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Enfermería Global

On-line version ISSN 1695-6141

Enferm. glob. vol.12 n.30 Murcia Apr. 2013




Rise and development of the History of Nursing in Spain

Surgimiento y desarrollo de la Historia de la Enfermería en España



García García, Inmaculada*; Gozalbes Cravioto, Enrique**

*PhD Doctorate by Granada University. Professor from the Nursing Department. Granada University. E-mail:
**PhD Doctorate by Granada University. Professor from the History Department. Castilla la Mancha University.




En el presente trabajo se abordan diversas cuestiones referidas a la investigación acerca de la Historia de la Salud en España. En especial se analizan los avances producidos en España a partir de dos factores principales: los influjos culturales de su entorno europeo, así como las demandas sociales que han conducido a la propia formación universitaria en Medicina y en Enfermería. En el trabajo se aborda la existencia de una cierta tradición profesional y de estudios, hasta ahora poco conocida, pero es tenida en cuenta de forma creciente, así como la incorporación del moderno modelo de interpretación de la Historia Social de la Enfermedad. En este contexto se produce en España el desarrollo desde la Universidad de la investigación en Historia de la Enfermería, y se plantean algunos avances de conocimiento en diversos temas concretos, producidos en los últimos años.

Palabras clave: Historia de la Enfermería; Historia de la Medicina; Historia de la Salud; España.


In this paper we study different issues related to the research about the History of Health in Spain. In particular, we analyse the produced achievement in Spain from two main factors: the cultural influences of European environment and social demands that have led to the university education in Medicine and Nursing. The paper examines the existence of a professional tradition and studies, hitherto little known, but that it is being increasingly taken into account. At the same time, the paper studies the incorporation of modern interpretation model of the Social History of the Disease. In this context the University development of research in the History of Nursing is produced in Spain and some progress of knowledge in several specific items produced in recent years are considered.

Key words: History of Nursing; History of Medicine; History of Health; Spain.



The History of Health in Spain during the XIX and XX centuries has evolved, obviously, since two essential elements:

a) On the one hand, the cultural influence of its European environment that has been more linked, the advances of the knowledge produced in this area, as much as the practice of the science and the research in those near countries (mainly France, United Kingdom or Germany)

b) On the other, the social demands in the advance towards the modernity and the extension of the Public Health, canalised through the political action of the different governments or administrations since the transformations of the Liberal State (since 1833)(1).

The conjunction of both factors has been channelled in the formation of the professionals and in the research carried out at the Universities to a major extent. The study of the Historical evolution has never been a priority in the field of Health and science, consequently, the incorporation of the matter to the Medicine faculties constituted a late event, even more the History of Nursing in its corresponding degree. The first professorship of History of the Medicine was supplied at the Complutense University (then called Central) in the year 1921 and it was occupied by the Dr. Eduardo García del Real, and the extension of professorships at other Spanish Universities was produced much later (2).

The objective of this study is to analyse the historical framework in which the History of Nursing emerged and developed.


Reconsideration of a general inspection

Despite the Spanish tradition, there were relevant treaties not only in Medicine, but also about the History of this subject. The late development has been even higher regarding other health professionals, especially of Nursing, whose incorporation as a mainly university content has been very recent in Spain, where it had been considered as a "technical" (3) knowledge until today. The History of Nursing, developed during the last years, is a simple sub-product of the traditional History of Medicine, what is observed in the recent Spanish Congress of the History of Nursing (the first celebrated in Valencia in October 1994), that follows the model of the most classical Congress of the History of the Medicine (first Congress celebrated in Madrid-Toledo in April 1963).

It has been repeated many times the Spanish backwardness regarding the subject of Science, as a product of elements such as the Inquisition and the crisis of the 17th century. This conception, with its arguments in favour, takes part of the general pessimist view of the History of Spain; but in the most objective field of the History itself, the backwards of the Science in Spain, of which doctors-writers have been conscious (4), would not be any other thing but the product of the general failure in several aspects (of the liberal revolution, the industrial revolution, the democracy, the modernization, etc). This failure would have its final result in the fact that only two Spanish people, Santiago Ramón y Cajal and Severo Ochoa have deserved the Nobel Award in Science.

However, in the last decades, since the success of the political and social changes of the Transition, as much as the incorporation of the European Constitution, the facts have started to be observed in a different way. This rethinking of the overview of the History of Spain, encouraged by French and Anglo-Saxon Hispanic that above all during the last years called out attention regarding their own History weren't either haven of peace and of continuous advances. The necessity of the most objective observation to the History has succeeded against so self-criticism, historical review that it is extended to several passages read in a topic way (5).


