The History of Vostaneio Hospital of Mytilene

Abstract

Introduction: The Byzantine tradition of operating hospitals continued in Greece after the fall of Constantinople in 1453. A hospital carrying a significant history is the Hospital of Mytilene on Lesvos island.
Purpose: This historical review highlights the multifaceted work of the hospital on the island during the Ottoman period.
Material - Method: The methodology of historical research was used. Data was sourced from documents of the Patriarchate of Constantinople, a letter of the Synod and the oldest code of the mortgage estate of the Foundation. (1813).
Results: The civilian Hospital of Mytilene or ‘Hotel’ is the only Charity Organization of the ‘old city’. A Synodic letter dating from 1692 shows that the hospital started operating in Mytilene in the 17th century.
The main activities were nursing poor patients, providing free accommodation and food for all in need, acquisition and release of captives and prisoners and raising orphan children.
Conclusions: The Hospital of Mytilene on Lesvos island responded remarkably during the Ottoman era in nursing needs of both residents of the island and the wider region, according to the principles of the Byzantine and Orthodox tradition. It successfully continues its work to the present time.

Full text

NATIONAL BOARDS
ADVISORY BOARD
M. Levhi Akin Krum Katsarov M.Ali Ozguven Ioan Sirbu
Turkey Bulgaria Turkey Romania
Fikret Arpaci Stavros Kavasakalis Assen Petkov C. Turgut Tufan
Turkey Greece Bulgaria Turkey
Zeki Bayraktar Mustafa Kutlu Konstantin Ramshev Mustafa Turan
Turkey Turkey Bulgaria Turkey
Evgeni Belokonski Marian Macri Corneliu Romanitan M.Tahir Unal
Bulgaria Romania Romania Turkey
Mirela Bidilicã Apostolos Mantides Deniz Sagdic Krasimir Vasilev
Romania Greece Turkey Bulgaria
Hayati Bilgic Krasimir Mekushinov Georgios Sakarikos Victor Volcu
Turkey Bulgaria Greece Romania
F. Sevgi Hatipoglu Selcuk Isik Ivan Samnaliev
Turkey Turkey Bulgaria
Ersoy Isik Okan Ozcan Ali Sehirlioglu
Turkey Turkey Turkey
Official Journal of
Balkan Military Medical Committee
EDITOR – IN – CHIEF
Commander Christos BISSIAS, Greece
ASSOCIATE EDITORS
Lt Colonel Alexandra KARVOUNIARI, Greece
Lt Colonel Miltiadis ZIOGAS, Greece
Lt Commander Vasiliki ROKA, Greece
Albania
LTC Hekuran Braho
LT Bledar Kruja
Bulgaria
COL Assen Petkov
LTC Kalin Kanev
Greece
CDR Christos Bissias
LTC Alexandra Karvouniari
Romania
MAJ Bogdan Marinescu
MAJ Rares
Zamfir
Serbia
COL Djoko Maksic
LTC Boban Djordjevic
Turkey
COL Sait Sirin
COL Nuri Arslan

Instructions for authors
The Balkan Military Medical Review (BMMR) is the official
scientific publication of the Balkan Military Medical Committee
(BMMC), published every three months. Clinical and experimental
research articles, original case reports and review articles in gene-
ral and military medicine are published. Manuscripts are expected
primarily to concern on military medicine. Non-military subjects
are also welcome but they may be subject to delay, since the
military medical subjects have priority for publication.
A covering letter should accompany the manuscript, indicating
the items below:
a. Stating that the paper has never been published or has not been
submitted for publication elsewhere. The letter should be signed by
all authors. The contributors' and copyright transfer form (see
below) should also be submitted in original with the signatures of
all the contributors.
b. The studies previously presented in a Congress can be accepted
for publication. In this case, full title, date and venue of the congress
should be indicated.
c. The submittal should cover the responsibility and permission of
all the authors and it should strictly be signed by all of them.
d. The Approval Letter of the authority of the authors' institution
should also be included (military authority if applicable).
e. Ethical committee approval report (if applicable).
Ethics of scientific publishing:
f. Please note that the BMMR strictly adheres to ethical matters.
g. Plagiarism (stealing) of text from previously published papers by
another author is a serious offence, unless the material quoted is
appropriately indicated. Fraudulent data or data stolen from other
authors is also unethical and will be treated accordingly.
h. Manuscripts should be original and should not have been pub-
lished anywhere else. Failure to comply with this rule will be con-
sidered a double-publishing offence and treated appropriately.
i. Ethics of studies involving humans and animals: The editors draw
the authors' attention to the Declaration of Helsinki for Medical
Research involving Human Subjects and also to the Guiding
Principles in the Care and Use of Animals (DHEW Publication,
NIH, 80-23). Studies involving humans and animals or human or
animal material should have appropriate ethical approval and the
editors reserve the right to refuse publication on this basis.
j. In order to be published in the BMMR, approval certificate's copy
of the institutional ethical committee must be added to scientific
papers.
All manuscripts will be written in English. Official language of the
BMMR is English. All manuscripts should be English spell
checked.
Papers must be prepared complying with the following instruc-
tions:
The parts of a regular article should consist of the following sec-
tions: Title, Running title, Authors, Institute, Corresponding
Author and e-mail, Abstract, Key Words, Introduction, Materials
and Methods, Results, Discussion, Acknowledgments, References.
The words “Abstract”, “Introduction”, “Materials and Methods”,
“Results”, “Discussion”, “Acknowledgments” and “References”
should be written in bold and they should not be underlined.
k. Title: Should not exceed 25 words and should be specific and
informative.
l. Running title: Should not exceed 50 characters.
m. Author(s) and Institute(s): Authors' line should consist of the
first name, middle initials, and the last name of the author(s). The
last name should be written in capitals. Academic degree of
authors(s) will not be written. For the manuscript with more than
one author and department or institution, it should be shown by an
asterisk (*) after the last name in the authors' line.
n. Corresponding Author: The name, address, phone and fax num-
ber (as will be dialed internationally) and e-mail address of the
author to whom correspondence is to be sent should be clearly writ-
ten.
o. Summary: The aim of the study, setting, results and discussion
should be clearly summarized in a minimum of 50 words or in
maximum of 200 words.
p. Key Words: Up to five key words should be selected from the
chapter and subject titles of index medicus and be readily suitable
for indexing purposes and computer programs. Keywords should be
written in alphabetical order. (e.g.: Marrow transplantation for
Fanconi Anemia: Conditioning with reduced doses of cyclophos-
phamide without radiation. Keywords: cyclophosphamide, Fanconi
anemia, marrow transplantation).
q. Introduction: The aim of the study, other researches performed
by other authors should be pointed out briefly. The institution and
date of the study should be written. Introduction should not exceed
two pages.
r. Materials and Methods: The materials, methods, interventions
and the statistical analyses should be expressed in details. If the
research is supported by a scientific institution or a fund, it should
be expressed for the regular research articles.
s. Results: Findings obtained by the author(s) must be clearly stated.
(i). Illustrations and Tables: Table(s) should be shown in separate
page(s) after references and numbered with roman numerals.
lllustrations and figures should be numbered with arabic
number(s). The source and permission should be stated if figures or
illustrations are taken from other published books or journals. All
these materials (figures, illustrations, photographs) should be saved
in separate files and named according to their content, e.g. figure
No. 1, table No. 2, etc. In the text, their space should be kept empty
and the numbers of these materials must be written.
(ii). Units of measurement and abbreviations: Units of measure-
ment should follow the Systéme International. Standard units of
measurements and chemical symbols of elements may be used
without definition in the body of the paper. Abbreviations should
be given in parenthesis after their first mention in the text, and used
thereafter.
(iii). Statistics: Inadequate or incorrect statistical analyses fre-
quently cause rejection or delays in the review of manuscripts. If
necessary, authors should seek advice from a professional statis-
tician before the manuscript is submitted.
t. Discussion: Findings obtained should be compared with the find-
ings of the other researchers, and the authors' opinion and sugges-
tion(s) should be expressed.
u. Acknowledgements: Personal acknowledgements should precede
those of institutions or agencies.
v. References: References should be numbered consecutively in the
order in which they are first mentioned in the text. If there are more
than six authors, use the first three authors and then use ‘et al’.
(i). Books, as references, should be written in the following order;
last name and name of the section authors(s), title of the article, last
name and name of the editor(s), name of the book and number of
the volume of the edition publisher (company-country), date, page
number.
1. Gundogan MA: Endocrine Disorders. Eds.: Berk AO, Kocar
YH: Internal Medicine Diagnosis and Treatment, 1st ed., Ankara,
GATA Print House, 1990, pp. 797-946.
2. Mc Cullough J: Granulocyte Transfusion. Eds.: Petz LD,
Swisher SN: Clinical Practice of Transfusion Medicine, 2nd ed.,
New York, Churchill Livingstone, 1989, pp. 469-484.
(ii). Journals as references should be written in the following order;
last name and name of the author, title of the article, and abbre-
viation of the journal in the index medicus, volume and page
numbers, the year of publication. If the journal is not included in the
index medicus, full name of the journal should be written. 1.
Greenberg P, Cox C, Le Beau MM, et al.: International scoring
system for evaluating prognosis in myelodysplastic syndromes.
Blood 89:2079-2087, 1997. All articles should be written in
word.doc format only and in Times New Roman font 12. Double
spaces should be left between the lines. Manuscripts should never
exceed 15 pages (including the tables, illustrations and references)
All articles should be saved in a file and sent electronically to the

General Secretary of the respective National Board of the author.
Files should be updated, virus checked.
Scientists other than the current Editorial Board may be asked
for review if necessary. Peer reviewing process is also in use. The
editorial board has been authorized to refuse the articles that do not
comply with the publication rules. All rights of the BMMR are
reserved.
Letters to the Editor: Letters relating to previously published artic-
les in the journal and the replies of the author(s) will be published
in the "Letters to the Editor" section after consideration of the edi-
torial board. Letters should not exceed one page and five references.
Correspondence belonging to the "Letters to the Editor" section is
carried out by the editorial board. The editor may also invite any
experienced scientist on his/her field to write a letter to the editor.
Editorials, Short Notes and Reviews: The same rules apply as
"Letters to the Editor".
Proofs
Authors are sent page proofs for checking by the production editor
approximately one week after acceptance of the article. Proofs are
sent via NBs and should be checked and returned within 48 hours
of receipt.
Address for Article Submission for BMMC member countries:
National Boards of BMMC. No direct submission to The Editor is
allowed. In the manner of electronic submission, articles may be
submitted directly to the editor after the necessary permission is
taken from the national board at the e-mail
BMMR.GREECE@gmail.com. All correspondence will be carried
out via National Boards (or in information of National Boards for
electronic submission) for BMMC member countries.
Address for Article Submission for BMMC non-member countries:
Authors from BMMC non-member countries will be able to submit
articles at the following internet address:
BMMR.GREECE@gmail.com. The contributors' form and
copyright transfer form has to be submitted in original with the sig-
natures of all the contributors within two weeks from submission by
mail or fax.
The contributors' approval and copyright transfer form
Title : ______________________________________
We/I certify that we/I have participated sufficiently in the intel-
lectual content, idea, conception and design of this work or the
analysis and interpretation of the data (when applicable), as well as
the writing of the article, to take public responsibility for it and have
agreed to have our/my name(s) listed as (a) contributor(s). We/I
believe the article represents valid work. Neither this manuscript
nor one with considerably similar content under our/my authorship
has been published or is being considered for publication elsewhere,
except as described in the covering letter. We/I certify that all the
data collected during the study is presented in this article and no
data from the study has been or will be published separately. We/I
certify that, if requested by the editors, we/I will provide the
data/information or will cooperate fully in obtaining and providing
the data/information on which the manuscript is based, for
examination by the editors.
We/I also certify that we have taken all necessary permissions
from our institution and/or department (and national board) for con-
ducting and publishing of the present work. Financial interests,
direct or indirect, that exist or may be perceived to exist for
individual contributors in connection with the content of this paper
have been revealed in the covering letter. Sources of outside
support of the project are named in the covering letter.
We/I hereby transfer(s), assign(s), or otherwise convey(s) all
copyright ownership, including any and all rights incidental to that,
exclusively to the Journal, in the event that such work is published
by the Balkan Military Medical Review. The Balkan Military
Medical Review shall own the work, including
1) Copyright;
2) The right to grant permission to republish the article in whole
or in part, with or without fee;
3) The right to produce preprints or reprints and translate into
languages other than English for sale or free distribution;
4) The right to republish the work in a collection of articles in
any other mechanical or electronic format. We give the rights to the
corresponding author to make necessary changes as per the request
of the journal, do the rest of the correspondence on our behalf and
he/she will act as the guarantor for the article on our behalf. All
persons who have made substantial and essential contributions to
the work reported in the article, but who are not contributors, are
named in the Acknowledgment and have given us/me their written
permission to be named. If We/I do not include an
Acknowledgment, this means We/I have not received substantial
contributions from non-contributors and no contributor has been
omitted.
Author Signature Date
1. ___________________ ____________ ____________
2. ___________________ ____________ ____________
3. ___________________ ____________ ____________
4. ___________________ ____________ ____________
5. ___________________ ____________ ____________
6. ___________________ ____________ ____________
(TO BE MODIFIED AS APPLICABLE AND ONE SIGNED
COPY TO BE ATTACHED WITH THE ARTICLE)

