Attempts at introducing formal medical education in the Maltese Islands can be dated to the establishment of the first School of Anatomy and Surgery in Malta by Grandmaster Nicholas Cottoner in 1676 and further strengthened by the foundation of the Collegio Medico by Grandmaster Pinto in 1771. However informal practical training in medicine and surgery had been previously established in the Sacra Infermeria of the Knights. Until the arrival of the Knights of St. John of Jerusalem in Malta in 1530, doctors working in Malta were appointed by the Universita` from neighbouring Sicily and other parts of Italy and Spain, while Maltese medical practitioners proceeded abroad for their training. Documentary evidence suggests that in the late Middle Ages many of the local practitioners were Maltese or Sicilian Jews who most likely underwent their medical training in Sicily. In 1466 the Sicilian Jews were granted the right to found a University in Sicily, but this does not seem to have materialized. The Jews were expelled from the Kingdom of Sicily in 1493. Their place in Maltese medical practice was initially taken over by conversos and other Christian practitioners, but in 1517 the town council expressed its worry that "in this city and island there is no physician" [1].

The arrival of the Order brought an influx of medical practitioners to the Islands. During the initial years, the Order was mainly concerned with the defense of the Islands against the Turkish gradual invasion of the Mediterranean. They established their Sacra Infermeria, initially at the maritime centre of Malta at Birgu, and subsequently after 1574 at their new city Valletta. The Sacra Infermeria served as the shore hospital of the marine service of the Order and contributed towards the early training of surgeons and physicians. In the absence of academic facilities for the study of medicine in the Island, aspiring Maltese physicians had to pursue their studies and obtain qualifications abroad. They usually began their study of medicine in Malta at the Sacra Infermeria under the private tullage of one of the senior physicians for a period of two years, after which they then joined a medical school or university in Italy or France, such as those of Salerno, Rome, Florence, Paris, Montpelier and Aix-en-Provence. Those aspiring to become surgeons generally started their career as barber-surgeons (barberotti) in the Sacra Infermeria and subsequently joining the naval service to serve on the Order's ships for a number of years. They subsequently returned to the Infirmary for further training after which with proof of competence they became Junior Surgeons (Prattici). These trainees were subsequently encouraged to proceed abroad to further their surgical training. The medical and surgical trainees were not only encouraged to go abroad but were also assisted financially by the Order's Treasury. They were in addition placed under the protection of the Order's ambassador or some influential person to ensure that the trainees were attached to the best teachers available and that these teachers paid "une particuliere attention a observer sa conduitte et le progress de ses etudes" [2].

On 19 October 1676, Grandmaster Nicolo` Cottoner formalized medical teaching at the Sacra Infermeria by the appointment of Fra Dr. Giuseppe Zammit as lettore in Anatomy and Surgery, while the School of Anatomy and Surgery was founded on the 19 December 1676 at the Grandmaster's expense. Instruction in theoretical anatomy and surgery was given to the barber-surgeons of the Sacra Infermeria and to all other youths who aspired to join the surgical profession provided that they could read and write. Later lectures in the surgical aspects of physiology, pathology, semiotics, hygiene and therapeutics were added to the curriculum. By 1682 the course in surgery lasted ten years. Students were admitted at a young age after being examined by the teacher of anatomy and one of the surgeons - Michelangelo Grima started his apprenticeship at the age of twelve years. A set of rules governing the teaching of surgery and anatomy were published in 1729 and revised in 1739. Anatomical teaching during Dr. Zammit's tenure and that of his successor Dr. Giuseppe Farrugia was limited to the theoretical aspect with no anatomical dissection being demonstrated. In 1716 a dissection room was built in the cemetery of the Infirmary and the necessary instruments were obtained from Paris. Dr. Gabriele Henin was sent in 1721 to Florence to learn practical anatomy at the Hospital of Santa Maria Nuova. He was recalled in 1723 to succeed Dr. Farrugia. Anatomical lecture-demonstrations initially took place weekly during the winter months but they were subsequently held daily. Dissection material was readily available since the corpses of all persons dying in the Sacra Infermeria, including all the Knights, were to be dissected or autopsied. Students also received instruction during operations and were required to care for operated patients. They also received instruction about the use of the catheter. Anatomical teaching aids were also used for instruction. In 1741, the French painter Antoine Favray was allowed to obtain bones and other human parts from the School of Anatomy and was commissioned to prepare anatomical drawings. In 1766 Anthony Meyer donated twenty anatomical models in coloured wax to replace dissection material in the summer months [3].

