Joseph Becket Henry Collings
Reforms of the
Charitable Institutions of Malta

The Charitable Institutions evolved during the administration of the Order of St John of Jerusalem between 1530 and 1798. Previously, the only place of refuge for the sick had been the 14th century hospital of Santo Spirito, run by the municipality of Mdina and a small hospital at Rabat, Gozo.

In 1575, Grand Master Jean de la Cassiere (1572-82) founded the Sacra Infermeria at Valletta. The Infermeria which admitted male patients only, incorporated a Foundling Hospital. Following the expulsion of the Order from Malta, the French reserved the Sacra Infermeria exclusively for their troops. The British in their turn used it as a Station hospital.

In 1583, the Order of the Ursuline Nuns Hospitallers was invited to Malta by Grand Master Cardinal Hugues Loubenx de Verdalle (1582-95). The Ursuline ran the convent of Saint Mary Magdalen of the Penitents at lower Merchants Street, Valletta. This Magdalen Asylum for the reception of reformed prostitutes was suppressed by the French in 1798. The vacant building became the Male Civil Hospital. Maitland found the hospital a scene of filth and disorganisation, more in the nature of a public resort than a charitable institution for the cure of disease, where with the benefit of getting a ticket, the idle and the profligate were living at the expense of Government.⁹

The hospital had kept no records or accounts, and had gained such a notorious reputation, that few had recourse to that place. The Malta Mail of 1850 disclosed that the Maltese had lost all confidence in that establishment, and that rather than an asylum where medical skill went hand in hand with charity and humanity, the Civil Hospital had become an object of terror and disgust for the genuinely sick.¹⁰. The hospital closed down in 1850 following the conversion of the House of Industry at Floriana into the Central Civil Hospital. In 1852, the former Magdalen Asylum was adapted at a cost of £3202 into a new House of Industry for the reception and instruction of 100 female and 80 male orphans.¹¹

Facing the Male Civil Hospital, was the Casetta or House for Incurable Females founded by Caterina Scappi in 1625. The hospital, which backed on to the cemetery of the Sacra Infermeria, was enlarged in 1727 by Grand Master Antonio Manoel De Vilhena (1722-36). The Casetta admitted poor female patients suffering from incurable and chronic diseases, women with acute illnesses, female lunatics, and parturient women. In addition, prostitutes with venereal diseases were compelled to enter the hospital for treatment with mercury. About twenty prostitutes were in hospital at any one time. They proved quarrelsome and completely ungovernable, so that when the Casetta became incorporated into the Central Civil Hospital, separate wards had to be built to segregate them from the rest of the patients.

In 1850 the Casetta reverted to a Hospital for Incurables. It had beds for 250 aged and incurable females who required more care and attention than was available in the general workhouse. The building was wholly unsuitable for its purpose. Governor Le Marchant, remarked that there are not two feet distance between the beds occupied in many cases by persons affected with loathsome diseases arranged in narrow rooms by rows along the walls from one end to the other, ventilated and lighted by a single window and door at either extremity so that the impure atmosphere is carried over from bed to bed until it finds an only exit from the window.¹² On 3 October 1892 the patients were transferred to the new Poor House at Mgieret.

On 16 December 1732, De Vilhena had established the House of Charity or Ospizio, for the reception of aged and destitute paupers. This, however, did not provide for more than a very small number, as was evident from the many mendicants who were to be seen in every part of the island.¹³ The Ospizio lay on the Polverista Curtain next to the Msida Bastion burial ground. It was overlooked by the Floriana Barracks. Originally the gunpowder mills of the Knights, its rooms were damp, dark, low and partially underground. It served as a poor house, a female penitentiary, a foundling hospital for abandoned infants, a refuge for reformed fallen women, and a lunatic asylum. In 1832, the foundlings were transferred to the House of Industry at Floriana.