Copyrights and Disclaimer
The website of Balkan Military Medical Review is:
http://www.geetha.mil.gr/index.asp?a_id=3433
It purposes to publish the journal electronically so it can be
available to the scientific community on the web. This web site
is purely for educational purpose of the military medical and
civilian medical community. This web site does not supply to the
needs of individual patients. It is designed to support the
relationship between the patients/site visitors and their existing
physicians.
The entire contents of the Balkan Military Medical Review
are protected under international copyrights. However, the
Journal bestows a free, irreversible, worldwide, permanent right
of access to, and a permit to copy, use, distribute, perform and
display the work in public and to make and distribute derivative
works in any digital medium for any reasonable non-commercial
purpose, subject to proper reference of authorship and ownership
of the rights to all users.
Neither the Balkan Military Medical Review nor its
publishers nor anyone else involved in creating, producing or
delivering the Balkan Military Medical Review (in web or CD
format) or the materials included therein, assumes any obligation
or responsibility for the accuracy, completeness or usefulness of
any information provided in the Balkan Military Medical Review
(in web or CD format), nor shall they be under legal obligation
for any direct, indirect, incidental, special, consequential,
penalizing or punitive damages arising out of the use of the
Balkan Military Medical Review. The materials published in the
Balkan Military Medical Review undergo peer reviewing process
as much as possible to ensure fair balance, objectivity,
independence, pertinence and relevance to educational need.
The editors of the material have consulted sources believed
to be reliable in their efforts to provide information that is in
harmony with the standards accepted at the time of reviewing
and posting. However, in view of the possibility of error by the
authors, editors, or publishers of the works contained in the
Balkan Military Medical Review, neither the Balkan Military
Medical Review, nor its publishers, nor any other group
involved in the preparation of material contained in the Balkan
Military Medical Review represents or authorizes that the
information contained herein is in every respect accurate or
complete, and they are not responsible for any errors or omissions
or deletion or for the results obtained from the use of such
material. Readers are encouraged to confirm the information
contained herein with other sources. Patients and consumers
reading articles published on the website of the Balkan Military
Medical Review should review the information carefully with
their professional healthcare provider. The information does not
aim to replace medical advice offered by the physicians. The
Balkan Military Medical Review and its publishers make no
representations or certificates with respect to any treatment,
action, or application of medication or preparation by any person
following the information offered or provided within or through
the Balkan Military Medical Review. The Balkan Military
Medical Review and its publishers will not be responsible for
any direct, indirect, consequential, special, exemplary, or other
damages arising from hereon.
You agree to hold innocent and indemnify the Balkan
Military Medical Review, its publishers, the Editors and their
board, and the contributors to the Balkan Military Medical
Review, against any responsibility for any claims and expenses,
including reasonable attorney's fees, relating to any violation of
the terms of this agreement or arising out of any materials
submitted by you.
You agree that this agreement and the terms and conditions
of this, including all disclaimers set forth herein, shall accustom
to the benefit of the editors and their boards, and the contributors
to the Balkan Military Medical Review, as third party
beneficiaries hereto, to the same extent that this agreement
inures to the benefit of the Balkan Military Medical Review.
The Balkan Military Medical Review reserves the right, at
its sole caution and discretion, to change the terms and
conditions of this agreement from time to time and your access
of the Balkan Military Medical Review will be supposed to be
your acceptance of and agreement to any changed terms and
conditions.
Balkan Military Medical Review may contain links to web
sites operated by other groups. These links are provided purely
for educational purposes. Such links do not suggest Balkan
Military Medical Review's approval of material on any other site
and Balkan Military Medical Review disclaims all responsibility
with regard to your access of such linked web sites.
Confidentiality of data relating to individual patients and
visitors to the Web site, including their identity, is respected by
the Balkan Military Medical Review Web site. The Balkan
Military Medical Review Web site undertakes to honor or
exceed the legal requirements of medical/health information
privacy as applicable.

Official Journal of
Balkan Military Medical Committee
Volume 15, Number 2, 2012
CONTENTS
57.
Editorial
Original Article
58.
Factors that Create a Successful Nursing Team in a Hospital Setting
Doynovska R., Vanesa V. (Bulgaria)
Case Reports
64.
An Ovarian Hernia with a Leiomyoma of Ovary
Popivanov G., Belokonski E., Mutafchiyski V., Tabakov M., Paneva R. (Bulgaria)
68.
Axillary Vein Thrombosis: Presentation of Four Cases and Review of the Literature
Bisbinas I., Karabouta Z., Georgiannos D., Bissias C. (Greece)
76.
Neurological Symptoms in Patient with Complex Tuberous Sclerosis
Genov K., Lesidrenski H., Stratieva S. (Bulgaria)
Review Articles
81.
The History of Vostaneio Hospital of Mytilene
Κοurkouta L., Ιppioti D., Papoulia F., Papathanasiou I. (Greece)
87.
Medical Ethics in Peace and War: An Historical Perspective
Magiorkinis E., Bissias C., Petrogiannis N., Diamantis A. (Greece)

Editorial
Dear colleagues, dear friends
The April-July 2012 issue of the Journal comprises an interesting collection of articles.
The first article elaborates on the factors that create a successful nursing team in a hospital
setting; the ability of ‘the team’ to create a good working atmosphere building a good rapport among
its members is of major importance.
The next three articles present interesting case reports by general surgical, orthopaedic and
neurology colleagues. We always start our differential diagnosis with the most common and ‘benign’
but we should always keep a high index of suspicion for the uncommon or more complex…
The history of an old hospital on the island of Lesvos in Greece is ‘sampled’ in the next
article; an institution with significant tradition and enormous contribution to the local population and
beyond.
The last article touches on a very important subject: that of medical ethics in general and
during war-time.
Best regards
Editor-in Chief
Commander Christos BISSIAS (Navy)
Associate Editors
Lt Colonel Alexandra KARVOUNIARI (Air Force)
Lt Colonel Miltiadis ZIOGAS (Army)
Lt Commander Vasiliki ROKA (Navy)
Balkan Military Medical Review
Apr-Jun 2012; 15(2): 57

Original Article
Factors that Create a Successful Nursing Team in a Hospital Setting
Rositza DOYNOVSKA1, Virsavia VASEVA2*
Affiliation of the authors:
1. Clinic of Pneumonology and Phthysiatrics, MHAT – MMA, Sofia, Bulgaria
2. Educational-Scientific Research Department, MHAT – MMA, Sofia, Bulgaria
Corresponding author:
Rositza Doynovska, RN
Clinic of Pneumonology and Phthysiatrics, MHAT – MMA, Sofia
3, St. G.Sofiisky Str.
1606, Sofia, BULGARIA
Tel: +359888221114
E-mail: doynovska@mail.bg
Balkan Military Medical Review
Apr-Jun 2012; 15(2): 58 - 63

Abstract
Introduction: The goals of any
organization are attained through the
realization of a certain number of tasks;
as for that purpose, the employees are
normatively distributed into groups. In
order to achieve higher efficacy of work-
related performance, the activities of
these groups, i.e. the realization of the
goals of the organization and the
personal satisfaction of its individual
members, have to be analysed. At
present, work groups/teams strengthen
their position as the most efficient in
medical practice.
Objective: The aim of this study was to
examine and analyse the working
atmosphere and the personal status in
the team as a part of the factors that
influence the creation of an effective
nursing team in a hospital setting.
Materials and methods: An anonymous
sociological investigation was conducted
among 247 nurses working in military
hospitals. The results were presented in
diagrams and numerical values.
Results-Conclusions: The responders
have given a high evaluation of the team
atmosphere (73%) with significant
differences related to the age,
educational level and specialty profile
and no difference related to the length of
service. Because of the “teamwork
principle” in hospital activities, the team
atmosphere is of high importance in
choosing a work place within the health
institution, with respect to the
possibilities for achieving successful
professional development and
establishing one’s position within the
team. By its essence, work is decisive for
the professional status. The closeness in
the responders’ answer percentages
reveals a relatively similar opinion on
the importance of the employee’s status
within the team and of work-related
behaviour. The opinion that the
employee is mostly responsible for their
position within the team (63.1%) is
prevalent, while this of the impact of
external factors on the attitude towards
the individual team member is less
shared (13.8%).
Key-Words: job satisfaction, military
hospital, nurses, team, work atmosphere
Introduction
A hospital, like any organization, has
fixed objectives and technical requirements
for their realisation. These objectives are
attained through a certain number of tasks;
as for that purpose, the employees are
normatively distributed into groups. Other
groups that are not subjected to
preliminary arrangement are also formed.
As a result, two main types of groups are
differentiated: formal and informal ones.
Work in the hospital setting is realized by
the formal groups (organizational units),
but concurrently, the so-called informal
groups are formed within them, based on
the individual members’ social needs. This
informal group formation is determined by
physical, economic, social and psychologi
cal reasons.
Contemporary concepts of “team
building” include issues, such as common
goal achievement, intra-team cohesion,
team structure, individual status, team
responsibility. Requirements to contempo
rary labour organization are continuously
increasing. A part of them is associated
with changes in the educational-
qualification level of the members of
individual groups and the need for
implementing flexible forms of labour
organization [1]. In order to achieve higher
59 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

efficacy of work-related performance, the
activities of these groups, i.e. the
realisation of the goals of the organization
and the personal satisfaction of its
individual members, have to be analysed.
The members of work groups are
interdependent during the completion of
their work assignments and, therefore, they
support each other [2].
Because of the large heterogeneity of
professions in the field of healthcare, the
general overestimation of one or other
specialty contradicts to the present
effective management of human resources,
in particular with the requirement for a
wide team approach. Healthcare activity is
not an isolated, individual activity but,
before anything else, it is a group activity
[3]. At present, team work strengthens its
position as the most efficient in medical
practice. The team communicates
constantly. Communication is related with
the process of establishing inter-individual
relationships [4]. When this process
proceeds correctly, each of the participants
can grow gradually, in both personal and
professional aspects [5]. For the formation
of an efficient interaction between the
individual and the organization, it is
necessary to define not only the essence of
this interaction, but also what personal
characteristics determine the individual’s
behaviour in the organization and the team
[6]. Because of these reasons not all
individuals can work within a team.
Objective
To analyze the working atmosphere
and the individual’s status within the team
as factors that influence the creation of an
effective nursing team in a hospital setting.
Materials and methods
An anonymous sociological inquiry
was designed and conducted among 247
nurses working in the multi-profile
hospitals, affiliated to the Military Medical
Academy. The responders were investi
gated, depending on their age, length of
service, profile and educational level. The
importance of the investigated factors was
evaluated by them according to a six-point
scale, starting from 1 (very low job
satisfaction) to 6 (very high job
satisfaction). The data from the
investigation were processed by the
statistical software packages
STATGRAPHICS v. 4.0; SPSS v.13.0 and
EXCEL for Windows. The results were
presented in diagrams and numerical
values. The significance of the conclusions
was determined at p<0.05.
Results and analysis
In the studied healthcare institutions,
the investigated 247 individuals did not
differ significantly by age, length of
service and medical profile. There was a
large difference in respect of the
educational level, with predominance of
the individuals with professional
bachelor’s educational-qualification degree
(70.04%) and bachelor’s degree (19.43%)
and master’s degree (10.53%),
respectively. Out of the investigated
medical nurses, 86.24% were at the age of
up to 49 years. More than half of the
responders had a length of hospital service
of up to 20 years. The distribution was
even, with no significant difference
(р>0.05). A natural correlation has been
established between the education and the
length of service of the responders
(χ²=48.13, р<0.01). There was no
significant difference (р>0.05) in the
distribution by specialty profile.
Based on the obtained results for the
significance of working atmosphere in
accordance with the responders’ age, the
highest values were found in the 40-49-
Doynovska R. et al: Factors that Create a Successful Nursing Team in a Hospital Setting 60