The School of Anatomy and Surgery prospered under the 30-year directorship of Dr. Henin, who can be considered the Father of Anatomy in Malta. Henin became gravely ill in 1753 and died the subsequent year. He was succeeded by Dr. Enrico Maggi who actively occupied the Chair of Anatomy for only a few months being in turn seized by an apoplectic fit. Over the next ten years the post remained vacant, possibly because of the intrigues of the Inquisitor Mons. Gregorio dei Duchi di Salviati who wanted his private physician Dr. Vincenzo Galli to occupy the post. Maggi successor was Michelangelo Grima who was appointed in 1763 and occupied the post until 1797. During his tenure, the School of Anatomy and Surgery was incorporated into the Collegio Medico when Grandmaster Pinto founded a University of Studies in 1769. Under Grima the School of Anatomy was revived and public anatomical dissections were reintroduced. Grima's course of anatomical instruction extended over one year. To obviate the dictation of notes Grima published textbooks on traumatic surgery and on anatomy. The latter textbook was published in Venice under the title Instituzioni d'Anatomia in 1781 and gives a detailed description of the bones, ligaments and joints of the human body. The second part remains in manuscript form with the title Trattato della sarcologia, angiologia e nervologia in the form of dictated notes dated October 1785. Grima was succeeded to the post in 1797 by Dr. Aurelio Badat who occupied the post until 1813 [4].

After the expulsion of the Jesuit Order from Malta in 1768, GrandMaster Pinto de Fonceca appropriated all the revenue accruing from its property in the Island with the aim of establishing a Pubblica Universita` di Studi Generali in the Collegium Melitense which had been set up through direct papal intervention in 1592 and which had been run by the Jesuits to teach Philosophy, Theology, Grammar and Humanities. The decree constituting the University was signed by Pinto on the 22 November 1769, having been authorized to do so by the papal brief Sedula Romani Pontific received on the 20 October 1769. On the 25 May 1771, a Collegio Medico was set up as one of the faculties. At the time of foundation of the University, the Principe dell'Accademia dei Medici was Michelangelo Grima who also held the Chair of Anatomy and Surgery. Together with Grima the faculty was made up of the following doctors: the Professor of Medicine Giorgio Locano, the Retired Principal Physician Gaetano Azzopardi; the Principal Physicians of the Sacra Infermeria Giorgio Imbert, Gio Domenico Biagio and Giuseppe Bigeni; and the Physician for the Poor of Valletta Lorenzo Thien. The first statute of the new university was published on the 22 May 1771. There was a Preparatory Course leading to the Degree of Master of Arts comprising Latin, Italian, Greek and Roman History, philosophy, physics and mathematics. The Academical Courses or Faculties included Theology, Law and Medicine. The Medical Course lasted for five years, the student obtaining a Bachelorship after two years, a Licentiate after four years and the Doctorate after the final year. The subjects studied included botany, chemistry, anatomy, surgery and medicine. The licence to practice the profession was only given after serving six years at the Infirmary [5].

With the occupation of the Islands by the French in 1798, formal University teaching was abolished by General Napoleon Bonaparte by degree published 18th June 1798. Plans to introduce the teaching of anatomy, medicine and midwifery never materialized because of the civil strife that resulted from the uprising of the Maltese against their new masters. A few weeks after the French were forced to leave, Sir Alexander Ball re-instituted the University on 6th November 1800 and medical studies were resumed that same year with the first three doctors qualifying in 1804. During the first two decades of the nineteenth century, only a licentiate was granted to successful candidates. The doctorate was introduced in 1822, this being granted a year after the end of studies. The licentiate was abolished in 1838 [6].

In 1832 the University was noted to have become "deficient in professors.....and neglected to such a degree as to render instruction incomplete". Because of the adverse state of affairs, the university was a subject for investigation by the 1836 Royal Commission. This led to the publication of the 1838 Fundamental Statute of the University of Malta which brought the medical faculty into line with medical schools in England. In 1879, Mr. P.J. Keenan expressed the opinion that "this little School of Medicine and Surgery might....be able to hold its own with any other Medical College in the British Empire and be fairly entitled to the recognition and privileges accorded to students in the Universities and Colleges of Great Britain, Ireland and the Colonies". In 1898-99 permission was granted to medical graduates from Malta to sit for the final examination of the Conjoint Board of the Royal College of Physicians and the Royal College of Surgeons, and for the diploma of the Society of Apothecaries of London. In 1901 the Medical Degree of the Malta University obtained official recognition throughout the British Empire and entitled graduates to be registered in England as Colonial Practitioners. This recognition was suspended after 1977 as a result of a trade-unionistic dispute between the medical profession and the Government. Recognition for temporary registration in the United Kingdom was eventually re-established in 1986 [7].

