, a figure suggesting a household size of 4.7 individuals. This figure is in excess to that quoted for four villages in Gozo during the previous century when mean household size was estimated at 3.7 - 3.9 individuals 39. A typical Gozitan household during the early nineteenth century has been reported to have consisted of six persons: two-three adults and three-four children. The actual average, excluding individuals living singly, was four per family in 1842 and 1851, but rose to almost five by 1861. A married couple produced an average of seven to ten children, half of whom normally survived infancy. In 1837, 48% of the annual deaths were of children under five years 40. The patient with the highest gravidity in the present series was a 40 year old married woman from Nadur who was in her 19th pregnancy at admission. All previous pregnancies were normal and she had 16 living children. Her husband was a 46 year old laborer. The mean parity by maternal age shows a gradual increase of parity with increasing age suggesting that no general method of birth control was in use (Table 4). Methods of avoiding conception in the late nineteenth century were known to the female population in Malta, though they were discouraged by the medical profession since the methods were considered to lead to congestion of the womb and subsequent invalidism 41. Some women practiced abortion; while coitus interruptus could have been the form of contraception used 42. MATERNAL AGE under 20 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49
mean parity 0.09 1.0 2.7 3.6 5.9 7.1 10.8
range 0-1 0-6 0-8 0 - 10 0 - 11 0 - 18 5 - 14
TABLE 4: Mean previous pregnancies by maternal age
Mortality was apparently high even after childhood. Thus of the 747 known patient and spouses fathers, 339 (44.7%) were registered as dead at the time of hospital admission. This high mortality is in line with the known youthfulness of past society. In the late 18th century more than half the brides (51.3%) in Malta had one or both of their parents dead at the time of first marriage. The average age of the population in two villages in Malta was 28.7 - 30.3 years 43. The life expectancy in Gozo averaged 30.5 years before 1837. This low average life time was due to the fact that 48% of the annual deaths before 1837 were of children under five. By 1851, life expectancy fell further to 29.8 years, but after their twentieth birthday it rose to 42 years, lower than the overall rate of 44.1 years. It slightly 12
improved by 1861 so that while in 1842 82 per 1000 of the population were over sixty, in 1861 the rate rose to 96 per 1000 44. The larger percentage (99.2%) of admissions was registered as paupers with only two cases being registered as paying patients. One unmarried woman of British parentage was admitted with the Comptroller's authority and registered to be normally resident at Sliema (Malta). She was aged 18 years and her occupation was that of a 'domestic'. She resided in the hospital for 52 days. The second case was similarly an 18 year old unmarried mother from Valletta (Malta) admitted on the recommendation of the Assistant Secretary of Government. Her occupation was similarly that of a 'domestic'. She resided in the hospital for 94 days. A third case had no note regarding her paying status. She was a 36 year old widow from Notabile (Malta) whose occupation was that of a 'servant'. She resided in the hospital for 14 days. The infant was illegitimate. The low socio-economic status of the patients delivering in the Government hospital in the late 19th century is not surprising, since hospital confinements were usually limited to necessitous women or difficult cases, besides unmarried pregnant women who sought refuge at the time of their confinement. The majority of women registered their occupation as lace-workers (362 women: 91.4%), while the remainder registered occupations such as spinners (19), servants (4), domestics (2), laborer (1), housewife (4) and beggar (3). One entry was illegible. The very high proportion of gainfully occupied women reflects the low socio-economic status of these families since the female found it necessary to supplement her spouses’ earnings. The lace industry was introduced in Gozo from Genoa in 1846 and developed fantastically by 1861. Women working lace earned over £0.013 a day. A woman spinning cotton from four in the morning till nine at night gained £0.014 after deducting costs. A woman agricultural laborer earned from about £0.017 to £0.037 45. The spouses’ occupation showed a wider diversity with the majority being registered as laborers (225 husbands: 62.2%). The next common employments were fishermen (43: 11.9%) and carters (28: 7.7%). The occupation profile (Table 5) reflects in part the social strata of the Gozo population in the late 19th century. In 1861, 66% of the population was gainfully employed. Of these 60.3% were artificers and laborers, 26.8% were employed in agriculture, 6.4% were mariners and fishermen, 3.5% were employed with commerce, 0.8% were government employees, while 2.2% were priests, land proprietors and in the professions 46. Members of the Regiment earned from £0.035 a day for privates to £0.204 for lieutenants. Artificers earned about £0.15 daily while masons earned £0.083 daily in 1864. Agricultural laborers earned about £0.125 daily, while fishermen earned about £0.009 a day after deducting expenses 47.
OCCUPATION ARTIFICERS AND LABORERS
(Laborer: 225; Carter: 28; driver/cabman: 8; gravedigger: 3; stonecutter: 2; servant: 1)
AGRICULTURE (farmer: 5)
MARINERS & FISHERMEN (fisherman: 43; sailor/seaman: 13)
COMMERCE (Baker: 5; carpenter: 5; dyer: 2; fishmonger: 4; shoemaker: 3; tradesman/dealer: 2; butcher: 1; barber: 1; lace-maker: 1)
GOVERNMENT EMPLOYEES (Nurse: 5; Gunner: 2; porter: 2) TABLE 5: Spouses occupation
In 34 of the admissions the father was unknown (illegitimacy rate 8.6%). Of this group 27 women were unmarried, 4 were widowed, while 3 were married. An illegitimacy rate of 8.6% is high when compared to rates of 2.1% with a maximum of 4.3% at Rabat (Gozo) reported for the late 18th century 48. There were 11 maternal/paternal fathers in this study who were registered as unknown computing an overall illegitimacy rate of 1.7%. Prostitution was not foreign in Gozo, but after 1851 no prostitutes were officially registered. There was no brothel on the island. Amorous adventures were perhaps not uncommon, but any mischief arising was many times remedied by a hasty marriage. Unmarried girls sometimes even sought a pregnancy to force a marriage unwanted by parents. Pre-marital intercourse or cohabitation, like abortion, was a reserved sin with the penalty of excommunication 49. All the women delivering at the hospital were Roman Catholics. The mean age of the unmarried women was 25.6 years with the youngest being 15 years and the oldest 40 years. The occupation of the unmarried was generally given as 'laceworkers', while two were listed as 'domestics'. Five women came from Malta, three of whom were admitted by the Comptroller's or the Ass. Secretary to Government's authority. Two were paying patients. The mean duration of stay in the hospital was 22.6 days antenatally and 16.7 days postpartum, the longest staying patients being the ones from Malta - 117, 60, 107, 51 and 84 days. Only seven Gozitan women stayed a prolonged duration - 69, 48, 58, 55, 44, 75, and 63 days, the first being detained 61 days in the puerperium to act as a nurse in the hospital. The other women stayed for a period of 1 - 27 days (mean 16 days). Two unmarried women discharged themselves at request prior to delivery. The majority of these women were primigravida (21: 77.8%), three were secondagravida, while three were having their fourth or fifth child. The five widowed patients were generally older (mean age 39.0 years; range 28 - 46 years) and multiparous (mean parity 4; range 1 - 9). Three were registered as lace-workers, one a 14
servant and one a beggar. All were non-paying patients except one whose status was not registered. She was a servant who normally resided at Notabile (Malta). The mean duration of stay in the hospital was 17.6 days (range 1 - 49 days). The beggar was aged 46 years, a grand multipara with nine previous pregnancies, was admitted in labour and stayed only one day of the puerperium. The servant from Malta was aged 36 years, was having her fifth child and was admitted one day prior to delivery staying 12 days of the puerperium. The three married women having illegitimate children were aged 28 - 30 years, and were having their 2 - 5 child. Their occupations were registered as laceworkers (2 women) or spinner (1). All resided in Gozo. The duration of hospital stay ranged from 8 61 days antenatally and 7 - 14 days postpartum. All but two illegitimate infants who survived the puerperium (n = 32) were all cared for by their mother. One was given to a nurse, while another was assigned to its grandmother's care. The church-run St Julian Hospital had a special ruota for the deposit of illegitimate babies. The hospital continued to receive illegitimate children, but not unwed pregnant mothers after the establishment of St John the Baptist Hospital. St Julian Hospital closed its doors in 1866 to become the Gozo Seminary. Fathers, from motives of conscience, generally maintained their unwanted or illegitimate children 50. Five women in the study had been previously widowed and had remarried. Their mean age was 35 years (range 28 - 40 years) and they had a mean of five previous pregnancies (range 1 - 9) with a mean of 2.5 living children (range 1 - 4). Their new husband's age ranged from 19 - 46 years (mean 35.8 years). The husband's occupations were registered as laborers (3 husbands), a farmer (1) and a porter (1). One woman may have been widowed during her current pregnancy. She was aged 29 years with 2 living children (3 previous pregnancies with one abortion). Her husband had been a gunman with the RMFA aged 47 years. The child was registered as legitimate. The average age of females applying to remarry in the late 18th century in Malta was 34.2 years, these remarrying after a mean of 3.1 years after the death of their original spouse 51.