In 1837, the insane were removed to the former home of Fra Fabrizio Franconi at Floriana, which henceforth became known as the Ta' Franconi asylum for lunatics, idiots and epileptics. In 1884 the Ospizio had 391 male and 311 female paupers, 21 female prisoners, 13 voluntary inmates of the Magdalen Asylum and 6 foundlings living in appalling conditions. Governor Sir John Lintorn Simmons (1884-88) proposed to replace the Ospizio and the Hospital for Incurables with a single new building. He also recommended the removal of the Magdalen asylum to the Convent of the Good Shepherd at Balzan, the female prisoners to the Corradino, and the foundlings to the orphan asylum.¹⁴

In 1734, De Vilhena had founded a Conservatorio at Floriana for 160 poor girls. On 24 August 1824, Governor Hastings (1824-26) converted it into a House of Industry. More than 300 poor girls were maintained here. They were taught to sew, weave, knit, make cigars and shoes, and plait straw baskets, but were not allowed to go out.¹⁵ The Royal Commissioners of Inquiry of 1837 suppressed the House of Industry, as it was not deemed appropriate to have orphaned girls, penitent prostitutes, and foundlings all under one roof. However, it still had eighty-seven residents when More O'Ferrall became Governor of Malta.

In his report of the state of the Charitable Institutions Joseph Becket Henry Collings had advised the Governor to shut down the hospitals in Valletta and transform the House of Industry into a new Hospital of 350 beds. On 11 September 1848, plans for the proposed hospital were laid before the Council of Government, which approved the expenditure of £1925. An additional sum of £818 was voted on 25 June 1849 to build six separate chambers and two wards for the mercurial treatment of the prostitutes. Accordingly, the House of Industry was vacated. Some of its girls were sent to the Civil Hospital to work as nurses; twenty-six received a gratuity of £3 and were married off or taken on by relatives; nine were given an allowance of 3d a day and were taken in by private families for instruction; forty-nine were removed to the Poor House and set to work.¹⁶

The Central Civil Hospital was opened on 1 May 1850. The Malta Mail hailed its virtues. We cannot speak in terms too strongly of the arrangement of the wards, the spaciousness of the beds, the light and air supplied, and its general accommodation for patients; every necessity is provided for, every possible want is foreseen.¹⁷

In 1815 Maitland initiated his reforms of the Charitable Institutions. The governor noted that the Charitable Institutions had been run for many years without any fixed rules or regulations, and strongly deplored the prejudices that had impeded the introduction of his reforms into the hospitals.¹⁸

Maitland directed that from 1 February 1816 the Male and Female hospitals, the Poor House and the Department of the Grand Almoner for the distribution of outdoor relief were to be placed under the management of a Committee of the Charitable Institutions. This consisted of a patron (HE the Governor), presidents (the members of HM Supreme Council of Justice and the Treasurer to Government), and a number of vice-presidents who were to have the general management of the institutions. Four members, selected from the vice-presidents, constituted the Permanent Committee.

On the recommendation of Inspector of Hospitals Grieves, Maitland pensioned off Francesco Dimech, Physician to the Civil Hospital since 1800, Giovanni Andreotti and Antonio Casha former Assistant Surgeons at the Civil Hospital. On 19 November 1818, Maitland appointed Stefano Grillett First Physician to the Male and Female Hospitals. Concurrently, Assistant Regimental Surgeon Gavino Patrizio Portelli, 10th Foot, was recalled from Zante, in order to introduce into the civil hospital the improved system of those of the mother country.¹⁹

Portelli became First Surgeon to the Male Civil Hospital on 29 December 1818, and Professor of Anatomy and Surgery on 28 November 1822. On 1 September 1824, Francis Rawdon-Hastings reduced the Committee of the Charitable Institutions, appointed in 1816 from seventeen members to six and further directed them to take on the administration of the recently established House of Industry in accordance with the minute of 26 August 1824, which had established it.