A series of Maltese medical practitioners have proceeded abroad to further their medical studies and to obtain post-graduate training from centres of excellence on the Continent. This practice dates to the time of the Knights of St John when a number of Maltese doctors proceeded to universities in Italy and France to pursue their studies generally sponsored by the Council of the Order. Under British rule in the nineteenth century, the practice of sending young men to further their studies at public expense was abandoned. However a number of Maltese practitioners continued to go abroad at their own expense generally to Italy and Great Britain. The Malta-British connection was further strengthened after the Second World War after which postgraduate studies were generally pursued in the United Kingdom. The brief interim after 1977 when UK. recognition for registration purposes was suspended, a cultural medical link with the continent to countries such as Belgium, France, Italy and Germany was re-established [8].

A number of other occupations are closely related to the practice of medicine, these gaining particular recognition in recent years. An old paramedical specialty dating to the medieval period is that of the barber-surgeon or barbarotti. Definite mention of barbarotti practising in Malta is made during the Medieval period. In 1486 the Jew Xema Girbi is known to have practised the profession at Mdina. It is not known what training the medieval barbarotti obtained prior to be allowed to practice their art. It is possible the simple barber-surgeon received his education from the hands of a "Master" and a guild or apprentice method of training was in force. After the advent of the Knights of St. John to Malta, the training of barbarotti became an essential part of the training of the surgeon. During the eighteenth century, the surgeon's training generally started in a barber's shop where he underwent a period of apprenticeship as a barber-surgeon at the Holy Infirmary, enriching his experience on the battlefield or in the naval service. He subsequently qualified as a junior surgeon. Towards 1765, the Bali Sigismondo Piccolomini, who was President of the Casetta delle Donne, originated the idea of training the maid-nurses of the institution in the duties of barberotti so that by 1728 a number of female barberotti were wanting to practice. The barber-surgeons were initially incorporated in the confraternity Universitas barbitonsorum representing the medical profession which was organised on the 10 October 1635. The barbers subsequently formed their own confraternity on the 3 June 1797. The barberotti continued to perform their medical functions well into the nineteenth century, and were only removed from the list of medical practitioners in 1921 [9].

One of the chief branches of the barberotti business was tooth-pulling or breaking. During the eighteenth and nineteenth centuries, the higher social classes in Malta were showing concern about dental care and hygiene and a number of surgeons were showing a special interest in the subject. The control in the practice of dentistry was introduced in the Police Laws of 1883 which required surgeon-dentists to obtain a licence from the head of Government before being permitted to practice, while in 1901 it became necessary for applicants to obtain a diploma from the university or other specially authorized school in Malta. The conditions under which the Diploma in Dental Surgery was granted by the university were laid down in the 1907 Statute of the University and Lyceum. Since the University of Malta served simply as an examining body and had no course of studies in dentistry, the candidate had to produce certificates showing that he had pursued for four years dental studies in a recognized institution abroad, and had received three years instruction in mechanical dentistry. In 1921 the University of Malta introduced a course of studies leading to a Diploma of Dental Surgeon. Revisions to the University statute in 1943 introduced the Degree of Bachelor of Dental Surgery, while the Diploma was abolished in 1947 [10].

The practice of Pharmacy likewise has ancient roots in the Maltese community. Apothecaries are known to have practised their profession during the late Medieval period. Their training in the art of pharmacy was probably obtained abroad from established schools in Sicily. It is probable that a School of Pharmacy was established at the Holy infirmary in 1676. Dr. Giuseppe Zammit, the first director of the School of Anatomy and Surgery, was in addition the teacher of botany. He set up a botanical garden in the vicinity of the Infirmary to promote the study in 1690, and also introduced the study of chemistry. Regulations for the school of pharmacy were laid down on the 17 December 1729. Candidates wishing to be admitted to the course of studies had to be approved by the Master Apothecary of the Holy Infirmary and had to have good knowledge of Latin. After completing their studies and examination, the successful candidates were granted a Diploma in Pharmacy by the Medical College. In the early years of British rule, the diploma and licence to practice pharmacy were issued by the Protomedicus and after 1821 by the newly constituted Medical Committee. In 1838, the University established the conditions for the course of pharmacy. Entry to the course required the Diploma of Master of Philosophy and Arts of the University or its equivalent. The Pharmacy course lasted two years and included studies in natural history, botany, general chemistry, practical medicinal botany, pharmaceutical chemistry and materia medica. Experience in practical work could be obtained from attending the Civil Hospital pharmacy or other private establishments. In 1921 the course of studies for the Diploma of Pharmacy was extended to a period of three years. In 1948 the Diploma was substituted by the degree of Bachelor of Pharmacy, the course of studies being extended to four years [11].

