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Cottonera Hospital and Malta as the ‘Nurse of the Mediterranean’

The Crimean War highlighted gross deficiencies in military hospitals, both to treat war injuries and soldiers taken ill in the course of duty. These deficiencies proved to be a catalyst for reform. Following an appeal by Florence Nightingale on her return to England after the war, a royal commission was appointed. A commission subcommittee report entitled ‘The Barrack and Hospital Improvements Commission on the Sanitary Conditions and Improvements of the Mediterranean Station’ was submitted to the UK Parliament in 1863.

In the mid-19th century there were four military hospitals in Malta: one in Valletta, the Knights of Malta’s former Sacra Infermeria, two in Vittoriosa and another in Spinola. There was also a sanatorium in Mdina.

The commission’s report highlighted “the unsatisfactory state of the hospitals within the (Malta) garrison”. It found the hospitals wanting in almost every respect and it put on record particular emphasis on the hospitals’ lack of ventilation and overcrowding. While the Mdina sanatorium, where convalescence was notably rapid, was judged to be a success, the commission expressed a “very unfavourable opinion of the hospitals”. It recommended the building of a 300-bed hospital in Valletta, on St Michael’s Bastion, and a 136-bed hospital in Cottonera. The report also recommended that Spinola Hospital and the sanatorium be retained at least for the time being. For a number of reasons, the Valletta hospital was never built.

On November 16, 1870, the Collector of Land Revenue informed the Chief Secretary to the Government that three plots of land had been purchased near Żabbar Gate and that the building of the new Cottonera Hospital could start. The hospital was designed and built by the Royal Engineers according to plans submitted by the commission. The new hospital was built on the pavilion principle, with wards occupying two end-to-end pavilions with large verandas for ventilation, with an administration block in between. The kitchen and stores were housed in outbuildings behind the hospital so that there was nothing in the hospital proper except the sick and what was immediately needed for their treatment and nursing, as proposed by Nightingale. Hot and cold running water was laid throughout the building.

The hospital opened its doors to patients in 1873. On August 28, patients at the old Vittoriosa hospitals were moved to the new Cottonera Hospital. The hospital was originally intended as a hospital for regiments serving in the Cottonera district. But on March 1, 1873, the system of regimental hospitals was abolished by Royal Warrant. Henceforth patients would be treated in general military hospitals, and Cottonera Hospital now took on the role of a general hospital.

The hospital was built on three floors, with two large wards each containing 32 beds, and two two-bedded wards for special cases on each of the first and second floors. There were another two wards in the basement, one for prisoners and the other for patients with contagious diseases. A day convalescence room was located on the second floor. The ground floor was mainly taken up with waiting rooms and surgeries.

In line with the commission’s findings and Nightingale’s proposals, great emphasis was placed on ventilation. Running the full length of the main wards and the ground floor were verandas nine feet wide, which allowed for the free circulation of fresh air while at the same time providing shelter from the sun and rain. The wards opened onto the verandas via large windows extending to within 18 inches of the ceiling.

Cottonera Hospital was built as a state-of-the-art hospital, in answer to all the concerns highlighted in the commission’s report. Each bed in the main wards was allocated the recommended 1,500 cubic feet. Little wonder that it was considered to be “one of the best hospitals of southern Europe” at the time.

An outbuilding, formerly a powder magazine, referred to as the barrack room or old barrack room, had a sanitary annex provided and was converted into a ward in World War I. It was used as an isolation ward and, as the need arose, as a ward for prisoners of war. This building was constructed some time between 1719 and 1745 on a design by Brigadier Rene Jacob de Tigné as part of the Cottonera Lines. These fortifications, which form the eastern perimeter of the Cottonera Hospital grounds, were built on the orders of Grand Master Nicolas Cotoner. The Cottonera Lines were designed by the papal engineer Antonio Maurizio Valperga. Construction, which started in 1670, was spread over decades and was never fully completed.

Cottonera Hospital was considered to be ‘one of the best hospitals of southern Europe’ at the time

Another outbuilding, to the north of the hospital grounds, was the Nursing Sisters Quarters. The building, on two floors, had four bedrooms on the second floor and the common areas for rest and recreation on the ground floor, and both floors opened onto spacious verandas. The other outbuilding forming the hospital complex was to be found in the southwest corner of the grounds. Also built on two floors with large verandas, this building housed the Surgeons’ Quarters.

The hospital complex, including the purchase of the land, cost £21,000.

Cottonera Hospital will always be remembered for the major role it played in World War I, when Malta was known as the Nurse of the Mediterranean.

At the start of hostilities on July 28, 1914, there were 278 beds in military hospitals in Malta. Of these, 167 were in Cottonera Hospital, which was the island’s main medical and surgical military hospital. By the beginning of April 1915, the number of beds had risen to 281. A short time later, when the barrack room (the former powder magazine) was converted into a ward, the number of beds reached 314.