year age group (74%) and equal values
were observed between the responders’
group of up to 29 years of age and the 50-
59-year age group (70%-70.4%) (Figure
1). The obtained results have shown an
expected/regular difference (χ2=36.54;
р<0.01). The results in accordance with the
length of service did not show any
significant differences (р≥0.05), as for
85.4% (n=211) this parameter had the
highest significance.
Figure 1. Age distribution of the investigated individuals in relation to the importance of work environment
(mean values)
There was a significant difference
between the responders’ educational level
and the significance of work environment
(χ²=12.54; p<0.01). A 73% of the medical
nurses with the bachelor’s educational-
qualification degree and master’s degree in
healthcare management, as well as 67% of
the professional bachelors considered this
parameter as the most important one. It
should be noted that the employees with
higher levels of education attributed higher
significance to the working atmosphere
within the team. It is composed of a large
number of components, such as traditions,
relations between the head of clinic
(department), senior medical nurse,
physicians and nurses, the management
style in the clinic, age of the team
members, patients, material and technical
base of the clinic, etc. Because of the
teamwork principle in the activities of a
team in a clinic, the team atmosphere is of
high importance in choosing a work place
within the health institution and with
respect to the possibilities for achieving
successful professional development and
establishing colleague relationships
(Figure 2).
Work environment was highly
evaluated by the responders in surgical
nursing (73%) and slightly lower by these
in internal medicine nursing (65%). The
difference was significant (χ²=14.48;
p<0.02), as for both profiles, the team
61 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

atmosphere was of decisive importance for
more than a half of the nurses, regardless of the difference in the percentages.
Figure 2. Educational level distribution of the investigated individuals in relation to the importance of work
environment (mean values)
In all hospitals, the responders
revealed high percentages of correlation
between the personal status, colleague
relationships, work-related behaviour and
working atmosphere. The personal status
within a team reflects how the other team
members perceive and evaluate the
individual. It is of high importance, since it
refers to the personal identification and
awareness of the position taken by the
individuals, as well as their significance
for the effective communication and
appropriate behaviour towards the other
team members [7].
In accordance with the age,
colleague relationships and the
professional status had the highest
significance for 60.32% (n=149) and the
lowest significance for 15% (n=37) of the
responders. The highest significance was
attributed by the employees of up to 29
years of age (37.7%), while the lowest by
those in the 50-59 year age group (27.2%).
The results have shown expected/regular
differences (χ²=44.17; р<0.04). Naturally,
colleague relationships have the highest
importance for the nurses aged up to 29
years. They are the youngest in the team
and are in the stage of most pronounced
and active professional development,
searching for professional models and
colleagues’ appraisal of their behaviour. In
the older-aged groups, it can be assumed
that the responders have already
established themselves as personalities and
professionals.
In accordance with the length of
service, the highest evaluation of the
professional status was given by the nurses
with up to 10-year length of service (37%),
correspondent with the highest positive
evaluation given by the youngest age
group. The lowest evaluation was given by
the nurses with up to 30-year length of
Doynovska R. et al: Factors that Create a Successful Nursing Team in a Hospital Setting 62

service. The relative proportion of the
highest evaluation given by all the
responders was 65%. There was an
expected/regular difference in the answers
(χ²=37.93; р<0.05).
There was also a significant
difference (χ²=27.69; р<0.001) between
the answers of the responders in
accordance with the educational level. The
average highest evaluation was given by
the employees with the three educational-
qualification degrees: 60.3% (n=121). The
highest significance of this parameter was
given by holders of professional bachelors
(63.5%) and the lowest by those with
master’s degrees (42.3%).
In the analysis of the parameter
according to the profile of medical
specialty, the distribution was even, with
no significant difference (р>0.05).
The high percentages of satisfaction
with this parameter mean that working
atmosphere is extremely important for all
employees. The effective working
atmosphere and the positive psycho-
climate are a part of the factors which
enable the high quality of provided
healthcare services, intra-team cohesion
and create empathy and desire for mutual
assistance.
In conclusion, it can be assumed
that the analysed factors have a big impact
on the formation of a successful nursing
team. The opinion that the employees form
on their own their position in the team
(60.3%) with their professional and
personal skills is prevalent with the highest
importance and correlation between the
youngest age group (up to 29 years) and
the nurses with up to 10-year length of
service. According to the educational level,
the personal status in the team is most
important for the professional bachelor’s
holders (63.58%). The responders have
given high evaluations of the team
atmosphere (73%) with significant
differences in accordance with the age,
educational level and specialty profile and
no difference in accordance with the length
of service.
References
1.Harizanova, M., Mirchev M., Mironova
N., Management, Printing House, Univer
sity of National and World Economy,
Sofia, 2006
2. Hristova, T., Human Resource
Management, PRINCEPS, 1996
3. Borisov, V., Healthcare Management,
Volume I, Foundations of Healthcare
Management, Filvest, 2004
4. Мухина С. А.,Тарновская И. И.
Практическое руководство к предмету
„Основы сестринского ухода”. –М.-
Родник, 1998
5. Achkova, M., Applied Psychology in
medicine and health care, KOTI Ltd.,
Sofia, 2001
6. Mirchev, M., General Course of
management fundamentals, VSU
“Chernorizets Hrabur”, 2001
7. Uzunova, F., Fundamentals of
Management, Varna, Technical University,
1997
63 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

Case Report
An Ovarian Hernia with a Leiomyoma of Ovary
Georgi I. POPIVANOV1, Evgeni I. BELOKONSKI1, Ventsislav M. MUTAFCHIYSKI2,
Mihail S. TABAKOV3, Rumiana P. PANEVA4*
Affiliation of the authors:
1. Clinic of Abdominal Surgery, Military Medical Academy, Sofia, Bulgaria
2. Clinic of Hepato-pancreato-biliary Surgery and Transplantology, Military Medical
Academy, Sofia, Bulgaria
3. Clinic of Abdominal Surgery, National Trauma Center “N. Pirogov”, Sofia, Bulgaria
4. Department of Clinical Pathology, National Trauma Center “N. Pirogov”, Sofia,
Bulgaria
Corresponding author:
Georgi Popivanov, MD
Clinic of Abdominal Surgery, Military Medical Academy
“Georgi Sofiiski” Str. 3
Sofia, 1606, Bulgaria
Tel.: +359 885 521 241, Fax: +359 2 952 65 36
E-mail: popgerasim@yahoo.com
Balkan Military Medical Review
Apr-Jun 2012; 15(2): 64 - 67

Abstract
The inguinal hernia sac usually contains
small bowel, colon and omentum but
other organs may also be found. A
sliding hernia occurs in 0.15-9% of all
inguinal hernias and 4.74% in infants.
In 2.9% of all cases and approximately
15-20% of the sliding hernias the sac
contains fallopian tube and ovary. The
condition is most common in children
under 5 years (71%) and is often
associated with genital anomalies; it is
less frequently seen in adult women
(29%). The ovarian leiomyomas are
very rare and about 70 cases have been
described in the English literature. We
report a 49-year-old woman with a left
incarcerated indirect sliding hernia
containing a part of the left fallopian
tube and leiomyoma of ovary. Although
rare, ovarian tumors should be taken
into consideration in adult women with
non-reducible groin hernia. A simple
ovariectomy is sufficient for the
treatment of the ovarian leiomyoma.
Key words: ovarian hernia, ovarian
leiomyoma, adult women, treatment
Introduction
The inguinal hernia sac usually
contains small bowel, colon and omentum,
but other organs may also be found. In
2.9% of all cases it contains fallopian tube
and ovary [1]. The condition affects
predominantly children under 5 years
(71%), whereas in adult women occurs in
only 29% [2]. Ovarian leiomyomas are
very rare and about 70 cases have been
described in the English literature [3].
Case Report
We report a 49-year-old woman
admitted with a painful, non-reducible
lump in her left groin just above the
inguinal ligament. Intra-operatively, we
found a sliding indirect hernia, containing
part of the left fallopian tube and well-
demarcated ovarian tumor with smooth
surface and firm texture. Because of the
questionable viability of the tube, a partial
resection was performed together with a
left ovariectomy and Lichtenstein repair of
the defect. Grossly, the tumor was 7 x 4
cm in size and had a pale and lobulated cut
surface. No normal ovarian parenchyma
was found. The histopathological
examination showed a leiomyoma of the
ovary (Figures 1, 2). Thus, the operation
was considered as sufficient from an
ontological point of view. A 6-year follow-
up examination revealed no recurrence
either of hernia or tumor.
Figures 1-2. Microscopic appearance of the tumor
(haematoxylin and eosin, B-06-6699-6670)
65 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

Discussion
According to McMillan, the first
case of ovarian hernia is described by
Soranus of Ephesus in A.D. 97 [4]. In 1756
Percival Pott performed the first operation
for ovarian hernia, removing the ovary [5].
In the last 20 years few case reports of
ovarian hernia in adults have been
published in the literature [6-8].
The frequency of the sliding
inguinal hernia is 0.15-9% in adults and
4.74% in infants [9, 10]. In 2.9% of all
cases and approximately 15-20% of the
sliding hernias the sac contains fallopian
tube and ovary [1, 11]. For the period
1992-2011, 8,110 inguinal hernia repairs
have been performed at our institution and
this was the first case of ovarian hernia
with leiomyoma of ovary in adult woman
which represents 0.01% of all cases.
Ovarian leiomyoma accounts for
0.5-1% of all benign ovarian tumors [12].
Approximately 70 cases have been
reported in the literature [13]. It may arise
from smooth muscle cells of the ovarian
blood vessels, cells in the ovarian
ligament, multipotential cells of the
ovarian parenchyma or cortical smooth
muscle metaplasia. Most of the
leiomyomas are unilateral and occur in
premenopausal women [13]. They are
asymptomatic and frequently represent
incidental findings. The differential
diagnosis with the other spindle cell
tumors such as fibroma and fibrothecoma
may be difficult, especially when the
tumor has a marked stromal reaction [14].
Desmin is a useful immunohistochemical
marker, which is always positive in
leiomyomas and negative in
fibroma/fibrothecoma [13]. The distinction
between leiomyoma and leiomyosarcoma
may also be difficult, because of the lack
of stringent criteria [15].
Conclusion
Despite its rarity, ovarian hernia
should also be taken into consideration in
adult women with non-reducible groin
hernia. The ovarian leiomyoma has a
favorable prognosis even in the cases with
a prominent mitotic activity or bizarre
nuclei. No local recurrences or metastatic
lesions have been found after complete
excision [15, 16].
Acknowledgments
The author would like to thank Dr
Kirien Kjosev for the encouragement.
References
1. George EK, Oudesluys-Murphy AM,
Madern GC, Cleyndert P, Blomjous AM.:
Inguinal hernias containing the uterus,
Fallopian tube, and ovary in premature
female infants. J Pediatr 136:696-8, 2000.
2. Mayer V, Templeton FG.: Inguinal ectopia
of the ovary and fallopian tube: review of
the literature and report of the case of an
infant. Arch Surg 43:397-399, 1941.
3. Tamada T, Sone T, Tanimoto D, et al. :
MRI appearance of primary giant ovarian
leiomyoma in a hysterectomised woman.
The British Journal of Radiology 79:126-
128, 2006.
4. McMillan WM.: Unusual viscera in
indirect inguinal hernia. Annals of Surgery
116:266-270, 1942.
5. Messmore IL, Beecham CT.: Bilateral
adnexial hernia in an infant. Am J Obst &
Gynec 103:593-595, 1969.
6. Golash V, Cummins RS.: Ovulating ovary
in an inguinal hernia. Surgeon 3:48, 2012.
7. Malik KA, Al Shehhi RM, Al Quadhi H, Al
Kalbani M, Al Harthy A.: Ovarian hernia.
Sultan Qaboos Univ Med J 12:225-227,
2012.
Popivanov G. et al: An Ovarian Hernia with a Leiomyoma of Ovary 66

8. Atkinson DS, Roth CG, Varma JD, et al.:
Gastrointestinal/Genitourinary Case of the
Day. AJR 173:786-794, 1999.
9. Nedin D, Aleksandrova A, Damianov D:
Sliding inguinal hernias. Classification
and intra-operative problems. Ed.:
Damianov D: Hernia, 1st ed., Sofia,
Medart, 1997, p75.
10. Gnidec AA, Marshall DG.: Incarcerated
direct inguinal hernia containing uterus,
both ovaries, and fallopian tubes. J Pediatr
Surg 21:986, 1986.
11. Gurer A, Ozdogan M, Ozlem N, et al.:
Uncommon content in groin hernia sac.
Hernia 10:152-155, 2006.
12. Tomas D, Lenicek T, Tuckar N, et al.:
Primary ovarian leiomyoma associated
with endometriotic cyst presenting with
symptoms of acute appendicitis: a case
report. Diagnostic Pathology 4:25, 2009,
doi: 10.1186/1746-1596-4-25.
13. Kandalaft PL, Esteban JM.: Bilateral
massive ovarian leiomyomata in a young
woman: a case report with review of the
literature. Modern Pathology 5:586-589,
1992.
14. Ozkan OV, Semerci E, Aslan E, Ozkan S,
Dolapcioglu K, Besirov E.: A right sliding
indirect inguinal hernia containing
paraovarian cyst, fallopian tube, and
ovary: a case report. Arch Gynecol Obstet
279: 897-899, 2009.
15. Lerwill MF, Sung R, Oliva E, et al.:
Smooth muscle tumors of the ovary. A
clinicopathologic study of 54 cases
emphasizing prognostic criteria, histologic
variants and differential diagnosis. Am J
Surg Pathol 28:1436-1451, 2004.
16. Prayson RA, Hart WR.: Primary smooth-
muscle tumors of the ovary. A
clinicopathologic study of four leiomyomas
and two mitotically active leiomyomas.
Arch Pathol Lab Med 116:1068-71, 1992.
67 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