Another paramedical profession which definitely dates to the Medieval period is that of nursing. Santo Spirito Hospital in 1494 employed a spitaleri performing the function of a male-nurse or cleaner. He was replaced by a female attendants, a garzuna and a servitrichi [12]. The arrival of the Knights of St. John saw the employment of "servants" who were detailed to look after the sick. Further nursing care in the Order's hospitals was given by the Knights themselves. Female employees in the medical services of the Order gave a contribution at the Holy Infirmary, at the Hospital for Women, and in the District Medical Service. The Holy Infirmary employed the ospedaliera and the sotto-ospedaliera who had the duty of caring for the foundlings deposited at the Infirmary and supervised the balie della casa or wet-nurses and balie di fuori or nutrici forastiere foster-mothers. During the best part of the seventeenth century the ospedaliera was recruited from members of the same family. An elderly and experienced woman donna per la tigna was further employed to medicate sufferers of ringworm. The Hospital for Women employed an ospedaliera, an ostetrice or midwife, a barberotta, a donna della mancia employed to serve the food, a spalmante and stufarola, both employed to administer anti-syphilitic therapy, and a spezialotta to administer medicines. The earliest known serva or servant/maid-nurse employed to look after the patients at the Woman Hospital received her appointment in 1655 [13].

While these servants obtained instruction in their duties through a guild method of "apprenticeship", very often maintaining a family traditional employment, there does not appear to have been a formal scheme of training for nurses. The first course of studies to train nurses in the Central Hospital was proposed by Dr. T. Bonnici in April 1882. However since the attendants participating in the course remained "generally illiterate", the results of this training were not immediately apparent. After 1895 The School for the Training of Nurses at the Central Hospital was reorganised with lectures being given by the Director of the School three times a week. The course of studies included a variety of subjects ranging from bed-making, attendance of medical and surgical cases, the use of the thermometer, methods of massage, the pre-operative preparation of patients, the use of the catheter, and the assistance in impending anaesthetic deaths. Examinations were conducted at the end of the course and the successful candidates were granted a certificate of efficiency as nurses and a badge to identify them as Certified Nurses. The first course was attended by twelve candidates, eleven of which passed the final examination. By 1898 enough hospital employees completed the course of studies in order that a decision could be made to limit the designation of "Nurse" only to certified individuals, the uncertified attendants being termed "Servants". In 1904 an illustrated guide on nursing in Maltese was published by Dr. J.S. Galizia [14].

While these initial measures in the training of nurses served to raise the standards of care in the Hospitals, the standards were not kept abreast with the contemporary developments in the field of nursing. Thus in 1934 the syllabus of studies was reported to be "too elementary" and the practical training as "inadequate". This report stimulated the enactment of Ordinance VIII of 1936 which contemplated the setting up of a register of nurses, the fixing of standards for recognition and the drawing up of a scheme for the establishment of a school of nursing. The following years saw the implementation of these schemes. The new St. Luke's School of Nurses opened in October 1938 but its function was interrupted during the Second World War. The program of studies was eventually in 1947 raised to the level obtained in British Nursing Schools and in 1952 Maltese nurses received recognition by the General Nursing Council of England and Wales [15]. A new nursing school was officially opened in the grounds of St. Luke's Hospital on the 5th June 1965. The School subsequently housed students attending the various training certification courses in the various paramedical fields, including midwifery, physiotherapy, radiography, chiropody and dental hygienists. Nursing studies were in 1987 taken under the management of the University of Malta by the establishment of the Institute of Health Care which was initially housed in the Pharmacy Building at the University, but subsequently returned to the Nursing School in 1992. The main aim of the Institute is to develop and regulate Health Care Sciences courses (such as Nursing, Medical Technology, Speech Therapy) leading to a certificate, diploma or degree. The first health care course conducted under the auspices of the Institute was the B.Sc. Nursing Studies with the first group completing their studies in June 1992. This degree course was later followed by courses leading to a Diploma in General Nursing, a Diploma in Midwifery, a Certificate in Nursing, and a Diploma in Psychiatric Nursing. In 1991 the B.Sc. Communication Therapy course was introduced [16].