The Royal Commission of 1836 proposed the formation of a single Board to superintend all charities. In accordance with their report, the Secretary of State for the Colonies directed that the principles established in England under the Poor Law Amendment Act 1834 for the administration of the public charities should apply to Malta. Thus, on 6 September 1837, Governor Henry Bouverie (1836-43) dissolved the Committee of the Charitable Institutions and transferred its powers to a Board of three members. The Governor addressed the newly-appointed Board, laid down some general regulations, and exhorted them to frame all necessary regulations for the admission, classification, feeding, and clothing of the destitute.

Such was the position of the Charitable Institutions when on 18 December 1847, Governor Richard More O'Ferrall disembarked from the Steamship Oberon to take over the administration of Malta. During his voyage he had been struck with motion sickness and had been attended to by Collings. It was a lucky chance that had brought Collings in contact with the new governor, for Collings had only become Assistant Surgeon of the Oberon on 7 September 1847. The governor was quite impressed with his qualities and abilities. Early in 1848, he commissioned him to inquire into the state of the Civil Hospitals, the Lunatic Asylum and Poor House, and the House of Industry. Collings submitted his findings on 15 April 1848. His report further enhanced his reputation.

On 29 December 1848, he was appointed to the newly established post of Inspector of Hospitals and Prisons, on an annual salary of £250 and an allowance of £40 as carriage expenses for inspection of the village dispensaries.

In 1851, More O'Ferrall replaced Bouverie's Committee of Charitable Institutions and Government Charities with the Commissioners of Charity.²⁰ In 1858, the Office of Inspector of Charities and Prisons was substituted by that of Comptroller of the Charitable institutions.

Joseph Becket Henry Collings was the son of Thomas Collings, Chief Clerk to the Naval Commissioners and Accountant of Works for the building of Bighi Naval Hospital. He was brought up in Malta, and spoke Italian and Maltese. On 19 September 1839 he passed the examination in Botany of the University of Malta. However, he did not qualify locally but obtained his diploma in surgery from Edinburgh University on 26 April 1843.

Collings joined the Naval Medical Services on 27 June 1844, aged twenty-two years. After a short spell at the Royal Naval Hospital Haslar, he embarked on duty for the East Indies. In February 1846, while on duty in Borneo he contracted a severe fever and had to be returned to Haslar for the preservation of his life.²¹ In November, he was invalided on half pay to Hibernia. In March 1847, Collings had recovered sufficiently to join first HMS Nautilus, and then HMS Trident but in September transferred to the Oberon as his health was still delicate.

On 6 September 1848, Collings was granted two years leave of absence by the Admiralty to accept a civil situation under the Government of Malta. The appointment of yet another foreigner provoked discontent among the local profession. The Malta Mail commented that The medical and surgical profession in Malta had a right to ask who this individual was that he was to be put over their heads with a salary of £500 a year, the highest salary of the native surgeon in the hospital being only £200 a year, .... and to fill an appointment that not only theoretical study, but also long practical experience, and publicly recognised superior ability are usually conceived to be the qualifications.²²

The paper held that there would have been no complaints had the government brought to Malta a learned professor of long practice and experience for the improvement of either the medical school, or the practice of medicine and surgery at the Civil Hospital. However, when it was found that the individual so selected and favoured, was not of an age to admit of that experience on which high attainment in medical and surgical sciences so mainly depends; was not an individual who had attained any notable repute in the short period of commencing his career; had not distinguished himself by any particular remarkable operation or cure; and had occupied no particular distinguished situation in medicine or surgery, but had merely been the surgeon of the Steamer Oberon who had formed an acquaintance with More O'Ferrall during his sea sickness, it was natural for the whole of the Faculty in Malta to cry out against his nomination. Thus, was the whole of the profession of medicine and surgery vilified and degraded by an appointment in no way based on what usually leads to such promotions, but by putting a junior over the heads of many, and when among other absurd reforms the dietary plan of the new inspector was published, it excited universal ridicule, coupled with universal resentment in the island.²³