Case Report
Axillary Vein Thrombosis: Presentation of Four Cases and Review of the
Literature
Ilias BISBINAS1, Zacharoula KARABOUTA2, Dimitrios GEORGIANNOS3, Christos
BISSIAS4*
Affiliation of the authors:
1. LtCol (Army), MD, FRCS, FEBOT, MSc, PhD
Consultant in Orthopaedic and Trauma Surgery,
424 General Military Hospital, Thessaloniki, Greece
2. MD, MRCP, MRCPCH, DCH, MSc
Consultant in Paediatrics, AHEPA University Hospital, Thessaloniki, Greece
3. Major (Army), MD, Senior Clinical Fellow in Orthopaedic and Trauma Surgery,
Royal Bournemouth Hospital, Bournemouth, UK
4. Cmdr (Navy), MD, MSc, Consultant in Orthopaedic and Trauma Surgery
Naval Hospital of Athens, Athens, Greece
Corresponding author:
Ilias Bisbinas
19 Monastiriou Street, Thessaloniki, 546 27, Greece
Tel.: 00 30 2310 381000, ext 1925
E-mail: ibisbinas@hotmail.com
Balkan Military Medical Review
Apr-Jun 2012; 15(2): 68 - 75

Abstract
Four patients with axillary vein
thrombosis (AVT) are presented.
Thrombosis in the deep veins of the
upper limb is quite an infrequent
medical problem presented to doctors in
different specialities and with varying
patient profiles. Medical and surgical
trainees come across those cases in
emergency departments and
unfortunately there is often a delay in
diagnosis. Bearing in mind its significant
morbidity and potential mortality, early
diagnosis of AVT is extremely
important. Innocent swelling with
venous engorgement in the upper limb
and predisposing factors from the
patient’s history should alert the
clinician for further investigations to
confirm or exclude it before it is too late.
Key-Words: Axillary vein thrombosis,
Delayed diagnosis, Management
Introduction
Deep vein thrombosis (DVT) is a
very well known medical entity. In the
majority of the cases DVT is connected
with the deep veins of the lower limbs.
Upper extremity thrombosis appears to
comprise about 1-2% of all deep venous
thrombosis [1] and it is rarely seen further
distally to the axillary vein level [2].
Axillary vein thrombosis is difficult
to diagnose. Early and persistent swelling
in the upper limb, especially when acco
mpanied with superficial venous plethora
should always alert the physician.
We report four cases of axillary
vein thrombosis of different aetiology:
fracture in the thoracic outlet (extrinsic
trauma), catheter-related in an oncology
patient (tumour history, intrinsic trauma),
contraceptive pill ingestion (thrombophilic
tendency) and finally effort (Paget-
Schroetter syndrome).
Case 1 (Trauma case)
A 66-year-old right-handed female
patient presented in the emergency
department after a fall down 12 stairs. She
landed on her right shoulder and right
thoracic wall. Clinically, there were
painful bruises of the right shoulder, right
upper limb, skull and obvious deformity of
the right clavicle.
On examination there was reduced
sensation in the ulnar nerve distribution
over the right hand without motor function
compromise.
Plain X-rays revealed a skull
fracture, right clavicular middle-shaft
fracture and 1st, 3rd and 5th rib fractures
(Figure No 1).
Figure No 1. Plain x-rays of clavicle and right
upper ribs demonstrating a middle-shaft fracture of
clavicle and fracture of the 1st rib. Case 1
She was treated conservatively with
a broad arm sling and analgesia. The ulnar
nerve paraesthesia resolved spontaneously
but she developed swelling 10 days later as
other bruises were settling down. Although
it was attributed to the related fractures,
four weeks later the swelling had not
settled and her superficial ipsilateral upper
limb veins were more prominent
69 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

comparing to the other side. That was
aggravated by hand dependency and
activities such as knitting, with obvious
venous distension of the hand and forearm.
A venogram showed complete blockage of
the axillary vein with well-developed
venous collateral circulation (Figures No 2
and 3). The patient was treated with
anticoagulation.
Figure No 2
Figure No 3
Figures No 2 and 3. Venograms showing blocked
axillary vein with well developed venous collateral
circulation in the trauma patient (Case 1)
Case 2 (Tumour case)
A 45-year-old patient with a known
history of multiple myeloma was referred
to the surgical team with a few weeks
history of swelling in his right arm. He had
a known multiple myeloma lesion in his
sacrum and many lytic lesions in the spine.
He was about to finish a chemotherapy
regime using a Hickman line and he
developed a whole arm swelling with vein
distension and “dusky” colour skin
associated with hypaesthesia in the hand.
The clinical picture was even more
complicated because he had a concomitant
phrenic nerve paralysis and a chest
infection, causing remarkable breathing
problems.
There were suspicions about
axillary vein thrombosis but an ultrasound
showed patency and good flow without
any sign of thrombosis. Following this,
because of all his other problems, the
attention on the swelling was reduced. He
concentrated on that again before the end
of his chemotherapy regime when the
swelling got worse and venous
engorgement was added.
A venogram showed blockage of
the axillary vein. The patient was treated
on streptokinase thrombolysis and Low
Molecular Weight Heparin with dramatic
improvement of his right arm symptoms.
In this patient the axillary vein
thrombosis was finally attributed to his
oncology history as well as to the chemical
inflammation that was caused to the intima
of the vein wall.
Case 3 (Coagulation-related case)
A 19-year-old female patient
without any medical or trauma history, on
contraceptive pill for the past two years,
presented in the emergency department
with a twenty-day history of swelling and
heaviness in her left upper limb. Initially it
Bisbinas I. et al: Axillary Vein Thrombosis:Presentation of Cases and Review of the Literature 70

was attributed to allergy and her General
Practitioner treated her on anti-allergic
medications. She reported swelling, pins-
and-needles sensation, “dusky” colour,
heaviness and discomfort all over her left
arm, which used to get worse during
daytime without improvement on anti-
allergic medications.
The patient was admitted and a
venogram showed complete block of the
axillary vein (Figure No 4). She started the
appropriate anticoagulation protocol and
she was put on Low Molecular Weight
Heparin having improvement from the first
10 days of treatment. In this case, axillary
vein thrombosis was considered a
complication of the oral contraceptive pill.
Figure No 4. Venogram showing complete
blockage of the axillary vein (Case 3)
Case 4 (Orthopaedic case)
A 21 year-old welder was referred
to the Orthopaedic team because of
persistent “muscle contusion” and swelling
of his left arm, not responding to anti-
inflammatory medication. The patient, who
was active and athletic working out in the
gym on a daily basis, had a swelling of his
left non-dominant arm with some
distension of the superficial veins for the
past two weeks (Figure No 5). There was
no significant past medical history and the
patient was taking no medications. He had
discomfort at the gym during the past
month associated with difficulties in
exercises involving the shoulder.
Figure No 5. Photographs showing the swelling
and venous engorgement in the upper limb with
axillary vein thrombosis (Case 4)
Initially that was attributed to
muscle contusion after the exercises but
instead of getting better with NSAIDs
prescribed by his General Practitioner, it
got worse.
The patient was admitted and had a
venogram that showed complete blockage
of the axillary vein. He was treated using
Low Molecular Weight Heparin. This case
was diagnosed as “effort axillary vein
thrombosis” (Paget-Schroetter syndrome).
Discussion
DVT is not an uncommon medical
problem that physicians and surgeons
come across in their practice. It was in
1846 in Berlin when Virchow, one of the
“fathers” of modern Medicine was the first
to associate the aetiology of DVT with
endothelial injuries, local or systemic stasis
in the blood circulation or blood
hypercoagulability [3].
Although a lot has been written and
attention has been focused on lower limb
DVT, paucity of data regarding the upper
limb DVT, axillosubclavian thrombosis,
has been published [4].
71 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

Axillary vein thrombosis can be
primary or secondary. Primary AVT is
called Paget-Schroetter syndrome and is
attributed to increased effort in the
dominant upper limb [5-7]. Secondary
AVT can be related to a variety of
underlying medical problems as
malignancies and systemic diseases,
anatomical conditions in the locality, long
lines/catheters, failed dialysis access graft
or even trauma [2, 8, 9].
Post-traumatic axillary vein
thrombosis is rarely seen because the vein
is well protected in the armpit up to the
thoracic outlet below the clavicle.
However, fractures in the bony frame of
the thoracic outlet, clavicle and 1st rib, put
in great danger the brachial plexus as well
as the subclavian-axillary vessels [10, 11].
When there is a post-traumatic neural
lesion following a fracture, an associated
vascular lesion should be suspected.
Axillary vein thrombosis can follow
directly, complicating vein injury from the
bone fragments, or because of increased
pressure in the vein from displaced bone
fragments and fracture haematoma [12].
With the development of the
chemotherapy and the applications of long
line-catheters the possibility for intrinsic
parietal lesion in large veins and chemical
inflammation has increased [8, 13]. As a
result of that, oncology patients tend to
have axillary vein thrombosis either
because of mechanical aetiology or
thrombotic tendency [14].
Apart from those reasons, when
there is any kind of thrombophilia and
hypercoagulability, thrombosis can occur
theoretically in any deep vein. DVT is one
of the very well recognised complications
of the oral contraceptive pill and it can
potentially happen even in the axillary-
subclavian vein [15]. There is a
pharmacologic influence of the hormones
in the pill on the pathogenesis of DVT in
women on oral contraceptives [16].
Following effort, AVT occurs after a
period of unusual or exaggerating
exercises most of the times in young,
healthy athletes [5, 6, 17]. Other times it is
strongly connected to a “muscle sprain”
during sport activities [18].
The most common clinical picture
following axillary vein thrombosis is
drawn with swelling in the arm, which is
enlarged and plethoric with a prominent
pattern of dilated superficial veins over the
upper arm and anterior shoulder and chest.
Those are persistent and aggravated with
activity (venous claudication) and
dependency mainly during daytime [19].
The diagnosis can be made by an accurate
history, thorough clinical examination and
can be confirmed by Doppler ultrasound-
duplex scan or venography [1, 2, 20].
Doppler ultrasound scan is increasingly
valuable but sometimes inaccurate when
applied from peripheral going to more
central veins [21-23]. In those veins,
thrombosis can be missed with unfortunate
delay for the diagnosis.
Early anticoagulation or catheter-
directed thrombolysis using
streptokinase/urokinase is most of times
the treatment of choice [2, 14, 24-27].
However, depending on the cases, more
radical methods have been described. Such
measures include percutaneous
transluminal angioplasty or thoracic outlet
decompression with claviculectomy when
there is phlebographically demonstrated
intrinsic stenosis or extrinsic thoracic
outlet compression, respectively [27-29].
If the patient does not receive the
appropriate treatment in time, a potentially
fatal pulmonary embolism (PE) could be
one of the probable complications. Some
authors believe that upper limb DVT is a
“benign” non-lethal disease [30] with low
incidence of PE [2, 4, 31]. However, others
have reported significant incidence of PE
and rate of morbidity [25, 30, 32] (late
post-thrombotic sequelae) and mortality [9,
25, 32, 33]. The morbidity and mortality
incidence increases dramatically when
Bisbinas I. et al: Axillary Vein Thrombosis:Presentation of Cases and Review of the Literature 72

upper limb DVT is diagnosed in patients
with significant risk factors or while they
are admitted in a hospital for other reasons
or when the thrombosis is a result of
extrinsic obstruction [9, 14] (Table No 1).
Table 1. The incidence of Pulmonary Embolism (PE) as well as the mortality rate in clinical series of patients
reported in the literature
Marie et al
1998
N: 49
PE: 6 (12%)
Mortality rate:
0 (0%)
Hingorani et al
1997
N: 170
(group 1: 152 in-patients
and
group 2: 18 out-patients)
PE: 12 (7%)
* all of the them were from
the in-patient group
Mortality rate:
1-month rate
27 (16%)
3-month rate
58 (34%)
* all of the them were
from the in-patient
group
Montreal et al
1994
N: 86
PE: 13 (15 %)
Mortality rate:
2 (2%)
Kerr et al
1990
N: 123
PE: 10 (8%)
Mortality rate:
2 (2%)
Becker et al
1991
N: 329
(in this paper, the authors
reviewed the literature
1950-1991)
PE: 31 (9.4%)
Mortality rate:
4 (1.2%)
Lindblad et al
1988
N: 120
Primary: 73
Secondary: 47
PE:
In primary cases 0
In secondary cases 5
(10.64% in their group)
Mortality rate:
In primary cases 0
In secondary cases 4
(8.51% in their group)
Gloviczki et al
1986
N: 95
PE: 4 (4.21%)
Mortality rate: 0
Ameli et al
1987
N: 20
PE: 1 (5%)
Mortality rate: 0
Donayre et al
1986
N: 41
PE: 5 (12.19%)
Mortality rate: 0
Harley et al
1984
N: 14
PE: 5 (35.7%)
Mortality rate: 0
73 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