Midwifery practice has a very long history. The earliest reference to midwives practising in Malta dates to 1575, when Mgr Pietro Duzina enjoined parish priests to teach midwives the proper administration of the Sacrament of Baptism. The first legal enactment to control midwifery in Malta dates to 2 August 1624. According to this decree and subsequent regulations no woman was allowed to practice as midwife unless she had been examined and approved by the Protomedicus and granted the requisite licence which required renewal by every subsequent Protomedicus [17]. In spite of the state and ecclesiastical control of midwifery practice there was no formal teaching of midwifery prior to the nineteenth century, and midwifery training must have been based on the guild method of apprenticeship. This method of instruction resulted in a variable range of practising midwives, some well versed in their art while some were dangerous and incompetent. Some midwives were appointed by the lay and ecclesiastical authorities to act as court witnesses. On the other hand Dr Giuseppe Antonio Cren(i) in his request to initiate for the first time in Malta the formal teaching of the theory and practice of midwifery in 1772 commented that because of the unskillfulness of the practising midwives many mothers and infants frequently suffered injury and/or death. Dr Cren suggested a course of lectures delivered monthly or more frequently if necessary to prospective and practising midwives, besides practical demonstrations on an anatomical model which he had brought from Bologna where he had undergone his medical training. The request was submitted to Grandmaster Fra Don Emmanuel Pinto de Fonceca and passed on for consideration to the Senior Physicians including Dr G Imbert who turned down the suggestion of the grounds that since the midwives did not possess any knowledge of Italian, or any fundamental concepts of human anatomy, they were unlikely to profit from any formal instruction while the lectures could only be 'scandalous and full of inconveniences' [18]. In March 1802 Dr Francesco Butigiec was appointed Teacher of Obstetrics at the Women's Hospital at Valletta. Besides imparting the obstetric art to medical students, he also held separate classes for midwives who were taught 'orally and given explanations, where needed, in the national language as best he could". The lectures were given in Italian, but explanations were made in Maltese to circumvent the problem of the midwives bad command of Italian [19].

The school of midwifery functioned very erratically and was abolished in later years with a consequent deterioration in the practice of midwifery. In the 1842 census, 49 women registered midwifery as their profession. In March 1841 the newspaper "Il Globo" commented that midwives were causing maternal and perinatal deaths as a result of their ignorance. It urged government to provide a course of theoretical and practical instruction for midwives who were able to read and write under the direction of the Professor of Obstetrics. Similar recommendations were made by Dr T Chetcuti and Dr N Zammit in their report on the proposed University reforms in 1842 [20]. No action appears to have been taken, and on the 4 August 1853 the Commissioners of Charity deplored the fact that "competent midwives were rapidly diminishing and that ignorant women were assuming their duties to the serious detriment of the poor population", ascribing this state of affairs to the abolition of the School of Midwifery and recommended the re-establishment of the school and the enactment of legal measures to allow only qualified and certified midwives to practice. It was suggested that the pupils should pay five shillings monthly and perform servant duties while residing in the hospital during their period of instruction [21]. The school was eventually re-opened in 1854 with Dr G Clinquant being appointed to teach the practical part of midwifery to a number of women. However clinical material was scarce. New efforts were undertaken to reorganize the School of Midwifery but it was realised that the practical instruction must face obstacles arising from prejudices and scruples, and the teacher was warned by the Inspector of Charitable Institutions to be careful so as "not to arouse feelings of opposition and prejudices unless absolutely necessary". These difficulties persisted and were augmented by the absence of any anatomical models [22]. The School of Midwifery failed to provide a sufficient number of trained midwives in the community and in 1868 midwives were described as being "mere attendants capable only of uttering ejaculations and prayers, quite of their own making, while stretching forth their arms to receive a foetus naturally expelled from the womb, an assistance which any individual knows how to afford" [23].

