viernes, 25 de abril de 2014


Health care is an activity which exists since the origin of humankind. It is influenced by sociocultural circumstances which characterize every time and place in history. Within this sociocultural context, beliefs and among them religion along with the prevalent concept of sickness in every time are going to be crucial to analyze the evolution of health care.

Since its beginning, health care has been directly linked with satisfying the most basic needs for survival such as feeding, security assurance, shelter, coziness…and tied to two different periods during life where dependency from other people is blatant: childhood and old age. Therefore, the first background of health care are related to the beginning of the vital cycle, childbirth care and of each new incorporation to the community…focused on the basic needs' satisfaction. If in addition it is considered that first civilizations developed their activities within a hostile environment, where the number of natural foes of humankind were considerable, physical differences between men and women propitiated a work sexual division. Men devoted to external work which requires a higher physical strength. Women devoted to the close environment, especially to everything related with cares. This circumstance marked the becoming of history.

FOTO 001 Iatreia, Asclepeia y Xenodoquio

This women's entailment to care and the beginning of the vital cycle propitiate the appearance of women devoted to health care beyond their home. During Roman Empire there were women giving health care in childbirth and the newborn. Same happened during Middle Age, where women were recognized as caregivers, due to their distinguished characteristics related to fertility, be the bearer of every new family member, responsible for giving birth and in charge of protecting and feeding the new offspring.

Since its origins, the concept of disease of physical handicap had a magical component which stemmed from myths and superstition beliefs invented by the ancient man to control ideologically as a mean to reduce fear, explain the nature phenomena that were not explicable. In this context, disease is read into as an ill produced by spirits of god's punishment. Each disease was linked to superstition, the patient was attended by the members of her family which appealed to the warlock, quack or shaman.

These figures, witches, quacks…combined some rituals with their capacity to observe natural phenomena, gathering information of attended cases to apply it to new ones. Magical thinking is prevalent in the disease attendance in this way.

In this context, Catholic Church, takes the advantage of Cristian thinking promotes altruism, charity and sick and helpless attendance people as a path to follow in order to save one's soul. Hence it starts to monopolize health care by adapting and transforming the rituals and superstitions tied through the magical thinking to the disease into religious matters. That is to say, magical thinking is kept, but the focus is transformed. The shape changes but not the ground.

Thereby during Middle Age Hospital or closed institutions loomed up close to or at the sides of churches and cathedrals. These ones are built by nobles' and riches' exercise of charity preached by the Church as a path to salvation. These institutions devoted to the attendance of the least favored people in the society at that time had an important role during the big epidemics that razed Europe. In addition to the numberless shortages that these places piled up, an inadequate diet merged which caused the emergence of deficiency diseases, unknown by that time, to which. Skin diseases caused by vermin joined.

Health care in those places were given by religious man and women from different orders. It doesn't have to be forgotten that women kept on being the main provider of cares in the domestic environment. In this way, during the third century of our age, the Cesárea Bishop, Saint Basile creates an order devoted to Hospitals building for caring sick and helpless people. The Saint Benito Rule, in VI century will be the one which definitely mark the development of religious orders in Europe.

Medieval Hospitals encompassed four type of institutions: leprosarium, asylum and poorhouse; refuge and institutions dedicated to homeless sick people. All of them were located close to Cathedrals and rivers. Later, guilds built and maintained hospitals. The weight of care always relapsed on the different orders' sisters belonging to the hospital service and on the service personal employed in the institution.

During the Late Middle Age, an epoch where misery and famine were in the agenda, the population was at the mercy of big epidemics that devastated Europe. Pilgrimage paths to Jerusalen, Holy Land, and Santiago de Compostela come up. During those, thousands of pilgrims died. More hospitals and nurses were required to attend the wayfarers. The Church promoted Hospital building held up by collections opportunely carried out. Military orders tied to nursing, attention and protection of sick pilgrims loomed. These orders were a consequence of the crusades to Holy Land. There is not much information about cares given by this warrior nurses. On the contrary there is evidence that they built and equipped big hospitals and care the sick people themselves.

In this way the first Military Orders such as The Hospitable Knights of San Juan de Jerusalen, The Teutonic Knights; the Malt Order, The San Juan de Lázaro Knights and the Holy Tomb Knights, the famous Templars. The heyday of religious military orders also arrived to Spain and The Calatrava, Montesa Orders and Santiago Knights appeared.

FOTO 002 Hotel Dieu

The first acknowledged hospitals are: the Hotel Dieu in Lyon (France, year 542), Hotel Dieu in Paris (France, year 650) and the Santo Espirito Hotel in Rome (Italy, year 717). In Spain, the first one is the Merida Hospital, founded by the Bishop of the city.