The presented cases emphasise the value of
thorough history taking and clinical
examination more broadly rather than
concentrating mostly in our specialty field.
We have highlighted that the innocent
appearance of upper limb swelling should
raise the index of suspicion of a potential
underlying vascular lesion, the diagnosis
can be made early and appropriate therapy
commenced. Although quite rare, upper
limb deep venous thrombosis may be life
threatening.
References
1. Marie I, Levesque H, Cailleux N,
Primard E, Peillon C, Watelet J, Courtois
H. “Deep venous thrombosis of the upper
limbs. Apropos of 49 cases”. Rev Med
Interne; 19(6):399-408, 1998
2. Lindblad J, Tengborn L, Bergqvist D.
“Deep vein thrombosis of the axillary-
subclavian veins: epidemiologic data,
effect of different types of treatment and
late sequelae”. Eur J Vasc Surg; 2(3):161-
5, 1988
3. Virchow R. “Gessamelte Abhandlungen
zur Wissenschaftlichen Medizin. Frankfurt,
Meidinger Sohn, p. 219, 1856
4. Levy MM, Albuquerque F, Pfeifer JD.
“Low Incidence of Pulmonary Embolism
Associated With Upper-Extremity Deep
Venous Thrombosis.”Ann Vasc
Surg. 2012. [Epub ahead of print]
5. Adelman MA, Stone DH, Riles TS,
Lamparello PJ, Giangola G, Rosen RJ.
“A multidisciplinary approach to the
treatment of Paget-Schroetter syndrome”.
Ann Vasc Surg;11(2):149-54, 1997
6. Rutherford RB. “Primary subclavian-
axillary vein thrombosis: the relative roles
of thrombolysis, percutaneous angioplasty,
stents, and surgery.”Semin Vasc Surg.;
11(2):91-5, 1998
7. Shebel ND, Marin A. “Effort throm
bosis (Paget-Schroetter syndrome) in
active young adults: current concepts in
diagnosis and treatment.”, J Vasc Nurs.;
24(4):116-26, 2006
8. Aburahma AF, Sadler DL, Robinson
PA.“Axillary vein thrombosis. Changing
pattern of etiology, diagnostic and
therapeutic modalities”. Ann Surg;
57(2):101-107, 1991
9. Hingorani A, Ascher E, Lorenson E,
DePippo P, Salles-Cunha S, Scheinmann
M, Yorcovich W, Hanson J.
“Upper extremity deep venous thrombosis
and its impact on morbidity and mortality
rates in a hospital based population” J.
Vasc Surg; 26(5):853-860, 1997
10. Peivandi MT, Nazemian Z
“Clavicular fracture and upper-extremity
deep venous thrombosis, Orthopedics.;
34(3):227, 2011
11. Zabrosky A, Barabas A, Augoust A.
“Late vascular complication after blunt
trauma”.Acta Chir Hung;33(1-2):117-123,
1993
12. Lusskin R, Weiss C Winer J. “The role
of the subclavius muscle in the subclavian
vein syndrome (costoclavicular syndrome)
following fracture of the clavicle”. Clin
Orthop and Rel Res; 54:75-83, 1967
13. Balesteri L, DeCicco M, Matovic M,
Coran F, Morassut S. “Central venous
catheter-related thrombosis in clinically
asymptomatic oncologic patients: a
phlebographic study”.Eur J Radiol;
20(2):108-11, 1995
14. Donayre CE, White GH, Mehringer
SM, Wilson SE. “Pathogenesis determines
late morbidity of axillosubclavian vein
thrombosis”Am J Surg; 152(2):179-184,
1986
15. Earle KA, Lloyd MH.“Paget-
Schroetter syndrome in a patient on the
contraceptive pill”.N Y State J Med;
89(5):293, 1989
16. Kierkegaard A.“Side and site of deep
vein thrombosis in women using oral
contraceptives”. Acta Obstet Gynecol
Scan; 64(5):399-402, 1985
17. Medler RG, Mc Queen DA “Effort
thrombosis in a young wrestler.A case
Bisbinas I. et al: Axillary Vein Thrombosis:Presentation of Cases and Review of the Literature 74

report”.J Bone Joint Surg Am; 75(7):1071,
1993
18. Louis J.“Axillary vein thrombosis
mimicking muscular strain”.
J Accid Emerg Med; 16(3):233-4, 1999
19. Tilney NL, Griffiths HJG.“Natural
History of Major Venous Thrombosis of
upper extremity”.Arch in Surg; 101:792-
796, 1970
20. Kerr TM, Lutter KS, Moeller DM,
Hasselfeld KA, Roedersheimer LR,
McKenna PJ, Winkler JL, Spirtoff K,
Sampson MG, Cranley JJ.“Upper
extremity venous thrombosis diagnosed by
duplex scanning”. Am J Surg; 160(2):
202-6, 1990
21. Davidson BL, Elliott CG, Lensing
AW.“Low accuracy of color Doppler
ultrasound in the detection of proximal leg
vein thrombosis in asymptomatic high risk
patients. The RD Heparin Arthroplasty
Group”. Ann Intern Med; 117(9):735-8,
1992
22. Knudson GJ, Wiedmeyer DA, Erickson
SJ, Foley WD, Lawson TL, Mewissen, MW,
Lipchik EO.“Color Doppler sonographic
imaging in the assessment of upper-
extremity deep venous thrombosis”.Am J
Roentgenol; 154(2): 399-403, 1990
23. Kroger K, Schelo C, Gocke C,
Rudofsky G.“Colour Doppler sonographic
diagnosis of upper limb venous
thromboses” Clin Sci (Colch); 94(6): 657-
61, 1998
24. Jones JC, Balkcom IL, Worman
RK.“Pulmonary embolus after treatment
for subclavian-axillary vein thrombosis”.
Pstgrad Med; 82(1): 244-9, 1987
25. Becker DM, Philbrick JT, Walker FB
4th. “Axillary and subclavian venous
thrombosis. Prognosis and treatment”.
Arch Intern Med; 151(10): 1934-43, 1991
26. Kreienberg PB, Chang BB, Darling RC
3rd, Roddy SP, Paty PS, Lloyd WE, Cohen
D, Stainken B, Shah DM.“Long-term
results in patients treated with
thrombolysis, thoracic inlet
decompression, and subclavian vein
stenting for Paget-Schroetter syndrome.”
J Vasc Surg.; 33(2 Suppl):S100-5, 2001
27. Melby SJ, Vedantham S, Narra
VR, Paletta GA Jr, Khoo-Summers
L, Driskill M, Thompson RW.
“Comprehensive surgical management of
the competitive athlete with
effort thrombosis of the subclavian
vein (Paget-Schroetter syndrome).”J Vasc
Surg.; 47(4): 809-820, 2008; discussion
821. Epub 2008 Feb 14.
28. Rutherford RB, Hurlbert SN. “Primary
subclavian-axillary vein thrombosis:
consensus and commentary”.
Cardiovasc Surg; 4(4): 420-3, 1996
29. Caparrelli DJ, Freischlag J. “A unified
approach to axillosubclavian
venous thrombosis in a single hospital
admission.” Semin Vasc Surg.; 18(3): 153-
7, 2005
30. Gloviczki P, Kazmier FJ, Hollier LH.
“Axillary-subclavian venous occlusion: the
morbidity of a nonlethal disease”.J Vasc
Surg; 4(4): 333-7, 1986
31. Ameli FM, Minas T, Weiss M, Provan
JL. “Consequences of conservative
conventional management of axillary vein
thrombosis”. Can J Surg; 30(3): 167-9,
1987
32. Harley DP, White RA, Nelson RJ,
Mehringer CM. “Pulmonary embolism
secondary to venous thrombosis of the
arm”. Am J Surg; 147(2): 221-4, 1984
33. Montreal M, Raventos A, Lerma R,
Ruiz J, Lafoz E, Alastrue A, Llamazares
JF.“Pulmonary embolism in patients with
upper extremity DVT associated to venous
central lines-a prospective study”. Thromb
Haemost;72(4):548-50,1994
75 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

Case Report
Neurological Symptoms in a Patient with Complex Tuberous Sclerosis
Krasimir R. GENOV, Hristo G. LESIDRENSKI, Stratina S. STRATIEVA*
Affiliation of the authors:
Military Medical Academy, Clinic of Nervous Diseases, Sofia, Bulgaria
Corresponding author:
Associate Professor Krasimir R. GENOV M.D., Ph. D.
Clinic of Nervous Diseases, Military Medical Academy, Sofia, Bulgaria
3 Georgi Sofiiski str., 1000 Sofia, Bulgaria
Tel: (+359-2) 922 59 14
E-mail: K.Genov@abv.bg
Balkan Military Medical Review
Apr-Jun 2012; 15(2): 76 - 80

Abstract
Neuropathological lesions in tuberous
sclerosis complex are expressed in the
presence of tubers, subependymal
nodules and subependymal giant cell
astrocytomas. Numerous tubers
occurring in a large percentage of
patients are most often localized in the
frontal, temporal and parietal areas.
Neurological symptoms are common in
patients with tuberous sclerosis complex;
the most common is epilepsy, in
approximately 70 to 90% of affected
individuals who have become subject of
medical research. Seizures associated
with tuberous sclerosis in early
childhood are the type of infantile
spasms. Although infantile spasms
usually disappear spontaneously over
several weeks to several months, they can
be deployed in other seizures such as
generalized symptomatic epilepsy,
generalized tonic-clonic, myoclonic and
atonic seizures. Furthermore, autism and
mental retardation, hyperactivity,
aggressive behavior and sleep disorders
are described.
Key-Words: tuberous sclerosis complex,
neuropathology, epilepsy, autism, mental
retardation
___________________________________
Introduction
Patients with tuberous sclerosis
complex especially those with cerebral
involvement are clinically presented with
seizures of epilepsy, cognitive
involvement, and severe behavior
disorders, often of autistic character [1].
Neuropathological lesions in tuberous
sclerosis complex are expressed in the
presence of tubers, subependymal nodules
and astrocytomas consisting of giant
subependymal cells [1, 2, 4]. Numerous
tubers occurring in a large percentage of
patients are most often localized in the
frontal, temporal and parietal areas
(Figures 1, 2, 3, 4). Although infantile
spasms are difficult to treat by therapy and
are associated with poor prognosis,
epilepsy as a whole in comparison with
other chronic diseases is an independent
risk factor for higher incidence of
neurological problems. It was found that
the prevalence of depression was four
times higher in patients with epilepsy [5,
6]. Other neurological problems associated
with currently diagnosed epilepsy include
attention problems, anxiety and fear, and
increased risk of developing psychiatric
disorders. So, in the presence of multiple
cerebral tubers, epilepsy and mental
retardation, patients with tuberous sclerosis
complex are at high risk of developing
mental health problems [6, 7].
Case Description
It is about a 22-year-old male
patient with a 3-year history of the disease.
The onset was characterized by the
occurrence of tumor formations in the face
with sizes up to lentil grain and a reddish-
brown color. Similar formations appeared
at the age of 10 and are localized around
the nail plates of the I, II, III and IV fingers
bilaterally. Different spots on the skin of
the chest, abdomen and back appeared. At
the age of 5-6 years there were paroxysmal
conditions such as myoclonus, with an
incidence of 1-2 attacks per year. The
patient reported incidents of loss of
consciousness for about 2-3 seconds,
usually triggered by physical exhaustion
and accompanied by malaise. Over the
years, attacks are repeated characterized as
single and partial with secondary
generalization. Last attack was in April
2008. In June 2008 anticonvulsant therapy
was introduced, including Lamictal with a
daily dose of 250 mg (100mg in the
77 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

morning and 150mg in the evening) and
Finlepsin 200 mg, 3 times daily. On this
therapy the patient has not suffered
epileptic seizures. There were no
abnormalities in the neurological status.
Tests and Clinical examination
Complete blood counts and
biochemical tests showed no change from
the reference values. Electroence
phalography: Basic activity of the alpha
rhythm with a frequency of 9-10 Hz,
interspersed with frontal-temporal low
amplitude fast rhythm waves. Grouped
sharp theta waves in frontal-central right
areas with a wider right-sided distribution,
rarely with contralateral irradiation. CT of
the head showed calcifications with a
diameter of 5mm bilaterally periventricu
larly and in plexuses choreoideus of the
lateral ventricles. The ventricular system
was normally located, shaped and sized.
Structures in the sella turcica and the
posterior cranial fossa revealed no
abnormalities. MRI of the head showed
post-contrast enhancing signal small
subependymal nodules in the walls of both
lateral ventricles supratentorially and also
asymmetric bilateral signal changes (in the
cortex, sub-cortex and deep cerebral white
matter), which can be an expression of
gliosis, based on the microangiopathy
(Figures 1, 2, 3, 4).
Ultrasonography of the abdomen:
Conclusion - Multiple cortical renal cysts.
Ophthalmological status: right eye: papilla
- with clear borders, at the level of the
retina, vessels and macula - without
detours. Temporally in the middle
periphery a chorioretinal lesion was
described including a central prominent
fakom, whitish in colour. Left eye – no
abnormal findings.
Figure 1
Figure 2
Figure 3
Genov K. et al: Neurological Symptoms in a Patient with Complex Tuberous Sclerosis 78