MEDICAL CHARACTERISTICS The disease of pregnant women were considered in the late 19th century as either exacerbations of the casual deviations from a perfectly healthy condition which thus transgress the limits of health; or incidental disease not directly due to pregnancy but whose progress is specifically modified by it; or affections of the sexual organs; or finally anomalies in the development of the fetus 52. The abnormalities specific to pregnancy were considered separately. The patients admitted to Victoria Hospital during the period under review were reported to have variable medical conditions the majority being incidental 15
disease, some of which however were directly or indirectly responsible for causing a fetal/neonatal and/or maternal death. Thirty five patients (8.8%) admitted to the hospital were reported to have some form of pre-existing condition or were currently suffering from some symptomatology or disorder (Table 6). There were two cases of antepartum haemorrhage (0.5%), one of which terminated in a preterm delivery at about 27 weeks gestation. The female infant died two days after delivery from debility. The second case delivered at term without any adverse outcome. There was only one case of eclampsia admitted to the hospital (0.3%). This occurred in a 17 year old primigravid woman whose first fit occurred four hours prior to admission. The patient continued being seized frequently by eclamptic fits. Delivery was 'manual' with the birth of a mature female child. Both mother and child survived into the puerperium. ANTEPARTUM DISORDERS a] Deviations from health conditions 1. oedema, dropsy, anasarca 2. varicose veins - haemorrhoids 3. gastric disorders 4. acute gastro-lumbar pain ?cause 5. lumbago 6. debility ?cause b] Incidental disease 1. Respiratory disorders a) asthma b) bronchitis c) Phthisis pulmonaris d) Pneumonia 2. Heart disease 3. Renal disease - nephritis 4. Other a) ophthalmia, blindness, conjunctivitis b) nevifibroma c) weak mind d) semiparalysis right hand e) abscesses c] Pregnancy disorders 1. metrorrhagia - A.P.H. 2. Eclampsia
no of cases 3 1 5 1 3 1
1 2 2 1 1 1 4 1 1 2 1 2 1
TABLE 6: Antenatal medical disorders
The majority of disorders considered as deviations from healthy conditions caused only a minor inconvenience to the patient. Two cases, one of anasarca and other of dropsy, terminated in a bad perinatal outcome. The case of dropsy was one of multiple pregnancy admitted in preterm labour at about 36 weeks pregnancy. Both infants were born alive though feeble and died later. The case of anasarca similarly terminated in a preterm labour at about 28 weeks of pregnancy. The male child was born in a feeble condition but survived 16
the puerperium. Oedema of pregnancy is associated with a large variety of conditions ranging from the effects of pressure by the enlarged uterus to hypertensive disorders of pregnancy. A number of the incidental disorders were associated with a bad obstetric outcome. The two cases of phthisis pulmonaris (tuberculosis) terminated in a maternal death, as did the case of pneumonia. Chronic disease of the air passages, especially of the lungs, in which the respiratory surface is diminished, may be affected by pregnancy and labour. Amongst acute disease, true pneumonia is a highly dangerous complication. Women showed a greater mortality from the disease than do males, and this mortality was particularly high during pregnancy. Pregnancy was not infrequently interrupted naturally. Induction of preterm labour was to be avoided. Medicinal treatment was the same as that used in the nonpuerperal state, digitalis having a special value, while venesections being practiced when threatening symptoms were present. The latter could bring on collapse and onset of labour. Tuberculosis had been previously considered to be a minor disease during pregnancy, but the lying-in condition was noted to have a more injurious influence where the disease was already present and it often accelerated a fatal end. Although pregnancy usually reached full term in spite of progressive tuberculosis, it was not rare for labour to come on some weeks too early; abortion could also take place, and was as injurious to the phthisical woman as was the lying-in period after a premature or a full term labour 53. Tuberculosis appears to have been not an uncommon disease in the Maltese Islands in the 18th century especially towards its close. Towards the mid-nineteenth century poverty, bad housing conditions and overcrowding were certainly favorable for the spread of the disease. The improvements in the economic state of the Island and the introduction of sanitary reforms at the beginning of the last quarter of the century were accompanied by a reduction in the general death rate. The mortality from phthisis showed a parallel decline from 1 per 1000 population in 1874 to 0.8 in 1876 constituting 3.6% of the total amount of deaths 54. The mother dying from pneumonia was a 38 year old gravida 7 patient transferred to the Lyingin ward from the Medical Female ward of the Hospital because of premature onset of labour at about seven months gestation. Delivery was mechanical. The mother became worse in the puerperium and died two days later. The infant died from prematurity. The cases of tuberculosis were similar. The first was a 23 year old gravida 4 patient who was admitted to the ward in preterm labour at about 8 months gestation. The patient became worse during the puerperium and died soon after delivery. The infant similarly died from prematurity. The second case was a 32 year old gravida 3 patient who delivered at term. The mother died ten days after delivery as a complication of her tuberculosis. The infant survived and was given out by the hospital to be nursed. Other conditions which terminated in a bad perinatal outcome in the present series included mothers with heart disease and nephritis. The former case was a 46 year old gravida 6 patient who was transferred in labour to the Lyingin ward from the Female Medical Wards of the Hospital at about eight and a half months gestation. The delivery was mechanical and the placenta was extracted after the birth of the child. The patient passed for the worse from the heart disease and died on the same day of 17
her delivery. The infant similarly died on the same day of birth from immaturity. The mother suffering from nephritis was similarly admitted to the Lying-in ward from the Medical Ward when premature labour occurred at the seventh month of pregnancy. The mother survived the puerperium, but the infant was a stillbirth caused by 'degeneration of the placenta'. Labour was apparently complicated by an intrapartum haemorrhage (abruption?). Puerperal disorders reported in the registers similarly ranged from minor symptomatology to severe disorders resulting in maternal deaths. The disorders reported included 7 cases of gastric disorders, 1 case of bronchitis, 1 case of enteritis, 1 case of postpartum haemorrhage, 4 case of sepsis, and a case of puerperal collapse following a prolonged labour. There were a total of seven maternal deaths in the series (2.0%). A number of these were associated with pre-existing maternal conditions while the remainder resulted from intra or postpartum complications. The four maternal deaths caused by pulmonary tuberculosis (2 cases), pneumonia, and heart disease have been previously described. The other three deaths were caused by enteritis, prolonged labour, and metro-peritonitis. The mother dying from enteritis was a 39 year old gravida 10 patient who had a normal delivery at term. She was apparently seized by an attack of enteritis which caused her death 15 days after her delivery. The infant remained healthy. The mother dying from prolonged labour was a 35 year old primigravida patient admitted to the hospital after labouring for three days at home. The cause for the prolongation of labour was noted to be 'spasmodic stenosis of the vaginal canal'. Delivery was manual, with the placenta being extracted immediately after delivery. The infant was stillborn. The patient passed suddenly for the worse being seized by a general collapse that led to her death a few hours after delivery. The cause