In Hispania with Goth Monarchy, during Visigoths reign between V and VIII centuries The “Fuero Juzgo” or “Judges' Book” came up. The name of our forefathers, the “bleeders” already appears in this book. In XIII century in Castille Reign according to the Code "The Seven Items" from King Alfonso X the Wise they ranked as alfajemes, also known vulgary as barbers. They were to shave and bleed in separated places, not in squares and streets.
Our forefathers already started to marshal guilds and brotherhoods with an important growing of liberal professionals such as ours.

FOTO 003 Fuero Juzgo o Libro de los Jueces. Law I Judge or Book of Judges

It is written that during XIV century the first Barbers' and Surgeons' Brotherhoods are founded under the invocation of Holy Patrons Saint Cosme and Saint Damian. These brotherhoods were religious–beneficial institutions. Although in their statutes norms about professional practise were dictated in as much as to practice as barber–surgeons they had to be examined by two brotherhood's surgeons.

It has to be noted that every Group, Guild, Association, etc. was realizing that it is not only "to give care" but also to "know how to give care" what is all about. Therefore they grouped up and as it has already been said before belonging to a Brotherhood one had to pass an exam and be examined. Not only did they realize that know was important, but also study.

As an example, during year 1310 in Valencia the Barbers' and Surgeons' Brotherhood had one theoretical part and one practical part in the exam for its candidates. It is also collected in Barcelona in 1408 that its exams were the same as the Valencia's in the Barbers' and Surgeons' Professional Brotherhood of Saint Cosme and Saint Damian.

In Madrid, during year 1385, 11 hospitals were unified to one. "The General Hospital" divided into two houses: one for the infectious and another for the noninfectious sick people. In 1524, Carlos V established "Royal Hospitals" where tasks and personal funcions, amongs them the main nurse and the assistant nurses. The healthcare was also covered in brotherhoods, guilds and fraternities.

The capability to practise the profession was gathered in by King  Fernando and Queen Isabel, on the April 9th 1500 in a Royal Pragmatic dictated in Segovia which stated that:

We command that from now on, Senior Barbers and Examiners, neither accept nor bring on that either any barber or other alien person, may set up shops to lance or bleed, take leeches or suckers, extract teeth or molars, without previously having been examined by such Senior Barbers. In case any person should incur in aforementioned activities without the prescriptive examination as said, shall be declared perpetually incompetent to practice such job, and shall pay two thousand maravedies as penalty to our Chamber, etc…”

We know what our forefathers study. Hence in 1541 they had as study book, the “Book of Midwives and Pregnant, Parturient and Children Regiment”, in 1583 the “Treatise on venae festosin usefulness”; in the same year the “Treatise on bleeding usefulness”; in 1604 “Prematica by which the examination order is given to Novelist Surgeons”; in 1617 “Nurse Instruction and Comfort to Afflicted Sick People. And True Practise as to how the remedies prescribed by doctors must be applied. Very Indispensable for sick people to be well healed and helpful for medicine practitioners”; etc.

By Royal Document from Felipe V, on the 29th January 1711, the Bleeders Class was created. This supposed a first step for the coordination of the different jobs and professions that formed an all in the different branches of the science advocated to healing sick people.

In 1843 the “Medicine and Practical Surgery Auxiliary in the art of healing” was approved and in 1846 the “Ministering” were.

FOTO 004 Book of Midwives and Pregnant, Parturient and Children Regiment. Treatise on venae festosin usefulness

Such laws were substituted by the Royal Order on 9th September 1857, the so called “Moyano Law” (due to the Promotion Minister Mr. Claudio Moyano) who under the shelter of the Organic Sanitary Law of 1855 regulated the auxiliary sanitarians professions, thus recognising practisioners and midwives as practisioners of one job.

In 1896 Dr Federico Rubio y Gali opens up the first Santa Isabel of Hungary Secular School of Nursing.

In the Basque Country
Talking about village barbers, bleeders, ministrants or lady nurses takes us to other ages of the sanitarians profession of Nursing. From XIV century barbers to the present time nursing professionals there has been a lot of changes.

Gipuzkoa was not alien to what happened in other places more or less close to it, being the history of healthcare very similar to the one of the world it belonged to. Intuitive nursing gave way to oral tradition by elders in every family or community, being the X and XV centuries when people, first by charity, novelty and affection, later by a salary were identified as the ones dedicated to attend the basic needs of disease affected.