Collings, however, was not a complete novice. He had gained limited experience in hospital management in the public hospitals of London, Edinburgh and the Royal Naval Hospital Haslar. In addition, he maintained that his intimate knowledge of the habits and character of the Maltese enabled him to modify his experience to their needs. Collings was familiar with the dispensary system in England and Scotland, and put their establishment in Malta at the heart of his reforms. By 1849, he had introduced a new system of management in the Civil Hospital, and had opened a number of village dispensaries. His reforms were well intended, but he was accused of being more interested in cutting costs than in the welfare of the poor. Indeed in April 1849, More O'Ferrall reported to the Secretary of State that the improved regulations and strict discipline introduced into the running of the Male Civil hospital had reduced costs from £1846 to £1520 annually.²⁴

The Malta Mail affirmed that his appointment was directed to destroy the hospital practice in Malta without in any way improving the local school either in surgery or medicine, by, as it were closing the hospital against the sick and needy, in order to work a disgraceful low and mean economy at the expense of the poor victims of sickness, disease and physical injuries.²⁵

Collings did not deserve the censure implied in the charges brought against him. In the preamble to his report, he had emphasised that his proposals were intended for the good of the poor, the advancement of science, and the benefit of the Maltese medical profession. In his letter to the hospital physicians he wrote: In your capacity of public servants your first consideration must be for the public whose money is not to be misapplied, while as men and Christians you must be scrupulously cautious in not refusing assistance where it may be really necessary. Remember that the government does not wish to diminish its acts of charity but it only desires that they be justly applied, while therefore on the one hand you should not admit into the hospital a case you know might be equally well treated in the dispensary you ought not on the other hand so refuse admission to a case which though of trivial nature has attending circumstances that render it deserving of hospital treatment.²⁶

Collings also inspected and regulated the new prison at Corradino which opened in 1849 to secure 129 male convicts. A wing for female prisoners was not opened till 1895. The prison was superintended by Dr Dionisio Vincenzo Portelli, former assistant surgeon at the civil hospital.

In 1857, Collings replaced Judge Micallef in the Legislative Council, upon the latter's resignation when judges became ineligible to sit on Council. On 1 March 1858, he succeeded Sir William Thornton as Auditor General of Malta and took up his place in the Council Chamber by virtue of his Office of Auditor General.²⁷² Concurrently, Gavino Patrizio Portelli, now Senior Physician of the Central Civil Hospital, became the new Inspector of Charities, while Dr Carmelo Mariani, Advocate for the Poor and one of the visitors of Corradino prison, became Inspector of Prisons. Portelli retired in December 1858 and was replaced by Mr Ferdinando Vincenzo Inglott with the new title of Comptroller of the Charitable Institutions.

Collings never fully recovered from his fever contracted in the east. Despite his failing health, his initial two years tenure was extended repeatedly. On 12 September 1856, the Admiralty declared him unfit for further sea service. He returned to England on 15 May 1858 in very poor health, and died at the Bradley's Hotel, Southampton, on 26 May 1858.

Three aspects of Collings' reforms will be considered as these had a significant impact on the care of the poor and the morale of the hospital staff. These were: (1) the establishment of village dispensaries, (ii) the regulations for hospital admissions, and (iii) the changes of the medical staff and their terms of service.

The Formation of Village Dispensaries was the corner-stone of his reforms. Prior to 1848, the Valletta Dispensary, which had opened in 1832, served the whole island, while the Medici dei Poveri looked after a number of villages. Patients from the countryside had to make their own way to the city to visit the dispensary. Inevitably, they delayed seeking medical help until their condition reached an advanced stage. It was assumed that early treatment would halt the march of disease and obviate the need for prolonged and expensive inpatient care. With the opening of the village dispensaries Collings hoped that convalescents would be, more speedily discharged, who are now retained longer in hospitals than they need be, because their cure cannot be perfected outside the hospital.²⁸