of death was recorded to be 'distocia'. One mother died as a result of puerperal infection, though a further three cases of sepsis were recorded (1.1%). The mother dying from puerperal sepsis was a 36 year old gravida 10 patient who delivered twins, the first alive by mechanical delivery, the second stillborn by manual delivery. The second fetus presented by the left hand (transverse presentation, hand prolapse). The placenta was extracted immediately after delivery of the second child. The mother developed metroperitonitis and died three days after delivery. Two cases of puerperal fever followed normal deliveries. The third complicated a case of face presentation which required a manual delivery. The case was further complicated by intrapartum haemorrhage. The infant was stillborn. Puerperal sepsis was a common problem resulting in marked maternal mortality and morbidity, and remained so well into the twentieth century when reorganization of maternity services, aseptic techniques and antimicrobials helped decrease both the incidence and mortality from sepsis 55. The first concentrated effort to control puerperal sepsis was undertaken at the turn of the 19th century with the publication and enforcement of the 'Regulations respecting midwives' 56. These regulations however took time to be well enforced in the Lying-in Wards at Victoria Hospital in Gozo. In August 1903 Dr N. Tabone, then Medical officer in charge of the Charitable Institutions in Gozo, wrote "What the midwife in charge is expected to do is to assist any women in labour, to give her first dressing after confinement and to entrust the further treatment of the patient to Hospital 18
nurses. Sir, I consider this system greatly objectionable both as regards danger of infection, which might be easily conveyed from the underlying Hospital to the Lying-in Ward and the want of practical knowledge on the part of the nurses to deal with puerperal cases. To remedy the inconvenience I feel it my duty to lay great stress on the advisability of discontinuing such a practice and beg to suggest that whilst excluding the female nurses from any duties in connection with what is expected to be performed by a trained midwife the midwife i/c be made to abide by the regulations provided by law, which establish besides other duties that any midwife in the exercise of her profession is to visit her patients twice a day for the period of eight days from the date of confinement" 57. The perinatal outcome for the child was generally good, there being a total of 16 stillbirths (stillbirth rate 44.0 per 1000 total births) and 23 neonatal deaths (neonatal death rate 66.1 per 1000 livebirths). The causes of death for the stillbirths as registered or as indicated by the medical data given included intrapartum asphyxia from prolonged labour or a traumatic delivery (8 cases - 2 face presentations with manual delivery, 1 breech delivery, 1 transverse second twin, 2 prolonged labour, 1 manual delivery, 1 deviation of fetal head with manual correction); cord complications (3 cases - 1 torsion of the cord, 1 cord prolapse in a case of contracted pelvis, 1 cord around neck); prematurity (2 cases); macerated stillbirths (2 cases); and one undetermined. The causes of neonatal deaths included prematurity (7 cases - one case of twins); trismus (5 cases); birth asphyxia/trauma (5 cases); debility (2 cases); enteritis (1 case), phlegmon (1 case); and one undetermined cause. Ten other infants were born in a feeble condition, but survived the neonatal period and were discharged from the hospital. There were ten premature deliveries, one a case of twin pregnancy (prematurity rate 27.9%). Only one survived the neonatal period to be discharged from the hospital. There were six cases of twin pregnancies (Twin pregnancy rate 16.8 per 1000 deliveries). The majority of these survived. Two cases were associated with a bad perinatal outcome. One patient delivered a stillborn twin after a manual delivery for a hand prolapse in a transverse lie in a second twin. The second case delivered prematurely and both infants died in the early neonatal period. The twin pregnancy rate in very much in excess to that reported for the Maltese Islands in the twentieth century with a rate of 10.21 per 1000 maternities 58. The majority of labours progressed spontaneously, there being only 23 (6.4%) cases of manual delivery, the remainder being natural sive mechanical deliveries 59. The manual deliveries were conducted by a medical practitioner except for four cases which are registered as conducted by the attending midwife. No further data is available regarding these cases. Abnormal deliveries were usually conducted by both the Medical Superintendant (Dr. Mercieca - 7 cases) and the Assistant Medical Officers (Dr. L. Portelli - 1 case, Dr. P. Sammut - 4 cases, Dr. N. Tabone - 14 cases). In some instances both the Medical Superintendant and the Ass. Medical Officer were involved (Dr. Merciecs/Dr. Sammut - 2 cases, Dr. MerciecaDr. Tabone - 4 cases). The operative procedure appears to have been undertaken for 'want of contractions' possibly secondary arrest of labour (5 19
cases); malpresentation (3 breech cases, one complicated further by a cord prolapse which terminated satisfactorily; one transverse lie in a second twin); malposition of the fetal head (2 face presentations, one malposition requiring adjustment); dystocia (1 obstruction of os uteri, one contracted pelvis complicated by cord prolapse, one rigidity of vulva, one rigidity of cervix, one spasmodic stenosis of the vaginal canal); one case of impacted shoulders; and a case of manual delivery performed in a patient with eclamptic fits. Ten cases (43.5%) terminated in a stillbirth, while two cases terminated in a maternal death. One of the cases of manual delivery is detailed in the correspondence books for the hospital60 since the attending Resident Medical Officer Dr N. Tabone was reported by the Medical Superintendent Dr. B. Mercieca to the Assistant Secretary to Gozo Mr P. Trapani for asking assistance from the private practitioner Dr. P. Sammut rather then calling him from Marsalforn or the District Medical Officer for the Rabat area Dr. Debono. The case involved a 35 year old gravida 7 woman admitted in labour at 1700 hours on the 28 July 1887. She gave a history of having had a manual delivery in her previous pregnancies. It appears from the correspondence that in spite of very strong uterine contractions for a period of 25 hours labour had not progressed satisfactorily, and vaginal examination failed to identify the presenting part. After a further five hours of very strong tetanic contractions, a malpresentation (breech presentation) was identified, and the attending Resident Medical Officer decided to call for help since the necessary "...operazione ostetrica, come principio fondamentale non die giacumai essere eseguita da un solo pratico, ma questi die essere accompagnato se non da 2, almeno da un altro ostetrico." The patient was delivered of a stillborn female infant on the 30 July at 0030 hours after a labour lasting 31.30 hours. The mother survived the puerperium. The comments made by Dr. Tabone about the management of the case suggests that the breech was delivered using the method advocated by Francois Mauriceau in 1740 which required an assistant to pull on the legs. Dr Tabone appeared to have been unfamiliar with the single-handed method advocated by William Giffard in 1734 61. The third stage of labour was assisted in a total of 25 cases (7.0%), with the majority (12 cases) following a manual delivery by a medical practitioner, or after the birth of a stillbirth by a mechanical delivery (3 cases). The remainder were performed for a variety of purposes including atony of the womb with slight postpartum haemorrhage (1 case), preterm labour in a heart case mother (1 case), hyperadherent placenta extracted one hour after birth of the child (1 case), precipitate delivery complicated by cord rupture and uterine atony (1 case), feeble labour (3 cases, one complicated by postpartum haemorrhage, another after a twin birth). The remaining cases delivered their placenta spontaneously after a period of a maximum of 30 minutes.