Fresh efforts were made to organize a School of Practical Midwifery in 1868. It was contemplated that a more respectable type of student will be selected, that there will be the teaching of both the theory and practice of midwifery following which the candidates were to sit for a qualifying examination set by a properly constituted authority and the taking of an oath before being allowed to enter the profession. In order to give the scheme the widest publicity, the Comptroller of Charitable Institutions availed himself of the assistance of the parish priests and the police to inform the public of the prospective course. The course started on 24 November 1869. The lectures, delivered by Prof SL Pisani Senior Surgeon and Accoucheur, were given twice weekly in English and Italian. They covered the principles of midwifery, the nursing and treatment of puerperal disease, and the care of the infant. The students had many opportunities to assist at normal deliveries but they were unable to attend any pathological labours for lack of cases. The course lasted sixteen months but it was proposed to extend it to two years and to commence a course every second October. A large number of women presented themselves for admission, but many were rejected because of "their utter deficiency in the accomplishments indispensably required to comprehend the lectures". Eight students, including three Englishwomen married to army sergeants, joined the course but two women were later persuaded to abandon the course because of their low educational standards. The results of this experiment were considered by the hospital authorities as satisfactory and beyond expectations [24]. The second course was announced on 21 July 1871, but the illiteracy of the applicants remained a serious stumbling block. The pupils came from the lowest strata of the population and lacked the most elementary of schooling. The teacher had to limit himself to a few short talks in Maltese, and after assisting passively at a few deliveries, the pupils underwent an oral examination. No practical tests were given. The low educational and social status of the applicants remained a problem. However the profession did not apparently attract women from a better class. Prof SL Pisani on 18 February 1897 wrote "I have tried on one occasion to produce midwives of a better class - I did not succeed - only one had the courage to become a midwife but after a while she gave it up and did not continue to practice. I remember having engaged her to attend on an Austrian lady, the wife of an officer in the Black Watch. At the last moment, when her services were required, she deserted me and instead of herself she had the impudence to send me an ordinary nurse" [25].

The medical journal "Il Barth" in 1871 condemned this state of affairs and suggested that midwifery pupils should possess a primary education and a working knowledge of Italian to enable them to read and follow an obstetric manual, and that suitable candidates aged 18-20 years should be sought from among orphanages inmates and girls attending elementary schools. The journal further accused midwives of being grossly incompetent, unable to recognise the fetal presenting part, and who either failed to call the medical practitioner in time or attempted to hasten delivery causing extensive perineal lacerations. Others even dared to pose as doctors prescribing medicine for dysmenorrhoea and other complaints, besides pretending to correct uterine malpositions. The midwifery course of 1876 was suspended because of lack of accommodation for the student midwives in the Central Hospital, since their previous accommodation was given over to the clinical medical students. The course was resumed the following year, ending in October 1878 when eight students underwent their final examinations. Subsequent courses were extended to two year periods [26]. In 1883 Prof SL Pisani published his lectures in book form to distribute the manual to his students at the end of their course. In 1885 an artificial body was purchased by the government at the cost of £stg 10 to ensure adequate facilities for practical training [27]. In 1886 it was decided that only women aged 20-30 years would be accepted as students. The applicants had to be able to read Maltese since lectures were to be given in this language. In 1895 students were also required to be able to write and know basic arithmetic [28]. Prof Schembri, following the endeavors of Lady Sym Fremantle, in 1896 initiated the Military Midwives Class held for English speaking women to provide English-speaking midwives for the women of the military personnel stationed in Malta. Prof Schembri also published his lectures in English and Maltese in 1886-87 for use by his pupils. In 1898, the medical journal "La Salute Publica" still considered midwives a menace to public health [29].

In the beginning of the twentieth century Prof S Grech pressed for reforms in the School of Midwifery, but his efforts were in vain since the Comptroller of Charitable Institutions saw no need for changing the applicants requirements which included the ability to read and write Maltese, a fair knowledge of basic arithmetic and a good moral character. In 1907 it was made obligatory for the students to attend the course for Hospital Attendants at the Central Hospital and to pass the prescribed examinations in general nursing before they were able to sit for the theoretical examination in midwifery [30]. The school was finally placed on a sound footing in 1915 when the course of midwifery was instituted under the auspices of the University leading to a Diploma of Midwife. The Professor of Midwifery was in charge of the studies which lasted two years, and eventually increased to three years. Candidates were admitted to the course after attending a preliminary period of training in anatomy, physiology and theoretical nursing at the Central Hospital. The course was sanctioned by the Special Council of the Faculty of Medicine and the annual examinations were conducted by an Examination Board composed of the Professor of Midwifery and two other medical men [31]. Because no Gozitan candidate attended the Courses of Midwifery held in Malta and because Maltese midwives did not find it worthwhile to go to Gozo, the number of midwives on that island had dwindled down to almost vanishing point to the extent that the Department of Health found it difficult to obtain the services of a midwife at Victoria Hospital. This was only made possible by offering a special allowance above the established salary given to a midwife from Malta. To increase the number of Gozitan midwives a course for midwives was started in October 1937 at Victoria Hospital in Gozo with the final examination being held in July 1940 [32]. The School of Midwifery reverted to the Medical and Health Department in 1946, the first group under this scheme qualifying in 1949. The midwives had a better comprehension of the part they played in giving advice to pregnant women, and were more capable of spotting the initial signs of cardiovascular, renal and infectious disease [33]. By 1958 midwives were fully qualified to render the best service, but their numbers were limited and only five applicants turned up for the course starting in 1958 with only one finishing successfully. This resulted in a decline in facilities for midwifery training locally and registered nurses wishing to pursue midwifery had to do so in the United Kingdom. The School was re-opened on 31 October 1970 at the School of Nurses under the direction of a Midwifery Tutor with lectures given by Maltese senior medical staff. The course aimed at State Registered Nurses lasted one year with the students obtaining theoretical and practical training. Midwifery training reverted to the University of Malta in 1987 [34].