Figure 4
Figures 1, 2, 3, 4. Subependymal nodules located
in the walls of both lateral ventricles and
asymmetric bilateral signal changes in cortical, sub-
cortical and deep white matter of the brain
Consultation with a dermatologist:
In this patient almost all skin changes
typical for ST (tuberous sclerosis) are
manifested - hypopigmental macular and
facial angiofibromas, "textured" plates, and
Koenen tumors and fibromatous lesions
with changes in the internal organs and
neurological symptoms.
Discussion
Tuberous sclerosis is genetically
mostly autosomal dominant disease in
which abnormal cell differentiation and
proliferation are the main features. Despite
the autosomal dominant inheritance, in a
large percentage of cases it is a new
spontaneous mutation in one of two genes
(TSC1 and TSC2) (3). Our patient has no
family history and therefore we assume
that his illness was a result of new
spontaneous mutation in either gene
associated with tuberous sclerosis. The
clinical spectrum of tuberous sclerosis is
quite broad and includes skin, eye, brain,
kidney, liver, heart, lung and endocrine
disorders. Skin manifestations are diverse
and specific, and in a large percent of cases
lead to the diagnosis. Neurological
symptoms are varied and are caused by the
cortical tubers, subependymal nodules and
subependymal giant cell astrocytomas.
Clinically brain hamartomas are presented
with epilepsy (70-90% of cases), mental
retardation (50-60%), central paresis,
autism, lower intelligence, problems with
communication and behavior (4, 7). Our
case demonstrates neurological
manifestation in a patient with tuberous
sclerosis including symptomatic epilepsy
with ongoing seizures, progressing to
secondary generalization with tonic-clonic
seizures. In terms of diagnostic criteria for
tuberous sclerosis the subependymal
nodules appear to be the pathogenetic basis
of the symptomatic epilepsy in the patient.
References
1. Ridler, K., Bullmore, E. T., DeVries, P,
J., Suckling, J., et al. Widespread
anatomical abnormalities of grey and white
matter structure in tuberoses sclerosis.
Psychol. Med.; 31: 1437-1446, 2001
2. Benvenuto, G., Li, S., Brown, S. J., et al.
The tuberous sclerosis 1 (TSC 1) gene
product harmartin suppresses cell growth
and augments the expression of the TSC 2
product tuberin by inhibiting its
ubiquitination. Oncogene; 19: 6303-6316,
2000
3. Lamb, R. F., Roy, C., Diefenbach, T. J.,
et al. The TSC1 tumour suppressor
hamartin regulates cell adhesion through
ERM proteins and the GTPase Rho. Nat.
Cell. Biol.;2: 281-28, 2000
4. Crino, P. B., Miyata, H., Vinters, H. V:
Neurodevelopmental disorders as a cause
of seizures: Neuropathologic, genetic, and
mechanistic considerations. Brain Pathol.;
12: 212-233, 2002
79 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

5. Kyin, R., Hua, Y., Baybis, M., et al.
Differential cellular expression of
neurotrophins in cortical tubers of the
tuberous sclerosis complex. Anat. Pathol.;
159: 1541-1544, 2001
6. Xn. B., Michalski, B., Racine, R. J.,
Fahnestock, M. Continuous infusion of
neurotrophin–3 triggers sprouting,
decreases the levels of TRKA and TRKC,
and inhibits epileptodenesis and activity-
dependent axonal growth in adult rats.
Neuroscience; 115: 1295-1308, 2002
7. Nelson, K. B., Grether, J. K., Croen, L.
A., et al. Neuropeptides and neurotrophius
in neonatal blood of children with autism
or mental retardation. Ann. Neurol.; 49:
597-606, 2001
8. Gullapalli D, Phillips LH. Neurologic
manifestations of sarcoidosis. Neurol
Clin;20 (1): 59–83, vi, 2002
9. Stern BJ. Neurological complications of
sarcoidosis. Curr Opin Neurol; 17 (3):
311–6, 2004
10. Lower EE, Weiss KL. Neurosarcoidosis.
Clin Chest Med.; 29 (3): 475-92, ix, Sep
2008
11. Hoitsma E, Faber CG, Drent M,
Sharma OP. Neurosarcoidosis: a clinical
dilemma. Lancet Neurol.; 3 (7): 397-407,
Jul 2004
12. Zajicek JP, Scolding NJ, Foster O, et
al. Central nervous system sarcoidosis:
diagnosis and management. QJM; 92 (2):
103–17, 1999
13. Tahmoush AJ, Amir MS, Connor WW,
et al. CSFACE activity in probable CNS
neurosarcoidosis. Sarcoidosis Vasc Diffuse
Lung Dis; 19: 191–97, 2002
14. Borucki SJ, Nguyen BV, Ladoulis CT,
McKendall RR. Cerebro spinal fluid
immunoglobulin abnormalities in
neurosarcoidosis. Arch Neurol; 46: 270–
73, 1989
15. Juozevicius JL, Rynes RI. Increased
helper/suppressor T-lymphocyte ratio in the
cerebrospinal fluid of a patient with
neurosarcoidosis. Ann Intern Med; 104:
807–08, 1986
16. Rothkrantz-Kos S, van Dieijen-Visser
MP, Mulder PG, Drent M. Potential
usefulness of inflammatory markers to
monitor respiratory functional impairment
in sarcoidosis. Clin Chem; 49: 1510–17,
2003
17. Winterbauer, RH, Lammert, J, Selland,
M, et al. Bronchoalveolar lavage cell
populations in the diagnosis of sarcoidosis.
Chest; 104: 352, 1993
Genov K. et al: Neurological Symptoms in a Patient with Complex Tuberous Sclerosis 80

Review Article
The History of Vostaneio Hospital of Mytilene
Labrini ΚOURKOUTA1, Dimitra ΙPPIOTI2, Fotini PAPOULIA3, Ioanna
PAPATHANASIOU4*
Affiliation of the authors:
1. Professor, Nursing Department, Alexander Technological Educational Institute of
Thessaloniki, Greece
2. R.N., Nursing Department of Alexander Technological Educational Institute of
Thessaloniki, Greece
3. R.N., General Hospital “The S. Dimitrios”, Thessaloniki, Greece
4. Clinical Professor, Nursing Department, Technological Educational Institute of
Larissa, Greece
Corresponding author:
Papathanasiou Ioanna
E-mail: papathan1@yahoo.gr
Balkan Military Medical Review
Apr-Jun 2012; 15(2): 81 - 87

Abstract
Introduction: The Byzantine tradition of
operating hospitals continued in Greece
after the fall of Constantinople in 1453.
A hospital carrying a significant history
is the Hospital of Mytilene on Lesvos
island.
Purpose: This historical review
highlights the multifaceted work of the
hospital on the island during the
Ottoman period.
Material - Method: The methodology of
historical research was used. Data was
sourced from documents of the
Patriarchate of Constantinople, a letter
of the Synod and the oldest code of the
mortgage estate of the Foundation.
(1813).
Results: The civilian Hospital of
Mytilene or ‘Hotel’ is the only Charity
Organization of the ‘old city’. A Synodic
letter dating from 1692 shows that the
hospital started operating in Mytilene in
the 17th century.
The main activities were:
1. Nursing poor patients.
2. Providing free accommodation and
food for all in need.
3. Acquisition and release of captives
and prisoners.
4. Raising orphan children.
Conclusions: The Hospital of
Mytilene on Lesvos island responded
remarkably during the Ottoman era in
nursing needs of both residents of the
island and the wider region, according
to the principles of the Byzantine and
Orthodox tradition. It successfully
continues its work to the present time.
Key words: Mytilene, Vostaneio Hospi
tal, Ottoman, charity foundations.
The Byzantine Heritage of Nursing Care
Following the dissolution of the
Byzantine Empire, the local greek
population would have to live and find its
balances under the Ottoman rule. The
Church, with its powers, slowly tried and
essentially managed to help people recover
from their plights [1]. This constituted a
heavy burden with a steady and slow
progress through various events and
movements until the Church was able to
establish its position [2].
Originally, during the Byzantine
era, the monasteries played a significant
role in the provision of care to the needy
[3]. The Church continued its centuries-
long tradition of Christian charity,
providing for the needs of poor patients.
However, the destruction or dissolution of
many of the monastic institutions deprived
the Church from the resources required to
create new charities or continue with
others [1].
The Byzantine hospitals were also
called 'Hotels' or 'Guesthouses', terms
which persisted until the 19th century in
some cases [4, 5].
Hospital care after the End of the
Byzantine Era
Unfortunately, no significant data
exist regarding the nursing and social
policies of the state, the church or, indeed,
those of individuals during the 16th and
17th centuries [6]. The fact is that
traditional policies were continued with
significantly limited resources [6, 7].
A sense of cooperation was swiftly
put to use within the greek community and
formed one of the founding agents of
hospitals. The threat of a large epidemic
helped shape this cooperation further [8,9].
In the 17th century a guesthouse -
hospital was opened in Mytilene on the
island of Lesvos; this actually occured
before 1692, as shown by a synodic letter
Kourkouta L. et al: The History of Vostaneio Hospital of Mytilene 82

of that year signed by the Patriarch
Kallinikos B’, which specifies that this
guesthouse-hospital would “belong to the
jurisdiction and governance of the Bishop
of Mytilene” who also had the authority to
appoint its commissioners [10, 11].
This hotel continued its operation
during the 19th century, adapting to the
treatment needs of people at that time [9].
This historical study identifies and
promotes the important nursing and charity
projects provided by the Hospital of
Mytilene to the island's inhabitants and the
population of the wider region (residents of
nearby islands, Asia Minor etc) during the
Ottoman era.
The methodology of historical
research was used. Data were retrieved by
the ‘Mytilene Charity’ records and other
relevant publications on this subject such
as articles, studies, documents and
photographs. For the archiving of the
material, data were classified according to
source, alphabetical and chronological
order.
The Hospital of Mytilene during the
Ottoman Rule
The Mytilene Charity is a
continuation of Byzantine institutions.
Among them distinguished the Hospital of
Mytilene, which is the oldest charity
foundation established in the East after the
fall of Constantinople [10, 11].
The first reference about its
existence is found in a Synodic letter sent
by the Patriarchate of Constantinople in
March 1692 to the clergy and nobles of
Mytilene [12 - 15]; this document is kept
in the Library of the Greek Literary
Society of Constantinople [16, 17].
The next written report is from
1752 when Anthimos Vertoumis, the then
Bishop of Mytilene, inherits a land area,
called the "Great Garden", to the 'hotel'
[18, 19]. The estate is inherited under the
condition that half of its rent will be
utilised by the trustees of the foundation
for purchasing bread to be handed out to
the poor [10].
The 'hotel', which is known around
1820 as "Ospitalion" and later on as
"Hospital", provided free housing and
meals to the needy, elderly, orphans and
travellers regardless of their religion or
ethnic origin [12, 13, 15, 23].
The preserved records reveal that
significant sums of money were spent for
the release of prisoners and the return to
their families. Special consideration was
given to orphan children; they were
allocated to foster families and, on many
occasions, ‘contracts’ were signed and
clauses were put regarding their education,
upbringing, endowment and financial
support [25].
The funds and property of the
hospital, which gave it the opportunity to
develop these activities, came from:
1. Donations of wealthy Mytilene citizens
(Zafeiris Vournazos, Andreas Katsakou
lis etc).
2. Management of existing property
(agricultural and residential real estate).
3. Loans (1814)
4. Contributions of individual citizens [23,
25].
The Hospital of Mytilene during the 19th
century and beyond
In 1858 the original hospital of
Mytilene was demolished and a new
modern building was erected in the same
position financed by P. Vournazellis.
Systematic hospital care for poor patients
was organized [26].
The hospital comprised of a
dispensary, various medical departments
(internal medicine, surgical, obstetric,
ophthalmology), pharmacy, installation of
sterilization furnaces and about 42 beds.
The number of in-patients per year
exceeded 1,000 and those examined as out-
patients were over 8,000 (Figure 1) [27].
83 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