Malta was divided into twenty-one dispensary districts. These were later amalgamated into seven according to their geographical location. Each district had its own dispenser and dispensary, so that no inhabitant was more than a mile from medical aid. The districts of Valletta, Floriana, Cospicua, Senglea, Vittoriosa, Birkirkara, Qormi, Żejtun, Naxxar, Żabbar, Lija, Għaxaq, Luqa, Tarxien, Qrendi were attached to the Central Civil Hospital. Those of Citta-Vecchia, Żebbuġ, Żurrieq, Siġġiewi, Mosta, and Dingli were based on the hospital of Santo Spirito. The hospitals furnished their dispensaries with one of three medical chests. Each chest had medicines and dressings to treat two thousand, four thousand, or six thousand.

The best doctor in the village was encouraged to apply for the post of Dispenser of the Poor, but if none was suitable the one in the nearby village was offered the post. The dispenser tended the sick poor of his district at his dispensary during a specified hour. He adhered strictly to that time but was not expected to exceed it. At the request of the parish priest or syndic he assisted at their homes those poor who were too ill to attend the dispensary. He rendered assistance to the injured irrespective of their ability to pay, attended difficult cases of child birth, examined all foundlings and their nurses, oversaw the payment of outdoor relief, and certified to the state of health and poverty of all recipients for outdoor relief or relief in the Poor House. He attended the office of the Syndic during the payment of outdoor relief and examined the foundlings and their nurses.

Foundlings or deserted infants were provided with nurses who were answerable for the care of the children. The nurses were paid an annual rate according to the age of the child. The rates were: from birth to two years £3, two to seven years £2 8s, seven to twelve years £1 10s. No payment was granted for a child over 12 years.²⁹

The dispensaries played a pivotal role in the government's campaign against smallpox. All dispensers were encouraged to vaccinate the children of the poor before they reached their first birthday. If smallpox were to break out, how comforting would it be to know that owing to the universality of vaccination effected through the dispensaries, smallpox will be rendered completely innocuous asserted Collings.³⁰

The dispensers were obliged to reside constantly within their respective districts and were liable to be called out at any hour of the day or night to attend the poor of their districts. For their troubles they received an annual fee of six pounds for a village of 500 to 2000 people, nine pounds for one of 2000 to 4000, twelve pounds for a casal of 4000 to 6000, and fifteen pounds for a district of 6000 to 10000 villagers. Collings regarded this remuneration as ample, considering that the dispenser's private practice, instead of being interfered with, will be benefited by his public practice.³¹

The Dispenser kept three ledgers: a Dispensary Treatment Book, a Home Visiting Register, and a Hospital Referral Ledger. Every patient referred to hospital had to produce a ticket of admission signed by his dispenser. This had to state why the patient could not be treated locally. It also had to confirm that the patient was too poor to pay for medical attendance at home. The ticket was countersigned by the parish priest who attested to the patient's real poverty. Failure to produce such certification rendered the patient liable to pay hospital maintenance of 4d a day.

In 1848, the retirement of the police physician Leone Gravagna led More O'Ferrall to abolish the post of police physician and amalgamate its duties with those of the Dispenser for the Poor. This new position attracted a salary of £138. The Police Physician and Dispenser granted burial permits and assisted at all postmortems of suspicious deaths. He also attended the police force of the district, granted its members the necessary certificates in time of sickness, examined all food on sale and decided on its wholesomeness.³²

The dispensaries proved highly successful. The Malta Mail said that the present system of medical charities had greatly improved the public health in general.³³ The returns for 1849 showed that during the first six months of their existence, 16,958 were seen in the dispensaries, 3382 were visited at home, and 2728 children were vaccinated. Far more were seen in the casals in half a year than in the Valletta dispensary during the whole of 1848. In that year 12,900 had received treatment and 1130 children had been vaccinated.³² Table 2 shows the returns of the dispensaries for 1859.