The Maltese authorities throughout the ages have attempted to ensure that the population was well taken care of regarding the health requirements. Active measures to introduce training for adequate and expert medical care were initiated by the Knights of St. John with the establishment of a training program for barber-surgeons and surgeons in the Hospitals of the order and subsequently by the establishment of the Faculty of Medicine at the University. Training programs for paramedical personnel were introduced by the British authorities initially for midwives and nurses. In recent decades, the advancement in healthy care sciences required the authorities to introduce training courses in various fields ensuring the maintenance of standards in health care services offered.

1. G. Wettinger: The Jews of Malta in the late Middle Ages. Midsea Books, Malta, 1985; R. Ellul-Micallef: The Maltese Medical Tradition - Overseas contacts that have influenced its development. Malta: A Case Study in International Cross-Currents. eds. S. Fiorini and V. Mallia-Milanes. Malta University Publications, Malta, 1991, p.188

2. P. Cassar: Medical History of Malta. Wellcome Historical Medical Library, London, 1964, p.445, 481; P. Cassar: French Influence on medical developments in Malta. Ministry of Education, Malta, 1987, p.5; National Malta Library -Archives 1563, fols.294,348; NML - Archives 1583, fol.30

3. National Malta Library - Archives 262, fol.61; NML -Archives 279; vol.ii fol.833; NML - Archiives 578, fol.140; NML - Archives 646, fol.162; NML - Manuscript 378; NML -Archives 660, fol.211; A. Mifsud: Appunti sugli archivi di Malta. Archivum Melitense, 1912-13, ii:p.54; P. Cassar, 1964: ibid, p.437-448; J.L. Pace: The history of the School of Anatomy in Malta. The University of Malta, Malta, 1974, +.18p.

4. J.L. Pace: ibid; P. Cassar: The works of Michel'Angelo Grima (1731-1798). A bibliography with summaries and notes. St. Luke's Hospital Gazette, 1976, 9(1):p.3-20

5. P. Cassar, 1964: op. cit. note 2, p.445-448; National Malta Library - Archives 575, fols.459, 498t, 500; NML -Archives 1198, fol.97

6. H.P. Scicluna: Acts and documents relating to the French Occupation of Malta in 1798-1800. Archivum melitense, (no date), vol.15, p.5, 100; J. Cassar Pulicino: The re-opening of the University in 1800. Journal of the Faculty of Arts, 1958, i:p.144; P. Cassar, 1964: ibid, p.448-449

7. G. Mitrovich: The Cause of the People of Malta. London, 1836, p.41; S. Cumbo: Piano di Pubblica Istruzione. Malta, 1839, p.32; P.J. Keenan: An Inquiry into the System of Education in Malta. Charles Thom, London, 1878, p.60; P. Cassar, 1964: ibid: p.463-464

8. R. Ellul-Micallef: op. cit. note 1

9. G. Wettinger: op. cit. note 1, p.18; P. Cassar, 1964: op. cit. note 2, p.484-486; P. Cassar: Female employees in the Medical Services of the Order of St. John in Malta. Melita Historica, 1978, 7(3):p.227; Second Sanitary Law. Malta Government Gazette supplement, 13 May 1921, p.126

10. P. Cassar, 1964: ibid, p.513-516

11. G. Wettinger, op. cit. note 1, p.110; P. Cassar, 1964: ibid, p.497-499; G. Gulia: Cenni storici dell'istruzione superiore principalmente della scuola medica nei tempi dell'Ordine. Malta, 1886, p.7; National Malta Library -Manuscript 429: Bandi 1722-36, fol.292t; Malta Government Gazette, 28 April 1821, p.2564; Fundamental Statute of the University of Malta. Malta, 1838, p.46; Statute of the University of Malta and Regulations. Malta, 1921; Statute of the Royal University of Malta. Malta, 1948, p.53-65.