It won't be until XVI century when the writings that formed and organize people caring after sick people were found. The former paid special attention to anything related to birth, and maybe because of that, to the activity with the feminine world. The first mention to nurses as a complement to the toil that from IX century was being developed by religious orders (as seen in previous chapter) belongs to this age. This intimate relationship between nurses and religion gave to their jobs a spiritual sense, in which the feelings as a reflection of a vocation were prevalent. The need to properly prepare the people advocated to such jobs was the result of their almost complete submission to the religious administration. The latter was in charge of managing the healthcare because it knew the most efficient remedies. The nurse, subsidiary of the religious, had no option to increase her knowledge and hence her job was considered as domestic, without social appreciation.

In XVII and XVIII centuries the rules of the different religious orders for caring after sick people were kept. The nurses' change of attitude would not take place until XIX century where acquired knowledge was added to their good character.

In Bikaia since the momento Don Diego López de Haro founded the Village and gave the Puebla Letter, on the 15th June 1300, there existed The Magdalena's or Saint Lazaro's as medieval hospitals. The Saint Hospital was created by the end of XV century. It is written on the General Regulation dated on the 6th December 1645 that these institutions would work only as "shelters for Bilbao natives and neighbors, miserable, old and lacking ranch".

In Álava, despite the fact that there are data about Hermit Hospitals from 1167, the most famous case is that of the hospital people of the Santiago Apostle of Vitoria Hospital ruled as "healing hospital". They are known since 1466, although they were likely to be present since the hospital foundation in 1418. Also in 1514 there are references about Saint Joseph Hospital.

In Gipuzkoa, from 1485 to 1900, the number of either hospital or aid centers was very scarce. There were only eight centers. There are 1485 data about Saint Lazaro Hospital in the Saint Martin neighborhood off San Sebastián. From 1535 to 1719 it is known the existence of Saint Antonio Abad Hospital in the Saint Catalina suburb. Lately, in 1787, the latter hospital was moved to 31st August Street and in 1888 to the Navarra Avenue located in Manteo. The Tolosa hospital was inaugurated in 1860.

As a consequence of the aforementioned laws in 1855 and 1857 years the first professional associations of the nursing history of the Basque Country were created. When practitioners were given birth, they were integrated within the Bleeders College, differing from them only in the titling until in 1867 when the practice of the activity was forbidden if the OK wasn't given by the Faculties of Medicine after two years study and hospital practices.

During the second carlista war there was a bleeder surgeon in every battalion. He who was the practitioner in every village was contracted by the Town Hall. The long period of time of the different calista wars make the Ministry of War be where the most documentation about this matter existed. It was in charge of naming the different bleeder surgeons for every battalion.

In 1904 the nurses' and practitioners' careers are regulated. Two years later, the arrival at Spain of Queen Victoria Eugenia arrived was of great importance, since she brought in the Nightingale philosophy and soon the Men Section of the Red Cross was complemented by the Women Section, founded by the Queen.
Constitution of the Guipúzcoa Practisioners College

FOTO 005 Hospital del País Vasco. Hospital of the Basque Country

In 1915 it is published the "Practitioners Bulletin" and the legal recognition of the Dr Rubio's religious nurses.
In 1917 it is born the Basque–Navarrese Federation of Practitioners Colleges. The meeting was held on 24th September 1918 under the presidency of Mr. Iglesias and with the host president of the College Mr. Martinez de Pinillos acting as vicepresident. Representatives of the six northern colleges assisted (Álava, Gipuzkoa, Logroño, Navarra, Santander and Vizcaya) apart from Mr. Monfledo, Provincial Health Inspector of Logroño, agreeing by acclamation the following agreements:

Work for profession dignification.
Create "The North of Spain Practitioners Union".
Require the affiliation as mandatory.
Require all the job vacants foreseen by the law to be filled up.
To pursue the encroachment of roles/competences.
Ask for the suppression of restrictions to births assistance .
Propose to all Spanish Colleges to create the "The Body of Spanish Practitioners".

In 1918 the North of Spain (Álava, Gipuzkoa, Logroño, Navarra, Santander and Vizcaya) Practitioners Union was born. And in 1921 the National Federation of Practitioners was born.

In 1927 the first "Official Nursing" was created and two years later, in 1929, the mandatory licensing was established. This would change in a notably way sanitary outlook in general and nursing in particular. In 1928 midwives were integrated into the Practitioners College.

The 1936 events found the country lacking of a medical–sanitary infrastructure capable of facing the lot of daily needs. It was necessary to improvise hospitals and endow the existing ones with a minimum of personal ready to attend wounded and sick. Some abbeys were converted into military hospitals, being numerous the religious orders which lent themselves to such goal: The Saint Vicente de Paúl Daughters of Charity, Santa Ana's, Saint Jose's Sisters, Carmelites of Charity, Mothers of Teaching, Mercedaria Sisters, Consolation Sisters, Mothers of the Sacred Heart, Irish Mothers, Mary 's handmaids, Jesus' handmaids, Clarise Mothers, Sisters of the Cross, Little Sisters of the Poor.