This was the beginning of a programme of hospital expansion that was to turn Malta into one large hospital complex. That Malta should become the home of one of the British Empire’s largest systems of war hospitals was not anticipated in the early months of the war. It was not until May 1915 that the first badly wounded casualties from the Gallipoli campaign started to pour into Malta. The first convoy of 600 patients arrived on May 4, followed by a further 400 a day later, and on May 6 another 600 cases were brought ashore. Before the end of May, upward of 4,000 casualties from the Gallipoli campaign had reached Malta. A number of the more seriously wounded were admitted to Cottonera Hospital.

The end of May saw the number of hospital beds catering for the sick and injured rise to over 6,000 in 14 hospitals spread all over the island. The older hospitals, pre-eminently Cottonera, admitted the more serious cases and the newer hospital took mainly the minor cases. Between June and September, 22,000 sick and wounded disembarked in Malta, the number actually in hospital gradually rising from just over 4,000 at the beginning of July to just over 10,000 on September 30. At the peak of the Gallipoli campaign the average number of arrivals was about 2,000 weekly.

By the end of 1915, Malta was also receiving the sick and war casualties from the Salonika campaign. In the first week of December 1915, 6,341 sick and wounded arrived. To cater for these large numbers, tents were erected in a number of locations on the island, mainly as convalescent camps, but also to cater for more acute medical and surgical cases. The tent expansions at Cottonera and five other locations “were most carefully thought out as regards every medical and sanitary detail, when complete being models of their kind”. Tent expansions at Cottonera were closed in August 1917.

After January 1916, the number of sick and wounded fell very considerably with the scaling down of the Gallipoli campaign, only to rise again with a vengeance in the summer of 1916, as the Salonika campaign proceeded. However, the number of hospital beds remained in the region of 25,000, and reached a maximum of 25,522 housed in 27 hospitals by April 1917. The number of sick patients, suffering mainly from “dysentery and enteric group of diseases”, always exceeded the number admitted with war wounds. With the end of the Gallipoli campaign and the start of the Salonika campaign in October 1915, this trend in admissions became even more marked as a result of a rush of malaria cases from Salonika. Up until April 30, 1917, Cottonera, a mixed hospital catering for both the sick and injured, received 2,867 sick but only 308 wounded.

According to an eyewitness who visited all 27 hospitals and tent convalescent hospitals, “the development of the hospital accommodation of Malta has been one of the remarkable achievements of the Great War”.

Cottonera retained its position as a specialist centre for both surgical and the more serious medical conditions up to the end of the Great War. It was also a referral centre for diseases of the eye, and a mental clinic was started there. It housed one of the five leading radiology departments and one of the six well-equipped and well-staffed laboratories. That it was regarded as the leading military hospital is perhaps exemplified by the statement that Matron McDougall was “promoted from Għajn Tuffieħa Camp to Cottonera Hospital”. This is not surprising, considering that the other major military hospital was the Valletta Station Hospital, so negatively reported upon in 1863, while Cottonera was a purpose-built hospital.

Cottonera Hospital’s location, with its wide open spaces and shaded verandas, led a visiting senior Presbyterian chaplain to sum up the virtues of the hospital thus: “Across the harbour on a height which the breezes fan, stands the hospital of Cottonera. It is not too big, and its awning-shaded verandahs are full just now with men of two battalions of the Royal Scots. If an interesting view is a tonic, the inmates do not lack that stimulus.”

Among the more famous medical consultants who joined the army and gave their services at Cottonera Hospital and other hospitals in Malta were: Sir Charles Balance, surgeon to St Thomas’ Hospital, London; Sir Archibald Garrod, physician to St Bartholomew’s Hospital, London; Dr George Lovel Gulland, physician to the Edinburgh Royal Infirmary; Sir James Purves-Stewart, physician to Westminster Hospital, London; Sir Charters James Symonds, surgeon to Guy’s Hospital, London; Sir William Thorburn, surgeon to the Manchester Royal Infirmary and Dr Howard Tooth, physician to St Bartholomew’s Hospital, London.

No man is an island, and indeed no hospital is either; patients who have suffered the ravages of war need not just hospital care but also a social environment that promotes their overall well-being. That, in large measure, is what Malta provided. Tributes to the voluntary help given by Maltese society to the hospital war effort for the benefit of the patients in World War I poured in and continue to do so to this very day, a hundred years later. Maltese ladies, church charitable organisations of various denominations, St John’s Ambulance Brigade, the British Red Cross, Maltese Boy Scouts, all number among those who participated to the full in the “hearty cooperation of the civil population” in providing entertainment, solace, comfort and great kindness at what became synonymous with Maltese hospitality in World War I – the tea rooms, where the convalescing were looked after with such care and affection. Even the church bells stopped ringing, out of respect for the pain and suffering of so many.

In the words of Lord Methuen, Governor of Malta and architect of the hospitals expansion programme, writing in August 1916: “If the hospital arrangements have proved satisfactory, if the lives of 80,000 patients have been made happy during their time in Malta, a great amount of credit is due to the philanthropic work carried out on the island.”

By the end of World War I on November 11, 1918, Malta had hosted up to about 58,000 patients from the Gallipoli campaign and a further 67,000 from the Salonika campaign.