DISCUSSION The medical services in Malta and Gozo had been very well developed by the end of the 18th century as a legacy of the efforts and interests of the Knights of St. John. The majority of deliveries in the Islands were conducted in the home, generally under the supervision of a midwife or a birth attendant usually the mother of the mother-to-be. Midwifery practice was state and church controlled. The earliest evidence of state control of midwifery goes back to the first quarter of the 17th century. According to the regulations no woman was allowed to practice midwifery unless examined and approved by the Protomedicus and granted the requisite licence. The midwives required also a license from the Episcopal Curia to enable them to practice. Formal training of midwives was entertained in 1772 when Dr GA Creni proposed a course of instruction consisting of monthly lectures and practical demonstrations to women intending to take up midwifery. These plans never materialized. The first classes held for the instruction of midwives were organized in 180262. This contrasts with the situation in the United Kingdom, where is spite of a number of individuals who pressed for the training and control of midwives, it was only after 1870 that a voluntary examination of proficiency in midwifery was introduced. The situation was different on the continent particularly France, Austria and Prussia 63. The mean annual deliveries at Victoria Hospital in Gozo were 21.1, a number strikingly similar to that reported from Malta in the late 18th century. Hospital confinements in Malta were rare so that during the period 1750 - 1800 there were only 891 deliveries (17.8 annually) reported at Santo Spirito Hospital at Mdina, Malta 64. These women were usually necessitous women or unmarried mothers. The concept of midwifery care in the hospitals followed closely the concepts practiced on the continent particularly in France. The leading training school for midwives in France during the seventeenth century was the Hotel-Dieu in Paris. The hospital, in the tradition of its religious foundation, was a charity; anyone was accepted as a patient, and in the maternity wards no questions were asked. Many of the children were illegitimate. In 1678 some 1500 children were born. Women were admitted in the last two weeks of pregnancy. Puerperal fever was rife, even though visitors to the maternity wards were not allowed in without a pass 65. The Knights of St. John maintained a close relationship with French medicine, and the Professor of midwifery at the turn of the 18th century had trained in Paris 66. In his lecture notes of 1804, Dr. Butigiec refers to a large selection of authors ranging from the time of Hippocrates in the fourth century to contemporary obstetricians on the continent. On the latter group he refers to obstetricians from not only France, but also Austria, Italy, Holland, Germany and United Kingdom 67. In the United Kingdom, the first Lying-in institution for the relief of poor married women was only opened in 1739 by Sir R Manningham in Westminister. Permanent institutions were subsequently founded in the principal cities 68. The number of deliveries in these institutions remained low, so that in 1875 there were 394 deliveries in Queen Charlotte's Hospital, 400 21
in the City of London Hospital, 264 in York Road Hospital, and 155 in British Lying-in Hospital. At the beginning of the 19th century on the continent, the number of annual births in the Maison d'Accouchements (Paris) approximated 1842, while in the Hospital of St. Catherine (Milan) the number was 296 69. In the 19th century, under British rule, conditions in medical care deteriorated. By 1836 the Colonial Government was spending only ÂŁ6701 annually on hospitalization, just 67% of the amount spent in the preceding century by the Knights. Of this amount, only 7% was spent in Gozo, though the Gozitans formed 14% of the archipelago 70. By 1896 the situation had improved so that a total of ÂŁ42370 were voted for the Charitable Institutions, with however only ÂŁ640 being voted for the Gozo institutions 71. With the policies of hospital admissions for maternity cases it is not in the least surprising that the women delivering there came from the lower socio-economic groups of the community. This selection accounts for the discrepancies in the hospital statistics compared to the overall statistics for the Island 72. The stillbirth rate for the Gozo hospital stood at 44.0 per 1000 total births, a figure approximately 2.8 times the overall rate reported for Gozo in 1895 which stood at 15.9 per 1000 total births. The figure for Gozo was similarly higher than the reported for Malta during the same year which was reported at 12.2 per 1000 total births. The infant mortality rate for the Maltese Islands stood at 146.1 per 1000 live births, while the death rate for neonatal 'affections consequent on parturition' stood at 26.7 per 1000 live births. The rate of affections consequent on parturition was higher in Gozo at 97.1 per 1000 live births than in Malta at 21.3 per 1000 live births. These figures compare favorably with figures reported for England during 1838-39, when the neonatal death rate was 44 per 100 live births and the infantile death rate was 159 per 1000 live births 73. A larger proportion of the neonatal deaths from Gozo accounting for 42.7 per 1000 live births were attributed to tetanus neonatorum, a cause which was also prevalent in the hospital accounting for five of the neonatal deaths (rate 14.4 per 1000 live births). The rate of deaths caused by tetanus neonatorum in Malta was much lower at 7.4 per 1000 live births 74. This discrepancy between the Islands reflects the rural and social conditions prevalent on Gozo, conditions which were conducive to the development of tetanus in the newborn. In the late 19th century trismus was believed to be possibly caused by too high a temperature of the water used for the child's first bath 75. Difficult labour as a cause of neonatal death in Gozo in 1895 accounted for 10.3 per 1000 live births, in contrast to a rate of 14.4 per 1000 live births in the hospital. This difference suggests that there may have been a tendency towards referral of difficult cases to the hospital after failure to deliver at home. One case in the hospital series was referred to the hospital after labouring three days at home 76. The incidence of difficult labour reported for Malta in 1895 was 8.6 per 1000 live births 77. This lower figure from Malta suggests that more expert help was available in the form of midwives and medical practitioners on that Island.
Puerperal sepsis was a common problem in the late 19th century. The incidence of puerperal sepsis in Gozo for 1895 stood at 5.8 per 1000 total births, with a mortality rate of 1.5 per 1000 total births. The incidence of puerperal sepsis in the hospital was markedly higher at 11.0 per 1000 total births and accounting for a mortality of 2.8 per 1000 total births. The higher incidence in the hospital reflects the adverse puerperal care and attention given to delivered women, associated with the possibly increased recourse to operative interventions. The adverse conditions in the hospital were well described by Dr. Tabone in 1903 78. The incidence of puerperal sepsis in Malta was reported in 1895 as 3.7 per 1000 total births, and accounted for a mortality of 2.7 per 1000 total births 79. The management of the puerperium was aimed at preventing the development of this complication with semiisolation of the patient for ten days, syringing the vagina with 1 in 4000 solution of sublimate or Condy's fluid for about 20 days, and careful perineal care. Any signs of fever were to alert the attending midwife to call in a medical practitioner. It appears that the practice of vaginal douches was being questioned 80. The history of puerperal sepsis during the nineteenth century was one of tragedy since while it was becoming plain that the medical attendant during delivery was often the unconscious agent for transmitting the disease, yet no effort was made to control the transmission. After 1875, there was a gradual development of medical bacteriology which brought on enlightenment as to the aetiology of puerperal sepsis, and established the means of controlling the disease. The maternal mortality rates in various hospitals in Europe varied from one institution to another and were dependant on the incidence of puerperal fever. Hospital mortality from puerperal fever was markedly higher than in the general population. The maternal mortality rate for the City of London Lying-in Hospital during 1851-1875 averaged 27 per 1000 births. The figures for the Maison d'Accouchements (Paris) and Hospital of St. Catherine (Milan) approximated 44 and 31.8 per 1000 live births respectively. During the period 1880-1900 there was a general decline in maternal mortality in a number of countries in Europe. The decline was steep in some countries such as Belgium and Sweden, and slight in others such as England and Wales 81. When addressing the Royal College of Physicians in London in 1944, Sir Winston Churchill remarked that "The longer you look back the further you can look forward". No branch in medicine can claim a longer history than the art of midwifery. Until fifty years ago pregnancy and labour carried a significant risk of death for the mother. The primary concern for all health professionals was the high maternal mortality. This was brought down before and after the Second World War with the introduction of antimicrobials and freer access to blood transfusion. Prior to this a high fetal/neonatal wastage was acceptable. After the risks to the mother from pregnancy were minimized, then attention shifted to the perinatal mortality until this too was significantly reduced. Pari passu with developments in medical care, general improvements in the social conditions of the population have contributed towards the decline in obstetric mortality and morbidity. Nowadays the attention during pregnancy is towards the psychosocial aspects of labour. Mothers, having been released from the overwhelming fear of a possible death for themselves and their babies, want to 23
enjoy the experience of pregnancy and labour. This attitude, whilst encouragable, must not be promoted at the expense of the progress obtained in this century. The lessons learned from the past must not be forgotten.