Collings' Reforms of the Civil Hospitals

Collings perceived the Civil Hospital as a place of waste and inefficiency, but the remedy he prescribed was unpalatable. The hospitals had about 440 beds, but a quarter of these were occupied by patients who did not require hospital care. Collings classified these abusers of hospital accommodation into six groups.

• Group one consisted of impostors and malingerers who were not ill but were living at the expense of government because they had nowhere else to go. The impostors failed to comply with hospital regulations, were noisy, smoked, consumed alcohol, and proved troublesome when reproved. The malingerers initiated sores and simulated disease in order to savour the comforts of the hospital as long as possible. Collings advised the hospital staff to institute and consistently enforce a system of strict discipline, so that the convalescent shall find the restriction of hospital life irksome, and to frame their diets so as not to make it an inducement for them to remain.³⁵
• Group two was the simply old or infirm who were in hospital from motives of charity because there was not sufficient provision for them elsewhere. The simply aged required much attendance, destroyed a good deal of bedding and linen and made demands on the nurses. Collings removed them to the Ospizio and allocated £350 for their maintenance. He enlarged the hospital of Santo Spirito to accommodate 100 elderly patients, and in 1850 opened the Ospizio at Rabat, Gozo for 185 paupers aged over sixty years.
• Group three represented the unworthy, who though ill were not ill enough to justify expensive hospital care. The unworthy sought institutional care as there was no other means for obtaining relief away from the cities. They were admitted with small ulcers and trivial wounds that speedily degenerated owing to a pernicious hospital atmosphere and the effects on the system of an unusual diet.³⁶ Their sores took weeks to heal and the patients became a burden to the hospital.
• Group four comprised the undeserving who had the means to pay for private medical care. Collings regarded them with distaste for, by seeking charity, they perverted the aims of the institutions and robbed not only the government, but likewise the private practitioner.
• Group five were healthy mothers admitted with their sick children, and healthy children accompanying their ill parent. Henceforth, Collings decreed that only suckling infants were to be allowed in. He regarded them a troublesome lot. They were expensive to maintain, occupied rooms that should have been devoted to the sick, and took up much of the time and attention of the nurses.
• Group six included maternity patients admitted before the end of the eighth month of their pregnancy. By being in hospital before their baby was due they burdened the government, with the very unnecessary expense of three months instead of three weeks maintenance.³⁷

Collings calculated that the hospitals had about sixty aged, thirty unworthy, five undeserving, ten mothers and children, and five pregnant females who were, perverting the ends of the institution and costing the government £670 per annum in diets and replacement of bedding and linen.³⁸ To abolish these abuses he barred the Hospital Assistants from admitting patients, and introduced a precise set of admission rules. The regulations governing admission to the hospital stipulated that the hospital will be open only to the really poor needing hospital treatment and referred by the Medici Dei Poveri. The sick poor being those who depended for subsistence on their daily labour (day labourers) and who had such diseases as cannot be equally well cured at the dispensary. Cases of emergency such as accidents were admitted at all hours irrespective of the status of the patient.³⁹

Those seeking admission had to arrive between 06:30 and 13:30 during October to March, and between 07:30 and 17:30 during April to September. Their ticket of admission did not guarantee them a bed. All had to be first examined by the Principal Surgeon, the Principal Physician and by their juniors, who had to ensure that the patients were entitled to receive charity.

The cost of running the medical and surgical divisions was cut by modifying the bedding and curtailing the excessive use of medicines and leeches. Formerly the sick had been provided with a double bed made up of an upper woollen mattress thrown over a straw mattress. Collings regarded the woollen mattress, unnecessary, expensive, and unwholesome for wool tenaciously returns offensive odours and requires frequent washing.⁴⁰ He replaced it with a grass or straw bed. In 1847, a total of 63,000 leeches costing more than £300 had been used by junior doctors, who applied them whenever blood letting was prescribed by their seniors. Collings immediately put a stop to this idle practice and instructed them to use the cheaper lancet or cupping. Sponges used for the dressing of wounds were replaced by the less expensive corded tow.