Existence of a professional and studies tradition

The new sight of the History of the science in Spain, and the History of the Health and Medicine, has let to start revising some questions. As Barona stated (6), the evolution of the historical analysis of the science, as much as the health and treatment of the disease and ill people in Spain, has been integrated since the 18th century (when the Illustration had a strong presence in the country) in the European tradition of the historical study of the science, in general, and of medicine and health in particular. Relatively successful campaigns, of limited continuity, were launched many times, without having finished of consolidate the started line, but from the political power, and the influence of doctors and scientific from other European countries in some Spanish homologue also seems undoubtedly in many cases.

This less pessimistic verification, trying not to fell down in the opposite danger of the pendulum, is letting the recovering of the lost memory. There exists a field in which this recovery is particularly evident: the Spanish exile in Mexico, in France or in the Argentinian Republic, as a consequence of the Civil War (1936-1939). Part of the intellectual people and the Spanish science had chosen the democratic Republic and the Francoist triumph in the War supposed the pursuit, the depuration and in many cases the necessity of the exile (7).

According to the census established by Ordóñes(8), 325 Spanish scientists were established in the Mexican exile, enhancing among them the strong proportion of doctors (43%). It was parallel to another aspect incorporated to the research in this same line of recovering of the memory: the depuration of the Universities on the half of the triumphant system. For instance, the significant case of the Faculty of Medicine in Madrid, whose professors suffered in an intensive way the development and results of the conflagration (9).

This example of recovering of the buried memory is similar to the one that the historical research carries out nowadays towards the past time. The mentioned Barona enhances just the case of the Illustration, that has brought the attention of several researchers in Spain, and who has done important writings such as the ones by Piquer doctor, or the case of Quer, defender of the reality of the Spanish science at that moment (6). And also the interventions and practices of many doctors which have been studied since the bulky and well documented works in regards to Granjel (10).

However, these scientific developments were produced many times in the individual and voluntary field, and as a result the results were very limited. During that time it was produced the so called "militarization" of the Spanish science, linked to the initiatives of the navy (11). Even so, it is undoubtedly that the new development that is detected in the Spanish medicine of the 18th Century reached in a very direct form its effects in the New World, and it has been well distinguished for example in relation to Chile (12), and also regarding the practice and development of the medicine in Mexico. (13).

The analysis of the old literature allows to observe the existence of a large tradition in the field of medicine, beyond the most well-known and valued contribution by Miguel de Servet, it includes other forgotten but very important works as an advance of the science of its period, such as the treaty of medical intervention by Chirino (14), the medicine that was practiced in Sevilla in the middle of the 16th century described by Aviñón (15), the important treat of Laguna dedicated to the measures for preserving and fighting against the epidemics of bubonic plague(16), or the diverse treaties of Lobera de Ávila, among them the one dedicated to the different illnesses(17).

Of course, this new sight is directed in relation to the History of Nursing, and the cares of nursing. A very specialized nursing action, linked above all to the intervention of religious people at hospitals. This intervention reached a strong sanitary specialization.

This strong professional specialization of the nurses in great part of Spain was lost during the crisis of the 19th century, although it is true that this thesis can be discussed. There is data of powerful specialization in the 16th and 18th centuries, in the intervention in the existent hospitals in Spain.

There are notable cases of tradition in the proto-professional and specialized work with nurses. Specially, the "Congregación de los Hermanos Bernardino de Obregón", whose Instruction for nurses and relief of the sorrowful patients in 1967 had also its important movement towards the sanitary attention in the New World (18).

Also, it was very important the sanitary intervention of "San Juan de Dios" during the 16th century in Granada, patron saint of the Spanish nursing. The heroic and sacrificed work of the relief to the sorrowful patients, beyond the aspect of the care, it is directly related to that "religious" model that based its actuation above all in the spiritual relief regarding the pain and the salvation of the soul.

It is true that everything isn't religious sacrifice, but also the actuation on nursing would look for a certain structuration and systematization of the care. This fact is also detected in some Spanish documents, such as the "Directorio de López", aimed to an "unknown hospital", but where the Jesuits worked. The same tittle of its instruction signs out, it was a Directory of nurses and author of charity work to cure the body illnesses with the practice of applying the medicines that the doctors suggest, with "the best art and method that there is in it"(19). It is writing from the middle of the 17th century, by an author since his great experience at work in hospitals in Valladolid and Salamanca. The contribution was dedicated to all those who acted with charity and in the sacrifice that implies the attendance of ill people.