NOTES 1. P. Cassar, French influence on Medical developments in Malta, Malta, Ministry of Education, 1987, +27p. 2. P. Cassar, The Maltese Midwife in history, Malta, Midwives Assoc. Malta, 1978, +16p. 3. Commissioners of Charity. Letters issued 15 May 1851 to 4 November 1857 fol. 39, 103, and 137. Medical and Health Archives, Valletta. As reported in: P. Cassar, Medical History of Malta, London, Wellcome Hist. Med. Libr., 1964, p.412-413 4. Il-Barth 5 September 1871 p.42; 2 December 1871 p.83; 22 March 1873 p.26 5. Letters of Government issued 3 May 1887 to 5 March 1889 fol. 558. Medical and Health Archives, Valletta. See P. Cassar, op. cit. note 3 above p.414 6. Ibid, fol 253, 495 and 557 7. Colonial Estimates, Malta, 1896 Malta Government Gazette 20 December 1895, p.953, 956 8. P. Cassar, op. cit. note 3 above p.532 9. P. Cassar, Teaching of Midwifery in Malta at the beginning of the 19th century, St. Luke's Hosp. Gaz., 8(2):p.91-111 10. S.L. Pisani, Ktieb il qabla, Malta, Govn. Press Off., 1883; G.B. Schembri, The Midwife's Guide Book, Malta, Govn. Printing Off., 1896 +111p; G. B. Schembri, Taghlim ghal istudenti ta l-iskola tal Kwiebel ta l-Isptar Centrali, Malta, Govn. Printing Off., 1897 11. Ibid, S.L. Pisani, p.100-102 12. Ibid 13. G.B. Schembri, 1896, op. cit. note 10 above, p.65 14. S.L. Pisani, op. cit. note 10 above, p.100-102 15. A large number of contemporary books are known to have been used by Maltese medical practitioners and midwives, the majority of books being held by the National Malta Library. Other books included: O. Spiegelberg, A Textbook of Midwifery, London, New Sydenham Soc., 1887-88 2 vol; A.H. McClintock, Smellie's Treatise on the theory and practice of midwifery, London, New Sydenham Soc., 1878 vol 3; G. Vicarelli, Terapia ostetrica d'urgenza, Torino, Unione TipograficoEditrice, 1899; D.C. Vittorelli, Manuale di ostetricia ad uso delle levatrice, Napoli, R. Marghieri di Gius, 1884. 16. P. Cassar, The Church on Caesarean section in Malta in 1867, St. Luke's Hosp. Gaz., 1969, 11(1):p.48-52; P. Cassar, Clinical case histories and postmortem reports from the Malta Lazaretto in the 18 th Century, Mediscope, 1989, 13:p.9-13 17. P. Cassar, Vestiges of the parturition chair in Malta, St. Luke's Hosp. Gaz., 1973, 8(1):p.58-60 18. Regulations respecting midwives, Malta Govn. Gaz., 7 August 1899, p.774 19. J. Bezzina, Religion and Politics in a Crown Colony. The Gozo-Malta Story 1798-1864, Malta, Bugelli Publ., 1985, p.342 20. P. Cassar, op. cit. note 3 above, p.90-92 21. Register of Admissions and Discharges for Lying-in Women, Victoria Hospital, 29 March 1876 to 30 April 1893, 2 vol. Vol. II commenced on 29 March 1876 ending on 7 May 1884 +220p.; Vol. 24
III commenced on 13 May 1884 ending on 30 April 1893 +198p. Registers are paginated on alternate pages. 22. Correspondence Book for Victoria Hospital for period 9 February 1886 to 26 February 1889 +280p. 23. Correspondence Book for Victoria Hospital for period 6 September 1893 to 20 August 1903 +239p. 24. Malta Govn. Gaz., op. cit. note 7 above, p.948, 956 25. J. Bezzina, op. cit. note 19 above, p.60-61 26. Ibid, p.52 27. Admission Discharges Registers, op. cit. note 21 above. The dates given refer to the date of the first and last signed entry by the individual.; Correspondence Book, op. cit. note 23 above, p.219 28. Malta Govn. Gaz., op. cit. note 7 above p.956; Correspondence Book, ibid, p.218; Correspondence Book, op. cit. note 22 above, p.65,57-58,145,149-156,158-161; Admission Discharges Registers, ibid 29. Admission Discharges Registers, op. cit. note 21 above 30. Malta Govn. Gaz., op. cit. note 7 above 31. Admission Discharges registers, op. cit. note 21 above vol.3, p.30, 120, 121, 173, 175 32. J. Bezzina, op. cit. note 19 above, p.52. The birth rate in 1861 for Gozo was 31 per 1000 population or a total of 484 births. In the same year eight abortions/stillbirths were recorded. The calculated percentage of 4.4% is based on these figures obtained from the census undertaken during 1861. 33. F. Ciappara, Marriage in Malta in the late Eighteenth Century, Malta, Ass. News (M) Ltd., 1988, p.47-48 34. J. Bezzina, op. cit. note 19 above, p.72-73, 110 35. G.B. Badger, Description of Malta and Gozo Malta, 1838, p.73 36. F. Ciappara, op. cit. note 33 above, p.33 37. J. Bezzina, op. cit. note 19 above, p.52 38. F. Ciappara, op. cit. note 33 above, p.34-36 39. Ibid, p.41 40. J. Bezzina, op. cit. note 19 above p.53, 86-87 41. G.B. Schembri, 1896, op. cit. note 10 above, p.104 42. F. Ciappara, op. cit. note 33 above, p.118 43. Ibid, p.39 44. J. Bezzina, op. cit. note 19 above, p.53-54 45. Ibid, p.65-71 46. Ibid, p.59 47. Ibid, p.60-71 48. F. Ciappara, op. cit. note 33 above, p.84 49. J. Bezzina, op. cit. note 19 above, p.40, 110 50. Ibid p.52, 227-228 51. F. Ciappara, op. cit. note 33 above, p.58 52. O. Spiegelberg, op. cit. note 15 above, vol 1, p.336 53. Ibid, p.361-363 54. P. Cassar, op. cit. note 3 above, p.218-219
55. C. Savona-Ventura and E.S. Grech, Maternal mortality in the Maltese Islands, Int. J. Gynaecol. Obstet., 1987, 25:p.283-290; C. Savona-Ventura, Reproductive performance on the Maltese Islands during the Second World War, Medical History, 1990, 34:p.164-177 56. Malta Govn. Gaz., op. cit. note 18, p.774 57. Correspondence Book, op. cit. note 23 above, p.228-229 58. C. Savona-Ventura and E.S. Grech, Multiple pregnancy in the Maltese population, Int. J. Gynaecol. Obstet., 1988, 26:p.41-50 59. Admission Discharges registers, op. cit. note 21 above, vol. 2 p.150 60. Admission Discharges Registers, op. cit. note 21 above, vol. 3 p.71; Correspondence Book op. cit. note 19 above, p.145, 149-156, 158-161 61. W. Radcliffe, Milestones in Midwifery, Bristol, J. Wright & sons Ltd., 1967, p.33-34 62. P. Cassar, op. cit. note 2 above +16p 63. J. Donnison, Midwives and medical men. A history of Inter-Professional rivalries and women's rights, London, Heinemann Educ. Books Ltd., 1977, +250p. 64. F. Ciappara, op. cit. note 33 above, p.85 65. W. Radcliffe, op. cit. note 61 above, p.26-27 66. P. Cassar, op. cit. note 1 above 67. P. Cassar, op. cit. note 9 above 68. J. Donnison, op. cit. note 63 above p.25 69. J.M. Munro Kerr, R.W. Johnstone, and M.H. Phillips, Historical review of British Obstetrics and Gynaecology 1800-1950, Edinburgh, E&S Livingstone Ltd, 1954, p.263 70. J. Bezzina, op. cit. note 19 above, p.76-79 71. Malta Govn. Gaz., op. cit. note 7 above, p.952-958 72. Return of deaths in Malta and Gozo by districts and ages, Return of Births in Malta and Gozo, Comparative statement of cases of contagious disease reported. Malta Government Gazette No. 3738 - 3792, 1895. Fortnightly report prepared by Prof. S.L. Pisani C.G.M.O. and G. Caruana Scicluna Sanitary Inspector. Statistics reported for 1895 cover the period of 11 months from 1 January to 30 November 1895. 