The surgical procedures reached 300
yearly and the obstetric ones exceeded 100
[25, 26].
The prescriptions performed in the
hospital pharmacy for poor patients
reached over 15,000. The surgical
department also had adequate personnel
and a full toolbox (Figure 2) [27].
Nevertheless, the new hospital building
gradually proved insufficient to cover the
growing needs of the population and the
problem was intensified after many
disadvantaged refugees swept the island in
the early 20th century following the Balkan
Wars [25].
Figure 1:
Women’s Medical Ward, Vostaneio Hospital, Mytilene
Figure 2:
Operating Theatres, Vostaneio Hospital, Mytilene
Π
ί
ν
α
κ
α
ς
1
:
Χ
ε
ι
ρ
ο
υ
ρ
γ
ε
ί
ο
Kourkouta L. et al: The History of Vostaneio Hospital of Mytilene 84

By the efforts of Bishop Iakovos, a
collection of funds was started and on
March 25, 1927 the foundations of a new
hospital were laid and a re-build was
launched [19, 25]. Eight years later, on 8
November 1935 the new hospital of
Mytilene was inaugurated [25].
The name given to the institution
on 13 February 1934 was "Vostaneio
Hospital of Mytilene", in honor of the A.
Vostanis sons, who offered large amounts
of funds towards its construction [26].
Further actions shaped the area
around the hospital, which is currently
built in the third ‘row’. The first two in the
"Great Garden" are land donated by the
priest P. Skamiatoudas. Later, Periklis
Loukas donated 5 acres of land adjacent to
this area [28]. Following this, Panagiotis
G. Kapsimalis responded to the request of
the President and donated to the west side
of the foundations another 10 acres of land.
Today, the Hospital of Mytilene, the Home
for the Elderly and the Orphanage are built
in close proximity in this area [12, 29].
In the 1960’s, after many meetings
and consultations between the Ministry of
Social Welfare and the Administrative
Board of The Mytilene Charity, the
Hospital is acknowledged as a government
institution under the provisions of the law
2592/53 (Greek Government newspaper
147/Α/11.9.61). Despite the decisions
taken towards the reformation of the
Vostaneio General Hospital of Mytilene,
its territorial boundaries were, however,
not clearly delineated [30, 31].
Conclusions
The Vostaneio General Hospital of
Mytilene has been a source of great pride
for the local population throughout its long
history, combining with unique success its
charity and nursing work to the residents
of the island of Lesbos and the wider
region with projects of national magnitude.
References
1. Stavropoulos A., Hospitals and nursing
policy of the Greek ethnicity in
Constantinople (1453-1838), Thesis for
lectureship, University of Athens Medical
School, Athens, 1984.
2. Gedeon M. Patriarchical newspapers,
Athens, 1936-1938.
3. Κomninou-Ypsilandou A. After the Fall
(1453-1789),Constantinople,1870. Αthens,
Ν.Κaravia, 1972.
4. Miller T.S., The Birth of the Hospital in
the Byzantine Empire. Baltimore, The
Johns Hopkins University Press, 1894.
5. Miller T.S. Byzantine Hospi tals.
Dumbarton Oaks Papers, 38:53-63, 1984.
6. Κοurkouta L., The history of Nursing,
Athens, Pasxalidis, 2010.
7. Τrompoukis Κ., The Greek Medicine in
Constantinople (1857-1923), Αthens, 2000.
8. Giala Α., Greek Clergy, Doctors
Scientists from the fall to the national
revolution, Αktines, 367:18-20, 1976.
9. Simopoulou Κ., Foreign travelers,
Second Tome, 128, 1973.
10. Dimou F., History of Ottoman-
occupied Lesvos, 1935.
11. Thomaidis K., Investigation of
social protection institutions from the
antiquity up to the Revolution of ‘21 in the
Greek area, Athens, 1973
12. Jimis S., Giannakas Β.,“History of
Lesvos”, Philologists of Lesvos, Second
Edition, Μytilene, 1996.
13.Gedeon Μ., Patriarchal History
Monuments, Αthens, 1922.
14. Αmadou Κ., History of the Byzantine
State, Tome I., 1939.
15.Gedeon Μ,. Turkish Official
Documents, Constantinople, 1910.
16.Κampouri J.P., The last years of
Ottoman rule in Lesvos (1908-1912),
85 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

Bulletin of the Society of Lesbian Studies,
Μytilene, Τome V, 7-49, 1962.
17.Sifnaiou R., «Lesvos, its second half of
the 19th century through the consular
correspondence», Lesviaka. Bulletin of the
Society of Lesbian Studies, Μytilene, Vol.
VII, 286-301, 1991.
18.Stergellis Α., «Lesvos in the Years
1880 -1885 in the newspaper of
Constantinople "Neologos"», Lesviaka.
Bulletin of the Society of Lesbian Studies,
Μytilene, Τome V, 493-517, 1996.
19.Foudoulis I. Μ., «The description of the
island of Lesvos by the Bishop Gavriil
Soumaroupas of Mithimni (1618-
24/2/1621)», Holy Metropolis of Mytilene,
Μytilene, 1993.
20.Κontos K., The conquest of
Mytilene by the Turks, Lesviaka. Bulletin
of the Society of Lesbian Studies, Μytilene,
Τome V, 7-49, 1962.
21.Μoutzouris Ι., Episcopal
Historical List of Mytilene
http://www.immyt.net/.../episkopikos_istorik
os_katalogos_mitilinis.doc , Accessed on 3
Αpril 2011.
22. Paraskeyaidis P.S. Lesvos on Ottoman
rule. Second Edition, Μytilene, Ν.
Hristopoulou, 62-66,134-135, 2001.
23.Τsalikis G. Lesvos over the years. N.
Mytilene, Christopoulos, 170-175, 1998.
24.Τaxis Οi. Brief History and
Topography of Lesvos, Cairo, 1909.
Reprinted: University of the Aegean,
Mytilene, 1995.
25.Charity Shops of Mytilene.
http://www.mytilenecharity.com/institution
1.htm Accessed on 24 February 2011.
26.Simos Ι. Polichniates doctors in the last
years of Ottoman rule, Bulletin of the
Society of Lesbian Studies, 1996, VI’ 12-
18.
27.The History of Vostaneio Hospital of
Mytilene. http://www.vostanio.gr/
Accessed on 3 Αpril 2012.
28. Hospital of Mytilene
http://www.ithanet.eu/archives/582 .
Accessed on 12 January 2011.
29. Κaridis D. City and village in the early
Ottoman period,
www.arxaiologia.gr/assets/media/PDF/mi
grated/1401 Accessed on 15 March 2011.
30. Greek Decree Law, 2592/53.
31. Greek Government newspaper,
147/Α/11.9.61 & Greek Royal Decree, 597.
Kourkouta L. et al: The History of Vostaneio Hospital of Mytilene 86

Review Article
Medical Ethics in Peace and War: An Historical Perspective
Emmanouil MAGIORKINIS, Christos BISSIAS, Nikolaos PETROGIANNIS, Aristidis
DIAMANTIS*
Affiliation of the authors:
Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens
Corresponding author:
Captain Aristidis Diamantis, MD, PhD, HN
2 Karaiskaki, 15562, Cholargos,
Athens, Greece.
Tel: +30-210-6526711
E-mail: aristidis.diamantis@gmail.com
Balkan Military Medical Review
Apr-Jun 2012; 15(2): 87 - 95

Abstract
The purpose of this study was to explore
the historical perspective of the conflict
between the humanitarian role of
Medicine and the role of military
doctors during periods of warfare.
Historical archives and reports were
researched and an extensive research in
available literature was also conducted.
Hippocrates, the father of medicine,
with his oath sets a highly ethical
professional code dictating that
Medicine is the profession which “saves
lives and eases pain” whenever this is
possible, without discriminating between
friends and enemies. Military doctors
face the dilemma between their
humanitarian role as implied by the
Hippocratic oath and their military role
implied by patriotism and the duty to
the Fatherland. Louis Pasteur in his
oration at the dedication of the Pasteur
Institute in Paris, on November 14, 1888
stressed the contradiction between the
law of blood and death which is implied
during warfare and the law of work and
health which is implied during peace.
WW II Nazi medical atrocities and the
Nuremberg medical trial (NMT) was the
trigger that led to the formation of a
medical ethics code and a military
medical code, especially regarding issues
on human experimentation and
euthanasia. Research on biological
warfare and medical issues in the war
against terrorism are the current «hot
topics» of medical military ethics.
Key-Words:
Medical ethics, history, Hippocrates,
moral, Pasteur, Nuremberg medical
trial
Medical Ethics in Peace and War during
Antiquity
The first texts regarding medical
ethics are found in the written laws of
ancient Assyrians and civilizations of
Mesopotamia; the first written law
regarding the practice of medicine during
peace dates back to the age of the
Hammurabi code (1,760 BC) [1].
Within the Hamurambi code
(Figure 1), one can find specific
references to the medical rewards: “If a
surgeon has cured the limb of a patrician or
has doctored a diseased bowel, the patient
shall pay five shekels of silver to the
surgeon. If he be a plebeian, he shall pay
three shekels of silver. If he be a man's
slave, the owner of the slave shall give two
shekels of silver to the doctor”.
Punishments for medical malpractice are
equally strict: “If a surgeon has operated
with the bronze lancet on a patrician for a
serious injury, and has caused his death, or
has removed a cataract for a patrician, with
the bronze lancet, and has made him lose
his eye, his hands shall be cut off. If the
surgeon has treated a serious injury of a
plebeian's slave, with the bronze lancet,
and has caused his death, he shall render
slave for slave. If he has removed a
cataract with the bronze lancet, and made
the slave lose his eye, he shall pay half his
value” [2]. It is reasonable to assume that
those written laws are not the intellectual
product of the mind of a legislator but,
rather, the registration of common practi
ces established in the everyday life of
those civilizations.
In Ancient Greece, according to the
Greek philosopher Heraclitus of Ephesus
(535–475 BC), War was considered as:
War is the father of all and king of all, who
manifested some as gods and some as men,
who made some slaves and some freemen.
(Πόλεμος πάντων πατήρ εστί, πάντων δε
βασιλεύς, και τους μεν θεούς έδειξε τους δε
Magiorkinis E. et al: Medical Ethics in Peace and War: An Historical Perspective 88

ανθρώπους, τους μεν δούλους εποίησε τους
δε ελευθέρους), meaning good as well as
bad things [3] (Figure 2).
Figure 1. Hammurabi code’s stele in the Louvre
Museum.
Figure 2. Heracletus of Ephesus (535- 475 BC)
Hippocrates (Figure 3) (460–370
BC), the father of medicine, with his oath
[2] sets a highly ethical professional code
dictating that Medicine is the profession
which saves lives and eases pain whenever
this is possible, without discriminating
between friends and enemies: I swear by
Apollo, Asclepius, Hygieia, and Panacea,
and I take to witness all the gods, all the
goddesses, to keep according to my ability
and my judgment, the following Oath. To
consider dear to me, as my parents, him
who taught me this art; to live in common
with him and, if necessary, to share my
goods with him; To look upon his children
as my own brothers, to teach them this art.
I will prescribe regimens for the good of
my patients according to my ability and my
judgment and never do harm to anyone. I
will not give a lethal drug to anyone if I am
asked, nor will I advise such a plan; and
similarly I will not give a woman a pessary
to cause an abortion. But I will preserve
the purity of my life and my arts. I will not
cut for stone, even for patients in whom the
disease is manifest; I will leave this
operation to be performed by practitioners,
specialists in this art. In every house where
I come I will enter only for the good of my
patients, keeping myself far from all
intentional ill-doing and all seduction and
especially from the pleasures of love with
women or with men, be they free or slaves.
All that may come to my knowledge in the
exercise of my profession or in daily
commerce with men, which ought not to be
spread abroad, I will keep secret and will
never reveal. If I keep this oath faithfully,
may I enjoy my life and practice my art,
respected by all men and in all times; but if
I swerve from it or violate it, may the
reverse be my lot [4].
Hippocrates also suggested that
doctors should follow military campaigns,
since he considered that during wartime
periods doctors could collect valuable
experience on traumatology. Military
doctors face the dilemma between their
89 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