Collings' Reduction in the Medical Staff

Collings found too many doctors at the hospitals in Valletta, and too few in the other establishments. The Civil Hospital had two principal surgeons, one principal physician, four first class assistants, four second class assistants, two third class assistants, and two fourth class assistants. Collings reduced these from fifteen to ten. He fixed the new establishment to one Principal Surgeon, one Principal Physician, two First Assistants, two Second Assistants, two Third Assistants, and two Fourth Assistants, the latter to be employed at the Ospizio, and the other at the lunatic asylum respectively. This not only saved the Treasury £297 in salaries, but also, argued Collings, the fewer situations available to the medical men will check the inducement to study medicine with the view of practicing in Malta, and thus materially aid in reducing the number of doctors to the wants of the population.⁴¹

Collings pensioned off the elder and most experienced doctors. On 14 December 1849, Antonio Speranza, First Physician of the Civil Hospital and Salvatore Bardon, First Surgeon of the Female Hospital were retired on account of advanced age and incapacity.⁴² Bardon had been employed in the public services for fifty years, forty eight of which under the British Government. During the plague of 1813 he had been in charge of the General Plague hospital at Fort Manoel where during his year of duty he contracted but recovered from the plague. Dr Speranza had served for a similar period and was actively employed in the plague of 1813 and more especially in the cholera of 1837, where his conduct was eminently distinguished by courage and decision under circumstances of no ordinary difficulty.⁴³ Also retired due to incapacity were, Giovanni Francesco Aquilina, Senior First Assistant and Francesco Borg, Second Assistant Surgeon respectively.

The Malta Mail objected to the forceful retirement of Dr Speranza, and his replacement on 1 January 1850 by Gavino Patrizio Portelli. It condemned the way he was most strangely transplanted into the vacant post, on the grounds that a good surgeon might make a good physician, and that as an army surgeon Portelli was necessarily a physician.⁴⁴ Portelli was appointed Physician after his failing eye sight had forced him to give up his surgical post. The Malta Mail considered that the government had erred in deducing that he was fully competent for the office of Senior Physician, for whatever surgical merits he enjoyed, in the eyes of the paper, he had no such credentials as a physician.⁴⁵

The vacancy of senior surgeon created by the transfer of Portelli to the medical division, was expected to be filled by Giorgio Engerer, the next most senior surgeon. However, the governor proposed that the two highest offices, that of senior surgeon and senior physician of the Central Civil Hospital should be filled by election. On 20 December 1849 a ballot was held at the Council Chamber of the University at Valletta. This was contested by Luigi Pisani, physician and surgeon of the Gozo Hospital, Giorgio Engerer, surgeon of the Civil Hospital, Tommaso Chetcuti, medical officer of the lunatic asylum, Charles Galland, professor of anatomy and surgery, Filiberto Gouder, surgeon of Santo Spirito Hospital, and Salvatore Axisa, medical officer of the Ospizio. Of the forty-nine votes cast Luigi Pisani obtained twenty-six and was elected Senior Surgeon to the Central Civil Hospital; Engerer polled second with fourteen votes.⁴⁶

Collings regulated the working day of both principals and assistants. He alleged that the principals did little more than a ward round, and that they delegated most of their work to their assistants. Henceforth, the principals were to make two regular visits a day, at seven in the morning and at two in the afternoon during October to March, and at eight in the morning and at six in the afternoon between April and September. Before the visits they had to attend the receiving rooms and examine all patients referred by the dispensers. During the visits, they had to record the patients' progress in their ticket of admission, the medicines prescribed and the diets ordered. After the visits, they had to inspect the steward's room and testify as to the qualities of the provisions, examine the instruments under their charge, check the ward or kitchen utensils, and perform all operations and postmortems.