73. J.M. Munro Kerr et al, op. cit. note 69 above, p.257-293. 74. Malta Govn. Gaz., op. cit. note 72 above. In Gozo during the 11 month period in 1895, there were a total of 680 livebirths and 11 stillbirths. The birth rate was 35.6 per 1000 population. The corresponding figure for Malta were 8834 livebirths and 109 stillbirths. The birth rate stood at 58.0 per 1000 population. The There were a total of 1390 infant deaths reported from the Maltese Islands. 'Afflictions consequent on Parturition' accounted for 188 deaths in Malta and 66 deaths in Gozo. Tetanus neonatorum accounted for 29 deaths in Gozo and 41 deaths in Malta. 75. O. Spiegelberg, op.cit. note 15 above, vol. 1, p.325 76. Admission Discharges registers, op. cit. note 23 above, vol.3 p.171 77. Malta Govn. Gaz., op. cit. note 72 above. Difficult labour as a cause of infant death was responsible for 7 deaths in Gozo and 76 deaths in Malta. It was also listed as a cause for a maternal death in Malta. 78. Correspondence Book, op. cit. note 23 above, p.228-229 79. Malta Govn. Gaz., op. cit. note 72 above. There were a total of 4 cases of puerperal sepsis with one death reported from Gozo. In Malta there were 33 cases with 24 deaths reported. Other causes of maternal deaths identified from Malta included haemorrhage accounting for 5 cases and difficult labour accounting for one case. Incidental causes for maternal deaths cannot be identified from the published returns. 26
80. G.B. Schembri, 1896, op. cit. note 10 above, p.94, 107-108 81. J.M. Munro Kerr et al, op. cit. note 69 above, p.202-225; I. Loudon, Maternal Mortality: 18801950. Some Regional and International comparisons. Social History of Medicine, 1988,
Nicknames in Nineteenth Century Gozo C. Savona-Ventura L-Imnarja: Journal of the Ghaqda Maltija tal-Folklore, 2002, 7(1):p.26-27 [republished: Folklore. Gabra taâ€™ Kitba minn membri taâ€™ l-Ghaqda Maltija tal-Folklore (ed. G. Lanfranco). Klabb Kotba Maltin, Malta, 2004, p.177-179]
The use of nicknames has been prevalent in Malta throughout the ages possibly dating as far back as the Arab Period. Broadly Maltese nicknames have been subdivided into a variety of forms . The present study attempts to list the nicknames prevalent among the Gozo population in the late nineteenth century. The information was collected from the patient identification notes recorded in the Register of Admissions and Discharges for Lying-in Women at Victoria Hospital for the period 29th March 1876 to 30th April 1893 . These registers record a total of 396 admissions to the maternity wards of the hospitals. These women have been shown to come from the lower socio-economic strata of the Gozitan population . A total of 218 entries [55.1%] include the person's nickname together with the given forename and surname of the individual. There does not appear to be any nickname entry following the 25th March 1886, the inclusion of the nickname being apparently dependent on the whims of the admitting medical officer. During the period under review, a total of 202 individuals were identified by their nickname, but 16 cases were illegible while a number had multiple admissions thus reducing the total number of identified nicknames to 155. An alphabetical list of the identified nicknames follows, though a number marked with a ? are misspelt. All were preceded by the particle ta' (of).
1. J. Cassar Pullicino. Social Aspects of Maltese Nicknames. Studies in Maltese Folklore. Malta University Press, 1992, p.123-140 2. Register of Admissions and Discharges for Lying-in Women, Victoria Hospital, 29 March 1876 t 30 April 1892, 2 vols. Vol II commenced on 29 March 1876 ending on 7 May 1884, +220p. (alternate pagination); Vol III commenced on 13 May 1884 ending on 30 April 1893, +198p. (alternate pagination). 3. C. Savona-Ventura. A Maternity Unit in Gozo a hundred years ago. Maltese Medical Journal 1995, VII(I):p.55-61; C. Savona-Ventura. Giving birth in 19th century Gozo 1876-1893. Storja 2001, p.52-66 28
List of Nicknames A 1/77 Achcer B 19/81 22/85 03/80 13/78 02/79 18/76 06/77 03/81
Baeva Bajju Balal Besciesia Bezzina Brieret Brunu Bugian
C 12/79 12/76 20/77 18/82 02/77 02/82 07/80 20/78 09/78 04/84 15/85 30/81 14/83 13/85 24/81
Cacu Calcidonin Calura Carna Carnha Cascuza Causu Cheral Chischito Cinfa Cini Cormla Criterna Cumbos Cuschieri
D 06/80 Dobra E 09/82 Eksea F 05/79 12/83 11/77 04/78 05/84 04/85 20/81 24/78
Farfett Felici Ferhana Flusu Faqqar Fortin Fortuna Futur
(? Acer) (?) (?)
(?) (?) (?) (?cawsu) (?) (?) (?) (?) (?) (?Cumbo)
G. 01/79 32/81 22/80 16/84 25/80 08/77 15/83 02/81 04/77 06/78 11/82 22/76 08/82 01/85 19/77 20/76 15/77 08/85 02/83 04/83 17/76
Gadura (?) Gagu (?) Gandu (?) Geseran (?) Giacchi (?Giakk) Giacob Giaebri (?) gakbin Gahan Giannicu (?) Ginan (?) Ghingher (?Ginger) Giondu (?) Girbi (?Girba) Gisola (?) Gurdien Goga Gombor (?) Gora (?) Gostura (?) Gwan
G 26/80 Galetta 01/80 Gandlora 13/83 Gazzu
H 05/78 Hangun 14/77 Harbux 14/82 Hili
I 20/84 L-inglis K 09/79 14/80 11/76 07/79 14/78 12/87 03/79
Karrani Channu (?Kanna) Charie (?Kari) Cheiet (?Kejjet) Chis (?Kies) Cloru (?Kloru) Cola (?Kola)
L 15/79 08/83 17/84 24/84 20/80 11/83 22/84 03/83
Lafrena Lagari Lalg Lali Lazzru Licu Liximena Loranielli
M 29/81 Maeduish 13/82 Maeru 12/81 Marden 10/78 Martina 06/83 Masica 19/78 Masieh 01/78 Massi 22/81 Mastos 07/77Melliehi 08/81 Melha 09/84 Miru 25/81 Moncora 16/80 Mosnia 08/78 Munit
(?) (?) (?) (?Lalli) (?) (?) (?) (?) (?Mairu) (?) (?) (?) (?)