humanitarian role as implied by the
Hippocratic Oath and their military role
implied by patriotism and the duty to the
Fatherland.
Figure 3. Hippocrates (460-370 BC)
Various Greek philosophers dealt
with the role of physicians in organized
societies as well as medical ethics; except
from Hippocrates, there are numerous
references in Plato and Aristoteles (The
Republic, Laws, Timaeus, Symposium,
Nicomachean Ethics) all culminating to the
same advice for the physicians: not to
commit ‘Hybris’ against mother Nature.
Aristotle advices physicians to abandon all
efforts to save a patient who suffers from
incurable illness, supporting euthanasia in
some terminal cases [5].
During the Middle Ages and the
early scientific period, Arab doctors are
occupied with Medical ethics. One of the
most eminent Arab doctors, Abū Ḥāmed
Muḥammad ibn Muḥammad Ghazālī –
known as Al-Ghazali (1058–1111 AD)
referring to death and to the role of
physician, says [6]:
God has created the spirit of man
out of a drop of his own light; its destiny is
to return to Him. Do not deceive yourself
with the vain imagination that it will die
when the body dies. The form you had on
your entrance into this world, and your
present form are not the same; hence,
there is no necessity of your perishing on
account of the perishing of your body.
Your spirit came into this world a
stranger; it is only sojourning in a
temporary home. From the trials and
tempests of this troublesome life, our
refuge is in God. In reunion with Him we
shall find eternal rest - rest without
sorrow, joy without pain, strength without
infirmity, knowledge without doubt, a
tranquil and yet an ecstatic vision of the
source of life and light and glory, the
source from which we came.
Referring to medical ethics, one of
the most important figures in Arab
medicine is Ishaq ibn Ali Rahawi (854-931
A.D); his famous treatise Adab al-tabib
(Code of physician) [7] is one of the first
manuscript in medical ethics. In this book,
Rahawi labels physicians as "guardians of
souls and bodies" and in this treatise he
spells out all the deeds and acts a Muslim
physician must observe. Arab medicine
constitutes a dim light of hope in the Dark
Ages· muslim hospitals served people
irrespective of religion, colour or
background, by staff that operated on a
completely equal footing, whether
Christians, Jews or other minorities. A
Muslim doctor was also identified as
'Hakim', which in Arabic translates as
'wise'. Hence, unlike secular medicine
today, Muslim practitioners did not
perform abortions or sex change
operations. In Rahawi's book there are
twenty chapters, which include:
 What the physician must avoid and
beware of,
 The manners of visitors,
Magiorkinis E. et al: Medical Ethics in Peace and War: An Historical Perspective 90

 The care of remedies by the
physician,
 The dignity of the medical
profession,
 The examination of physicians, and
 The removal of corruption among
physicians.
Muhammad Ibn Zakariyā Rāzī (865-925
A.D.) - known as Rhazes - referring to
medical ethics, said:
The doctor's aim is to do good, even to our
enemies, so much more to our friends, and
my profession forbids us to do harm to our
kindred, as it is instituted for the benefit
and welfare of the human race, and God
imposed on physicians the oath not to
compose mortiferous remedies [8].
Figure 4. Mosheh ben Maimon (1135-1204 AD)
One can find traces of medical
ethics in jewish and christian texts. In
jewish texts there are references to medical
issues such as abortion, artificial
insemination, cerebral death, cosmetic
surgery, euthanasia, genetic control,
dangerous medical operations, the
procedure of circumcision (metzitzah
b'peh), organ donation, psychiatric care
and smoking cigarettes. Among the most
eminent jewish spiritual leaders was Rabbi
Moses ben Maimon (1135-1204 A.D.)
known also as Maimonedes (Figure 4)
who wrote “The Code of Maimonides
(Mishneh Torah), a code of Jewish
religious law [9]. One can distinguish the
deep influence of the Catholic Church in
texts from various philosophers of the
Middle Ages, such as those by St. Thomas
Aquinas (1225-1274); the metaphysical
references to the vague Divine
Punishment, the Heaven and Hell are more
than evident. The ethics of St. Thomas
Aquinas emphasized the cultivation of
virtues proper to the human person,
understanding this as the way to achieve
the good and happy life [10].
During the 18th and the 19th
century, Medical ethics resurged as a
separate branch of science and philosophy.
Thomas Percival (1740-1804) (Figure 5),
a British physician, was the first to refer to
the term ‘medical ethics’, by publishing his
book "Code of Medical Ethics," in the year
1803 [11]. At nearly the same time,
medical students attending the University
of Pennsylvania, began to be lectured by
physician Benjamin Rush regarding the
importance of medical ethics [12].
Percival's guidelines relating to physician
consultations have been criticized as being
excessively protective of the home
physician's reputation. Jeffrey Berlant is
one such critic who considers Percival's
codes of physician consultations as being
an early example of the anti-competitive,
guild-like nature of the physician
community [13]. In 1847, the American
Medical Association adopted its first code
of ethics, with this being based in large
part upon Percival's work.
Louis Pasteur (1822-1895) [14]
(Figure 6) in his oration at the dedication
of the Pasteur Institute in Paris, on
November 14, 1888 stressed the
contradiction between the law of blood and
death which is implied during warfare and
91 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

Figure 5. Thomas Percival (1740-1804)
Figure 6. Louis Pasteur (1822-1895)
the law of work and health which is
implied during peace :
Two contrary laws seem to be
wrestling with each other nowadays; the
one, a law of blood and death, ever
imagining new means of destruction and
forcing nations to be constantly ready for
the battle field- the other, a law of peace,
work and health ever evolving new means
of delivering man from the scourges which
beset him. The one seeks violent conquests,
the other the relief of humanity. The latter
places one human life above any victory;
while the former would sacrifice hundreds
and thousands of lives to the ambition of
one. The law of which we are the
instruments seeks, even in the midst of
conflict, to cure the sanguinary ills of the
law of war; the treatment inspired by our
antiseptic methods may preserve thousands
of soldiers. Which of these two laws will
ultimately prevail, God alone knows. But
we may assert that French Science will
have tried, by obeying the law of
Humanity, to extend the frontiers of Life.
Indeed, the law of humanity vs. the law of
the jungle, the law of health vs the law of
disease, the law of life vs the law of death.
A tremendous contrast noted by a pioneer
of Medicine!
Although medical codes can be
traced back to the Hamurabi law and wars
back to the early beginnings of the human
existence, the medical atrocities that took
place in concentration camps and clinics
under the Nazi regime and the Nuremberg
medical trial (NMT) (Figure 7) were the
trigger that led to the formation of a
medical ethics code and a military medical
code, especially regarding issues on human
experimentation and euthanasia. The so-
called Doctor’s trial -officially United
States of America v. Karl Brandt, et al.-
was the first of 12 trials for war crimes that
the United States authorities held in their
occupation zone in Nuremberg, Germany
after the end of World War II. The accused
faced 4,000 charges, including:
Magiorkinis E. et al: Medical Ethics in Peace and War: An Historical Perspective 92

Figure 7. The Nuremberg Trial
1. Conspiracy to commit war crimes and
crimes against humanity as described in
counts 2 and 3;
2. War crimes: performing medical
experiments, without the subjects' consent,
on prisoners of war and civilians of
occupied countries, in the course of which
experiments the defendants committed
murders, brutalities, cruelties, tortures,
atrocities, and other inhuman acts. Also,
planning and performing the mass murder
of prisoners of war and civilians of
occupied countries, stigmatized as aged,
insane, incurably ill, deformed, and so on,
by gas, lethal injections, and diverse other
means in nursing homes, hospitals and
asylums during the Euthanasia Program
and participating in the mass murder of
concentration camp inmates.
3. Crimes against humanity: committing
crimes described under count 2 also on
German nationals.
4. Membership in a criminal organization,
the SS.
Of the 23 defendants, seven were
acquitted and seven received death
sentences; the remainder received prison
sentences ranging from 10 years to life
imprisonment [15]. A result of the
Nuremberg trial was the Nuremberg Code
(1947), a set of research ethics principles
for human experimentation. Twenty years
later, the World Medical Association
(WMA) developed The Declaration of
Helsinki [16], as a set of ethical principles
for the medical community regarding
human experimentation, which is widely
regarded as the cornerstone document of
human research ethics [17, 18]. It is not a
legally binding instrument in international
law, but instead draws its authority from
the degree to which it has been codified in,
or influenced, national or regional
legislation and regulations [19]. In parallel
with the Declaration of Helsinki, the
General Assembly of the World Medical
Association adopted the declaration of
Geneva in 1948 which was amended in
1968, 1984, 1994, 2005 and 2006. It is a
declaration of physicians' dedication to the
humanitarian goals of medicine, a
declaration that was especially important
in view of the medical crimes which had
just been committed in Nazi Germany. The
Declaration of Geneva [20], as currently
amended, reads :
At the time of being admitted as a
member of the medical profession:
 I solemnly pledge to consecrate my
life to the service of humanity;
 I will give to my teachers the
respect and gratitude that is their
due;
 I will practice my profession with
conscience and dignity;
 The health of my patient will be my
first consideration;
 I will respect the secrets that are
confided in me, even after the
patient has died;
 I will maintain by all the means in
my power, the honor and the noble
traditions of the medical
profession;
 My colleagues will be my sisters
and brothers;
 I will not permit considerations of
age, disease or disability, creed,
93 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012

ethnic origin, gender, nationality,
political affiliation, race, sexual
orientation, social standing or any
other factor to intervene between
my duty and my patient;
 I will maintain the utmost respect
for human life;
 I will not use my medical
knowledge to violate human rights
and civil liberties, even under
threat;
 I make these promises solemnly,
freely and upon my honor.
Medical ethics was also complemented by
the Belmont Report, which was created by
the former US Department of Health,
Education and Welfare and was entitled
Ethical Principles and Guidelines for the
Protection of Human Subjects of Research;
it was authored by Dan Harms [21]. Today
the Belmont Report serves as an historical
document and provides the moral
framework for understanding regulations
in the United States on the use of humans
in experimental research. Research on
biological weapons, bio-terrorism, human
cloning and human experimentation in
large scale clinical trial are the hot topics
of medical ethics today.
References
1. Raymond M: The Code of
Hammurabi. Eds: Ministry of Culture and
Information, Iraq, 1979.
2. King L: Mesopotamia: The Code of
Hammurabi Eds: Washington State
University, 1996.
3. Hermann D, Kranz W: Die
Fragmente der Vorsokratiker. Eds: Zurich,
Weidmann, 1985.
4. Littré E: Oeuvres Completes
D'Hippocrate, Vol IV. Eds: 1844.
5. Scherer JM, Simon J: Euthanasia
and the right to die. A comparative view.
Eds: Maryland, Rowman and Littlefield
Publishers Inc., 1999.
6. Draper W: History of the conflict
between religion and science. Eds:
Available online at
http://www.gutenberg.org/files/1185/1185-
h/1185-h.htm, 2008.
7. Kaf al-Ghazal S: Medical Ethics in
Islamic History at a Glance. JISHIM 3:
12-3, 2004.
8. Islamic Science, the Scholar and
Ethics. Foundation for Science Technology
and Civilisation, 2006.
9. Moses M: Misneh Torah. Eds:
Jerusalem, Mosad Harav Kook, 1959.
10. Fagiolo E: Medical practice in the
thought of Thomas Aquinas. Med Secol 19:
783-96, 2007.
11. Percival T: Medical Ethics. Or a
code of Institutes and Precepts adapted to
the Professional Conduct of Physicians
and Surgeons. Eds: London, S. Russel,
1803.
12. Frewer A: Medical ethics in the
Enlightment. Medicine, Health Care and
Philosophy 5: 212-3, 2002.
13. Berlant J: Profession and
Monopoly: a study of medicine in the
United States and Great Britain. Eds:
California, University of California Press,
1975.
14. Louis Pasteur, Available online at
http://www.nndb.com/people/580/0000723
64/. 2012.
15. Nuremberg Trials, available online
at
http://en.wikipedia.org/wiki/Nuremberg_Tr
ials.
16. Assembly tWG. WMA Declaration
of Helsinki-Ethical Principles for Medical
Research Involving Human Subjects
available online at
http://www.wma.net/en/30publications/10p
olicies/b3/. Helsinki, Finland, June 1964.
17. Bošnjak S: The Declaration of
Helsinki - the cornerstone of research
ethics. Arch Oncol 9: 179-84, 2001.
18. Tyebkhan G: Declaration of
Helsinki: the ethical cornerstone of human
clinical research. Indian Journal of
Magiorkinis E. et al: Medical Ethics in Peace and War: An Historical Perspective 94

Dermatology, Venereology and Leprology
69: 245-7, 2003.
19. Human D, Fluss S. The World
Medical Association's Declaration of
Helsinki: Historical and contemporary
perspectives. Available online at
http://www.wma.net/en/20activities/10ethic
s/10helsinki/draft_historical_contemporar
y_perspectives.pdf. In: WMA, ed, 2001.
20. The Declaration of Geneva
available online at
http://www.wma.net/en/30publications/10p
olicies/g1/.
21. The Belmont Report
Available online at
http://www.hhs.gov/ohrp/humansubjects/g
uidance/belmont.html. 1979.
95 Balkan Military Medical Review
Vol. 15, No 2, Apr-Jun 2012