Each assistant was on duty every fourth day. During the visits the assistant on duty and the outgoing assistant remained constantly by the side of the principal. The former received his instructions; the latter accounted for any change in the condition of the patients during his guard. As the ward round progressed the other two assistants collected the tickets, took them to the dispensary, prepared the medicines prescribed, and distributed them to the sick. Like present day junior hospital residents, the day of the assistant was quite full. After the visits, he took immediate charge of the instruments assigned to him and compiled the diet list. He then proceeded to cup and bleed the patients, and performed any other operation ordered by his senior. He examined all urgent cases, monitored their treatment and observed any improvement or deterioration in their condition. He modified their medication and updated their ticket. In addition, he oversaw the issue of provisions from the stores, certified their quality and condition, and was present during the distribution of the diets.

The Malta Mail observed that the assistants, follow their chiefs at the morning and evening visits like a troop of servants employed to attend to every mechanical tasks that may be required of them. They have been treated in fact as menials and not as educated professional men.⁴⁷ It wrote that under this new discipline everything has naturally enough combined to bring them up with feelings of decided aversion to the work before them as well as to the institution to which they are attached. Instead of their connection with the hospital elevating them in the opinion of the public, it has on the contrary degraded and lowered them. The assistants who ought to be the main support of the hospital are precisely those who have least reason to be concerned or interested in its well doing.⁴⁸

As Inspector of Charities and Prisons, Joseph Becket Henry Collings had not only to inspect the prison, the poor house, the orphan asylum, the lunatic asylum and dispensaries but was also responsible to government for the correct running of the institutions and the professional conduct of its officers and servants. Overall his reforms received a mixed response. He was highly praised by More O'Ferrall for the manner in which he carried out his work not recklessly but with a due regard to the wants and miseries of the poor.⁴⁹ However, a system of health care based on the necessity to cut costs, rather than on the needs of the individual was bound to cause a degree of resentment and discontent. The governor acknowledged that the various changes which had been introduced and the reforms, which in some of the institutions may be called radical have not been effected without considerable difficulty and some discontent. A great reduction of expense cannot have been effected without trenching on many interests and giving rise to many lamentations, ostensibly for the sake of the poor, which were in reality in favour of abuses from which the poor were the principal sufferers.⁵⁰

The setting up of village dispensaries was a vast improvement on the previous system where all health care rested upon the Civil hospital in Valletta. Opening up the Central Civil Hospital in Floriana brought Collings into conflict with the Principal Medical Officer of the garrison, James Barry, who complained that miasma from the dead house and the hospital would be detrimental to the troops in the nearby barracks. The site of the hospital was not ideal and its deficiencies soon became apparent. Collings' work could not have been easy. Indeed in 1886 Governor Simmons maintained that when, in 1858, Inglott took over as Comptroller of the Charitable Institutions he found them in a terrible state of disorganisation. Lunatics were chained in cells, discipline amongst the staff of the institutions was at the lowest ebb, the control over the issue of the stores was ineffective, and abuses of all kinds prevailed in the institutions.⁵¹

It is hard to reconcile this statement with what Collings had achieved, even though he had already left his post as Inspector of the Institutions by March 1858. Inglott is said to have reformed the whole institutions, and did away among other with the system of keeping lunatics in chains.

In the latter half of the 19th century the care of the sick pauper improved significantly following the interest taken by religious bodies in their welfare. The most remarkable improvement in their care was brought about in October 1871 when nineteen Sisters of Charity were introduced into the various hospitals and asylums. Their softening influence and example⁵² had a far more beneficial effect on their well being than any other reform. On 1 June 1880 the Little Sisters of the poor opened their institution at Hamrun for housing and nursing the aged poor. The Good Shepherd Institution, for the sheltering of girls was opened at Balzan, and in 1880 the Vincenzo Bugeja Conservatory for poor orphaned girls was opened at Santa Venera.