The development of the hospital accommodation of Malta has been one of the remarkable achievements of the Great War

Cottonera Hospital ceased operations when the new Mtarfa Military Hospital opened its doors to patients in 1920. St Edward’s College was established on January 18, 1929, by a deed of foundation whereby Lady Strickland, Countess della Catena, wife of Lord Gerald Strickland, Prime Minister of Malta from 1927 to 1932, provided for the setting up of a Catholic college for Maltese boys, run on the lines of a British public school. The college admitted the first students in October 1929.

Cottonera Hospital was leased to St Edward’s College, on May 29, 1929, by an agreement between the representative of His Majesty’s Principal Secretary of State for War and the college’s Board of Governors, represented by Prof. Sir Augustus Bartolo, and by a subsequent deed dated June 12, 1931. The four main wards were converted into dormitories when St Edward’s admitted only boarders. In later years the verandas facing east were closed in with large windows, and those of the south pavilion used as accommodation for sixth formers. The wards now house the International Baccalaureate Sixth Form, the boarding house, classrooms and other facilities. The west-facing verandas on the ground floor were also closed in and are now the college canteen and various common rooms. The day convalescence room on the second floor is now the college library.

The barrack room or powder magazine is now the college chapel. The chapel was consecrated to St Edward, King and Confessor, on May 3, 1935. The only structural changes to the original building to convert it into a chapel were the opening of balanced sets of windows on all sides and the construction of a porch for the main door on the western wall. In the days of full-time boarding, services included daily morning Mass, afternoon litany and evening rosary, besides twice-weekly benediction and confession. Nowadays, Mass is celebrated in the chapel three times a week, for the junior, middle and senior schools. Many Old Edwardians received their First Holy Communion or have been married in the chapel.

The Nursing Sisters Quarters, which in 1929 became the headmaster’s residence and continued to be so until 2002, apart from some short periods during which it served as the infirmary and as the chaplain’s residence, now houses the nursery and kindergarten. The building facade underwent extensive structural restoration in 2012 to repair defects caused by enemy action in World War II.

The Surgeons’ Quarters is now a self-contained junior school. From 1929, when St Edward’s offered only a full-time boarding education, it provided accommodation for resident members of the teaching, nursing and support staff, both married and single. In 1993, an extension was built on the eastern aspect of the building to cater for the increase in the junior school population and to incorporate a music room, library, computer room and staff room.

In days gone by, prefects and monitors enjoyed the privilege of walking on the path along St James Bastion, or the College Bastions, as they are known to generations of Old Edwardians. Nowadays the path forms part of the inter-house cross-country route.

The St Edward’s sports complex, athletics track, football pitch, tennis court and other sports facilities at the foot of the bastion slopes were constructed between 2013 and early 2014.

Miss Violet Briffa, a young nurse at Cottonera Hospital and later matron at St Edward’s College 1930-1965.Miss Violet Briffa, a young nurse at Cottonera Hospital and later matron at St Edward’s College 1930-1965.

For many years the strong connection between Cottonera Hospital and St Edward’s College was personified by Matron Violet Briffa. A young nurse at Cottonera Hospital, Miss Briffa was matron at St Edward’s from 1930, the year following the college’s foundation, up until 1965; she was a towering personality who left her mark, the result of the realities of World War I and Cottonera on generations of Edwardians.

A totally unforeseen historic connection was the college’s second rector, Fr Henry Brackenbury Louis Hughes, known to older generations of Edwardians as ‘Fr Louis’. Fr Louis’s father, surgeon Captain Matthew Louis Hughes, was stationed in Malta between 1890 and 1898, during which he spent a considerable time at Cottonera Hospital. This was the time of one of the most momentous moments in Maltese medicine, the discovery of the causative micro-organism of Malta Fever, or Mediterranean Fever, by Prof. Major Sir David Bruce, in 1887.

It was Hughes who coined the term Undulant Fever, because it describes one of the most constant characteristic features of the disease. He also disapproved of the limiting geographic term, like ‘Malta Fever’, when none, in fact, existed. He is also credited with the change of nomenclature of the causative organism of the disease to Brucella melitensis (after Bruce). Like his co-workers at the time, including Bruce, he ruled out the likelihood of goats’ milk being a vehicle of infection. The truth was to emerge when this discovery was made by Sir Themistocles Zammit in 1905. Hughes left, for posterity, the much acclaimed monograph, Mediterranean, Malta, or Undulant Fever, published in 1897, and to this day is regarded as the classical description of Brucellosis, based on his observations at Cottonera Hospital and Malta generally.

Fr Louis, rector from 1945 to 1952, was a scholar of international repute. A graduate of Oxford, Pisa and Toronto, he converted to Catholicism and published a number of books, mainly on religious and historic themes. As rector of St Edward’s, he is credited with raising academic standards, not only at the college but in Malta as a whole. Fr Louis lectured extensively at the Royal University of Malta. He was also a member of the University Council and the Board of Education, and gave numerous public lectures.

St Edward’s will be holding an exhibition at the college, jointly with Fondazzjoni Wirt Artna, in the last quarter of 2014, to commemorate the role played by Cottonera Hospital in World War I, on the occasion of the 100th anniversary of the start of hostilities on July 28, 1914.

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