12. S. Fiorini, Santo Spirito Hospital at Rabat, Malta. The early years to 1575. Malta, Dept of Information, 1989, p.57

13. P. Cassar, 1964, op. cit. note 2, p.391; P. Cassar, 1978, op. cit. note 9, p.225-233

14. P. Cassar, 1964, ibid, p.402-403; J.S. Galizia, Il ctieb ta l'infermier, Malta, 1904

15. P. Cassar, 1964, ibid, p.403-404; Malta Government Gazette suppl., 20 September 1934, p.865; P.P. Debono, Medicine in Malta, Chestpiece, 1955, i:p.6

16. The New Nursing School and home at St. Luke's Hospital. Malta Review, 1965, 35:p.18-20; University of Malta - Annual Report 1991, Malta, Malta University, 1992, p.59

17. P. Cassar, The Maltese Midwife in History, Malta, Midwives' Assoc., 1978

18. P. Cassar, 1964, op. cit. note 2, p.412

19. P. Cassar, Teaching of midwifery in Malta at the beginning of the nineteenth century. St. Luke's Hospital Gazette, 1973, 8(2):p.91-111; P. Cassar, 1978, op. cit. note 17, p.6

20. P. Cassar, 1978, ibid, p.6; Il Globo, 4 March 1841, p.19; T. Chetcuti and N. Zammit, Rapporto ragionato della comissione incaricata dalla Societa Medica d'Incorragiamento di esaminare il progetto di studi reletivamente alla medicina. Malta, 1842, p.34; Malta Government Gazette, 31 December 1842, 1556:p.57-59

21. P. Cassar, 1978, ibid, p.6-7; P. Cassar, 1964, op. cit. note 2 above, p.413; Medical and Health Archives -Commissioners of Charity Letter Book, 15 May 1851 to 4 November 1857, fols.39,103,137

22. P. Cassar, 1964, ibid, p.413; Medical & Health Archives - Commissioners of Charity Inspectors Letter Book, 6 May 1851 to 3 October 1855, fol.279

23. P. Cassar, 1964, ibid, p.413; Medical & Health Archives - Letters to Government, 3 May 1867 to 5 March 1869, fol.560

24. P. Cassar, 1964, ibid, p.413-414; Medical & Health Archives - Letters to Government, 3 May 1867 to 5 March 1869, fols.253,495,557,558; 5 March 1869 to 31 January 1872, fols.339,445

25. P. Cassar, 1964, ibid, p.414; P. Cassar, 1973, op. cit. note 19 above, p.102

26. P. Cassar, 1964, ibid, p.415; Sulle Levatrice. Il Barth, 5 September 1871, Anno I(2):p.41-2; 2 December 1871, Anno I(4):p.83-84; 22 March 1873, Anno II(13):p.260-261; Medical & Health Archives - Letters to Government, 31 January 1872 tto 11 June 1878, fol.587; 1 July 1878 to 22 March 1883, fols.31,283

27. S.L. Pisani, Ktieb il qabla, Malta, Debono, 1883, +105p.; Malta Government Gazette, 10 June 1885, 3083:p.224

28. Government Notice No 154. Malta Government Gazette, 1885, p.414; Medical & Health Archives - Letters o Government, 23 March 1883 to 20 April 1888, fol.400; 10 April 1895 to 31 March 1903, fol.54

29. G.B. Schembri, The Midwife's Guide Book, Malta, Govn Printing Office, 1896; Schembri GB., Taghlim ghal l-istudenti ta' l-Iscola tal-Kwebel ta' l-Isptar Centrali, Govn Printing Office, Malta, 1897, +121p.; Pagina del male! Le levatrice. La Salute Publica, 25 July 1898, Anno II(31):p.1-2

30. P. Cassar, 1964, op. cit. note 2 above, p.416; Medical & Health Archives - Letters to Government, 1 April 1903 to 10 April 1909, fol.213; Malta Government Gazette, 15 February 1907, p.181; Government Notice No 130. Malta Government Gazette, 23 July 1909, p.663

31. P. Cassar, 1964, ibid, p.416; Malta Government Gazette suppl, 26 June 1915, p.54

32. Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1937, Malta, Government Printing Office, 1938; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1938, Malta, Government Printing Office, 1939

33. Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health department including the Emergency services for the year 1946, Government Printing Office, Malta, 1947; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department including the Emergency Services for the year 1949, Government Printing Office, Malta, 1950

34. P. Cassar, 1978, op. cit. note 17 above, p.9-10; Report on the Health conditions of the Maltese Islands and the work of the Medical and Health Department for the year 1958, Government Printing Office, Malta, 1961, p.7; University .... Annual Report 1991, op. cit. note 16