(?) (?Monsna) (?Munita)
N 16/78 Naduria 14/85 Nahli 16/76 Nanas
Gh 09/77 Ghaghi 27/83 Ghigha 0985 Ghistan 15/84 Ghnella
(?) (?Ghaja) (?) (?Ghonnella)
P 04/82 23/76 02/80 26/78 29/83 15/78 10/81 10/77 17/81 11/81 12/78
Partazan Patri * Peixu * Perin (?) Perisci (?) Pertina (?) Petit Pian Pieileicu (?) Pina (?Pinu) Preicet (?Precett)
R 12/85 Riehlu S 26/83 04/80 07/83 07/81 22/87 06/82 28/81 27/80 11/84 23/80 31/81 19/76 09/80 33/81
Saghi Savier Savina Scaland Scandarett Scei Scela Scifina Segruit Seudi Signura Sipitani Sneiter Suin
(?Rhielu) (?) (?) (?) (?) (?Skola) (?) (?Segwit) (?Sewdi)
T 02/78 Torek 21/81 Tropper 24/80 Tuna V 22/78 Valentina 13/79 Vaness X 07/84 Xuereb
Z. 15/76 14/76 11/78 03/77 16/77 03/78 21/78 17/80 23/78 09/81 03/82
Zabbetta Zaru Zbuna Zebbieh Ziri Znaifa Zoru Zott Zunzan Zuppet Sniet
(?) (?) (?) (?Zorru) (?) (?) (?Znied)
(?) (?Snieter) (?Sjuna)
Nineteenth century disciplinary enquiry at Victoria Hospital, Gozo. C. Savona-Ventura Malt Med J, 1994, 4(2):p.44-49
Disciplinary enquiries are a necessary regular important feature of employer-employee relationship especially in the public sector. The enquiry if conducted fairly and without prejudice serves to clarify misunderstandings which arise between employer and employee, and by studying the circumstances which led to the conflict can also be instrumental in identifying and correcting problems in that particular department for the betterment of the service. Unfortunately disciplinary enquiries are often conducted with an attitude of punishing the employee and protecting the employer - an attitude which, because of the defensive attitude which is taken by the employee and the "closemindedness" of the disciplinary board, puts aside the importance of identifing and correcting the problem which led to that situation in the first place. The present report describes such an enquiry into the actions of a junior medical practitioner employed with the public sector in the late nineteenth century, wherein the final attitude was in disciplining the officer without attempting to correct the circumstances which led to the incident . The incident occurred in the Government Hospital in Gozo. The Colonial Estimates for 1876 suggest that the medical staff at the Gozo Hospital included only a visiting Physician-Surgeon-Superintendent and a Resident Assistant Physician-Surgeon. Allowance was made for the occasional employment of Extra Medical Officers from outside the hospital , though it appears that it was preferable to utilize the services of the District Medical Officer for the Rabat area in times of shortage . The post of Medical Superintendent in 1887, the year of the enquiry, was occupied by Dr B.M.. It was not a residential post and the Medical Superintendent could leave the Rabat area provided it did not interfere with his duties and could attend emergency cases when requested by the Resident Medical Officer . Dr B.M. is known to have attended a number of abnormal deliveries in the Lying-in (Maternity) Ward of the hospital during the period from March 1876 to April 1893. Of a total of 23 abnormal deliveries, he was responsible for seven cases managed on his own and a further six cases assisting the Resident Assistant Medical Officer . The post of Resident Assistant Physician-Surgeon required the doctor 31
to live on the hospital premises . The post in 1887 was filled by Dr N.T. who was appointed to the post on the 13 October 1886 . The District Medical Service in Gozo employed a further three medical officers, of which Dr G.D. was responsible for the Rabat area. There were in 1851 a total of eight physician-surgeons practicing in Gozo suggesting a further three doctors involved with private practice. One of these doctors in 1887 was Dr P.S. who during his medical career was a District Medical Officer in Gozo (March 1876 - July 1881), was appointed a Resident Medical Officer at Victoria Hospital (July 1881 - April 1886), after which he entered in private practice . The case which initiated the disciplinary enquiry involved a 35 year old woman who in the late afternoon of the 28 July 1887 was admitted to the maternity ward to deliver her seventh child. It appears from the correspondence that in spite of very strong labour pains, delivery was not progressing satisfactorily because of an abnormal presentation, the infant presenting by the legs. The attending Resident Assistant Medical Officer decided to call for help since the necessary "....operazione ostetrica, come principio
fondamentale non die giacumai essere eseguita da un solo pratico, ma die essere accompagnato se non da 2, almeno da un altro ostetrico." The patient was delivered of dead female child in the early hours of the 30 July after a labour lasting 311/2 hours .
The disciplinary enquiry was initiated not because of the bad outcome of the case, but because the attending Resident Assistant Medical Officer asked the assistance of the private practitioner rather than that of the Medical Superintendent or the Rabat District Medical Officer . A bad obstetric outcome for the infant was an accepted feature of obstetric practice in the late nineteenth century. The rate of infants born dead in the hospital amounted to 44.0 per 1000 total births, while the rate of infants dying in the first few weeks of life amounted to 66.1 per 1000 live births. The national stillbirth figure for Gozo was 3.1 times less at 14.2 per 1000 total births in 1895. The higher hospital rate may be accounted for by the fact that the hospital catered for women from the lower socio-economic groups and probably also for women who failed to deliver at home . The enquiry was initiated by the Medical Superintendent by letter sent the subsequent morning to the Assistant Secretary to Government. Dr N.T. was accused in the letter of acting contrary to the regulations by requesting in a difficult case of delivery the assistance of a private practitioner rather than that of the Medical Superintendent or the Rabat area District Medical Officer . The Medical Superintendent apparently discussed the problem with Dr N.T. and is alleged to have stated that his objection was to Dr P.S. having been called to assist the case . Dr N.T. responded by writing an emotional detailed report on the 1 August 1887 to the Ass. Secretary to explain his actions. He apparently had second thoughts about his letter and withdrew it. In response to a subsequent request by the Ass. Secretary for an explanation, Dr N.T. sent a toned-down version of the original letter on the 7 August 1887 . 32
In his explanation Dr N.T. reports that the Medical Superintendent was absent that night from Victoria being at his summer residence at Marsalforn. In view of the clinical condition of the patient, Dr N.T. at midnight of the 29-30 July had sent a carriage for Medical Superintenent to come to hospital. He however estimated that the Superintendent would arrive about one and a half hours later, a delay he considered prolonged in view of the clinical situation . Dr P.S. lived only a short distance away from the hospital, and on hearing of the problem spontaneously offered his services. In view of the urgency of the case Dr N.T. accepted his help . Dr N.T. further commented that he had no official instructions to ask the District Medical Officer for help in the absence of the Superintentent, besides which the DMO at midnight could have been outside the city attending to his duties . Dr N.T. was subsequently reprimanded by the Assistant Secretary to Government in a note stating "Having carefully considered