Due to the great amount of women that lent their services at hospitals, more often than with no more knowledge but their good will, some little workshops were held. A total of 5506 of Military Sanity Auxiliary Ladies were formed through 116 workshops, and the High State, in May 1938 created the ID document for Auxiliary Ladies, reaching by the end of the civil war 12.307 licenses between nurses and auxiliaries.

The Red Cross of the Basque Country was created in 1937 in compliance with what stipulated in the Basque Country Provisional Government Decree. In it, it was named as “Association for the Aid to Wounded in act of Campaign, Calamities and Public Sinister Events”.

FOTO 006 Escuela Florence Nightingale. School of Nursing

In 1940 the Michelin and "Cementos Rezola" companies were the first ones in Guipúzcoa to have a practitioner in their workforce. In 1942 the Mandatory Health Insurance was created. And in 1944 the Official Auxiliary Sanitarian Colleges were created with independent sections for Practitioners, Nurses and Midwives. Its headquarters was in Pedro Egaña.

FOTO 007 Red Cross Nurses 1900

During year 1953 the professional titrations for Midwife, Practitioner and Nurse were unified under the Registered General Nurse (RGN). In 1954 and by means of the 20th March Order of the Governance Ministry, the National Council Regulation of Auxiliary Sanitarians was approved. During the same year and by means of the 30th July Order the Statutes of the Provisional Sanitary Colleges were approved. They are divided up into three sections: Practitioners, Midwives and Nurses. In 1955 the Midwives Colleges in Gipuzkoa was constituted.

The 13th January 1958 Order lays out the mandatory licensing for the Registered General Nurses, having to do it at the Practitioners Section the male nurses, in the Nurses Section the female nurses and in the Midwives Section the female RGNs specialized in obstetric assistance. On 1st April 1977 the Practitioners, Nurses and Midwives Colleges were unified. On 10th October 1978, the Statutes of Registered General Nurses College Organization by Royal Decree 1856/1978 dated on 29th June.

The first democratic elections are already celebrated during 1978 with the unified College and during 1983 the Sanitary Map of the Autonomous Community of the Basque Country was published. Also the Basque Country territorial sanitary ordination.

In 1979 and by Royal Decree the conversion of the Registered General Nurse School in University School of Nursing.

On 21st November 1997 the educational nursery unit of Donostia was transformed into the present Certified on Nursing School of San Sebastián – Euskal Herriko Unibertsitatea – Basque Country University.

There also existed pharmacy practitioners, ministrants, nurses, barbers, minor surgery practitioners, nurse of the infectious pavilion, etc…

FOTO 008 Red Cross Nurses 1917
What is nursing?
Position declaration of CIE adopted in 1998 and revised in 2004.
The scope of the nursing practice is not limited to specific tasks, functions or responsibilities, but it includes the giving of direct cares and the results evaluation, the defense of patients and health, the supervision and delegation onto others, the direction, the management, the teaching, the investigation research and the elaboration of a health policy for the health care systems. In addition, as the scope of the practice is dynamic and responds to health necessities, knowledge development and to the numerous technological progress, it is necessary a periodic exam to ascertain that it is still coherent with the present time health needs and favors much better health results”.

Juan José Expósito González

Juan José Expósito González
Raúl Expósito González

La Voz de Enfermería en la Enciclopedia Auñamendi.
Primera parte
Segunda parte

FOTO 009 Red Cross Nurses 1919

PHOTOGRAPHS / FOTOGRAFÍAS: Archive personnel file Manuel Solórzano

Jesús Rubio Pilarte
Enfermero y sociólogo. Profesor de la E. U. de Enfermería de Donostia. EHU/UPV
Miembro no numerario de La RSBAP

Manuel Solórzano Sánchez
Enfermero. Hospital Universitario Donostia de San Sebastián. Osakidetza /SVS
Colegiado 1.372. Ilustre Colegio de Enfermería de Gipuzkoa
Miembro de Enfermería Avanza
Miembro de Eusko Ikaskuntza / Sociedad de Estudios Vascos
Miembro de la Red Iberoamericana de Historia de la Enfermería
Miembro de la Red Cubana de Historia de la Enfermería
Miembro Consultivo de la Asociación Histórico Filosófica del Cuidado y la Enfermería en México AHFICEN, A.C.
Miembro no numerario de la Real Sociedad Vascongada de Amigos del País. (RSBAP)

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