Dr T......'s explanations, I have come to the conclusion that he has assumed a great responsibility in not calling early for the assistance of the PMO. Whatever may have been the circumstances of the case, it was not in my opinion an ordinary one, therefore he, Dr T......, was bound to act as directed by the Regulations. I regret very much that I must disapprove Dr T......'s action in this case." Throughout the series of letters regarding the episode, one cannot but sympathize with Dr N.T. who in the interest of his suffering patient put aside the standing regulations and asked for help from a private medical practitioner at hand, rather than waiting for his senior. The episode must have left Dr N.T. disillusioned. On the 17 August 1887, he applied for transfer to the Cholera Hospitals in response to a notice sent to Medical Men by the Lt. Governor the previous day. His request was turned down on the 22 August, though no reason for this refusal is recorded . Dr N.T. remained in his post of Assistant Medical Officer until November 1892. He was eventually appointed Medical Superintendent for Victoria Hospital in May 1903 . The reasons why the Medical Superintendent reported the case can only be left to conjecture. Was it strictly a rigidness to procedure or were there underlying personal interests? Dr B.M. had on other occasions reported the contractors supply the hospital with meat and bread for not supplying these items according to their contracts, suggesting a strict adherence to procedure . However Dr B.M. regularly applied for the concession to leave the hospital early during the summer months to go to his summer residence at Marsalforn  - was he afraid this concession would be stopped in view of the attendance of a private practitioner in his stead? Was there a personal antagonism to Dr P.S. as hinted at by Dr N.T.'s first letter ? Dr P.S. had been the previous Resident Assistant Medical Officer in the hospital from July 1881 to April 1886 and after his retirement to private practice had left the Medical Superintendent to man the hospital single-handed for a period of about six months . The adherence to the regulations of the Civil Servant was only to be expected reminiscent of the "modern" attitudes of Civil Servant administrators who because of the nature of their work fail to grasp the necessity of bypassing standing regulations or protocols in medical emergency situations. 33
NOTES 1. Correspondence Book for Victoria Hospital for period 9 February 1886 to 26 February 1889,
+280 fol: 30 July 1887 letter no 145 fol 145; 1 August 1887 letter no 151 (cancelled) fol 149156; 7 August 1887 letter no 152 fol 158-161; undated minute note following letter no 152 fol 161. 2. Colonial Estimates, Malta, 1876 Malta Government Gazette 20 December 1895, p.953, 956 3. On the 9 September 1886, the Medical Superintendent Dr. B.M. requested the Assistant Government Secretary for Gozo to grant him permission to leave his residence at Rabat at night for twenty days to go to his summer residence at Marsalforn. The emergency hospital duties were to be performed by the District Medical Officer for Rabat Dr G.D., since the post of Resident Assistant Medical Officer had not yet been filled after the termination of employment of Dr P.S. on the 30 April 1886. The hospital duties in the interim period had been performed solely by Dr B.M. This request was acceded to. Correspondence Book, op. cit. note 1, 29 April 1886 letter no 32 fol 30; 30 April 1886 letter no 33 fol 31; 9 September 1866 letter no 65 fol 57; 9 September 1886 minute note following letter no 65 fol 57-58 4. Every summer the Medical Superintendent requested permission to alter the time for the evening hospital rounds to enable him to go to his summer residence at Marsalforn. This request was regularly approved. Correspondence Book, ibid, 11 July 1887 letter no 142 fol 139 5. Savona-Ventura C, A maternity unit in Gozo a hundred years ago. Essay awarded the MAM Essay prize 1992. 6. Correspondence Book, op. cit. note 1 above, 22 March 1887 letter no 114 fol 105 7. Savona Ventura, op. cit note 5 above 8. Savona-Ventura, ibid 9. Correspondence Book, op. cit. note 1 above; Register of Admissions and Discharges for Lying-in Women, Victoria Hospital: 13 May 1884 to 30 April 1893, vol.3 fol 71 10. Correspondence Book, ibid 11. Savona-Ventura, op. cit. note 5 above 12. "La devo informare che questa notte, al tardi, il Medico Residente, Dr N T......, avendo avuto
bisogno, nello Ospedale, dell' assistenza di un altro medico, in un parto difficile, invece di chiamare me - sebbene a Marsalforno - o al medico Dist. Dr D......, chiamo` per aiutarle il medico privato Dr P S......." Correspondence Book, op. cit. note 1 above, 30 July 1887 letter
no 148 fol 145 13. "Il Dr M......., nel breve discorso tenuto fra noi sull' ultimo incidente mi ha dichiarato che se io
mi fossi valso dell' assistenza di un altro medico e non del Dr S....... la sarebbe stata una cosa compatibile. Per il che mi sorge il dubbio, anche secondo il rapporto da lui fatto, che le lagnanze sieno state fatta per parte sua solo perche` io ho avuto l'assistenza del Dr S......, cio` che non avrebbe forse avuto luogo, ove io avessi avuto l'assistenza di un altro medico anche privato." Correspondence Book, ibid, 1 August 1887 letter no 151 (cancelled) fol 155-
156 14. Correspondence Book, ibid, 1 August 1887 letter no 151 (cancelled) fol 149-156; 7 August 1887 letter no 152 fol 158-161 15. "Ma il Dr M........ si trovava allora assente da C. Vittoria, ed in villeggiatura a Marsalforno. A
mezzanotte, mandare in cerca di una vettura con ordine espresso al vetturino di informare il Dr M....... a Marsalforno che si bisognava di lui in Ospedale, finche` il Dr M......... potesse 34
giugnere in Ospedale, almeno almeno sarebbero scorsi un ora e 30 minuti. E lasciare scorresa tanto tempo finche` si fosse potuto incominciare a dare ajuto alla povera partoriente sarebbe stato secondo la mia misera opinione, un torto, una unumanita`, una ingiustizia che avrebbero pesato assui grava sulla mia coscienza." Correspondence Book, ibid, 1 August 1887
letter no 151 (cancelled) fol 152-153 16. "Il Dr P.... S......., medico privato, il quale allora si trovava a 5 passi di distanza dalla mia casa
di abitazione ufficiale, e in Piazza S. Francesco, conoscuito da me l'imbarrazzo in cui allora mi mettevano e il caso urgente e l'assenza del Dr M......... da C. Vittoria, spontaneamente si e` offerto a prestarmi i suoi servizi." Correspondence Book, ibid, 1 August 1887 letter no 151
(cancelled) fol 153 17. "....io non ho istruzioni ufficiali di ricorrere al Dr D....... qualora io aversi bisogno
dell'assistenza del Dr M........ quando il chiamare quest'ultimo del luogo suo di villeggiatura posso lasciar scorrere tanto tempo da compromettere a parare mio, la urgenza del caso che richiedere pronta assistenza medica. E il mandare a chiamare il Dr D...... a mezzanotte, nel dubbio che, questi a quell'ora potesse trovarsi furi di C. Vittoria ad attendere ai suoi doveri come Medico Distrettuale,.....". Correspondence Book, ibid, 1 August 1887 letter no 151
(cancelled) fol 154 18. Correspondence Book, ibid, undated Minute following letter no 152 fol 161 19. Correspondence Book, ibid, 17 August 1887 letter no 155 fol 164; 22 August 1887 minute following letter no 158 fol 168. 20. Savona-Ventura, op. cit. note 5 above 21. Correspondence Book, op. cit. note 1 above, 17 February 1886 letter no 7 fol 5; 22 September 1886 letter no 67 fol 60; 15 June 1887 letter no 134 fol 132; 7 September 1887 letter no 164 fol 173; 22. vide note 4 above 23. vide note 13 above 24. vide note 3 above