Another part on the sight of the recovering of the tradition of the studies can be aimed to the self-History of the Health that has been eclipsed by the History of Medicine until recent days. The origins of the History of the Health in Spain have to be searched in a specific study regarding this more worrying thing that talks about plagues and epidemics and that was published by Villalba Guitarte in 1803 (20).

So then, the first more or less complete History in relation to the health sciences in Spain was focused on the epidemics and, specifically in the disturbing plague that from time to time devastated the Spanish Empire and other territories from the Mediterranean surrounding. Villalba Guitarte pointed that the recent pandemics of his time had come from America: How strange it is that such a plague has been introduced in the ships crews of those countries, their clothes, their cargoes? ... It is unlikely that this time has come from America, for a few days before it was declared the epidemic in Cadiz; two merchant ships had come from that region. The author appealed to the Nationalism to analyze the past from a patriotic point of view: from the healthy land of Spain, the fatal roots of the plague would rarely grow, if a seed of warning didn't modify and spoiled it from time to time.

In the classical development of the History of Medicine two treaties of classic character would influence, where it was tried to summarized the writings that had been done in previous times. In this sense, two works that we can consider as monuments due to the amount of information will be representative, as much as the extension of the exposition. We refer, in first place, to the bibliographic history in 7 volumes by Hernández Morejón (21), and the 8 volumes of the Historical Annals published by Chinchilla, and four of them were dedicated in a specific way to the history of the Spanish medicine (22).

The anaylsis of the foundation in the work by Hernández Morejón shows the functionality of his contribution: a frame that represents from a point of view the wisdom, mistakes, moral and political behavior of the doctors from all ages and villages, that offer examples to imitate, and disenchants for no getting profit, it is the school of practical philosophy that teaches to improve and to get better the doctors, not only on the literary part, but also on the moral and political one. As it can be observed, the reasoning that is carried out is from the inside of the medical profession, and the prominence of the study has been centered in the more or less righteous actions of the doctors. This perspective is the one that is going to mark the approach to the History of the Health in Spain.


The social conception of the history of health

The produced changes in the research do not emerge from a unique reason, but from several elements. Without any doubt, the main one comes from the same transformation of the discipline of the History along the 20th century. The old politic or narrative history, based on individual facts or in the nations as an organic entity, had led a different type of History. From the middle of the 20th century, the History had transformed its sights to focus on the major part of the analysis subjects from a social perspective, both understood in the field of the social classes (vertical groups), and the horizontal groups (social sectors, age groups...) or the sights about the daily life (23,24).

It made no sense that the History was transformed and that a new perspective didn't arrive to the field of the History of the Science and the same Medicine. In fact, the History based on the prominence of the medical professional presented itself an archaism quite similar to the one that was found in the History based on the great characters. The transformation of the object of the History had to; at least, reach the historical analysis of the health items (25).

The proposals began to spread in the United States and other European countries from the middle sixties, since the suggestions made by Sigerist (26), and the studies carried out by Ackercknecht (27) would pose the necessity of focusing the sight into the social affection of the illnesses (28).

In this perspective, it would have a great importance the impact of the epidemics; in fact, the pandemics favoured that the illness, and the fight against itself, could be analysed not from the individual perspective but from the collective one. The examples of the continuity of these works in relation to the big epidemics through History are very evident and we don't necessary think to insist more on the matter. We are interested in the impact of these new perspectives in the carried out studies in Spain. Pedro Lain Entralgo, the highest representative of the "technical" traditiona l trend in the analysis of the History of Medicine, suggested at the end of the sixties what was gathered later by López Piñero (2): for a long time the History of the Medicine has been studied from a bibliographical point of view or from the point of view of the medical institutions. Nowadays, there's an increasing interest in the history of the medical ideas...the patient's story has been neglected, that is, the one of the society that the patient represents, as much as the several relationships between the society and the doctor.

López Piñero has been regarding the Spanish research the highest represented of the transition, during the last quarter of the 20th century, from the History of the Medicine to the Social History of Health and Illness. The new attention in Spain was provoked not only by the historical-geographical transformation in general, or by the European and North American influence, but it was also provoked by the new concerns about illnesses. The expansion of AIDS would show that the great pandemics weren't as overcome as it was thought (29). So then, that perspective has been renewed in a wide way, and the prominence of doctors has changed into the prominence of the History of Health (30) and also what is referred to the investigation of itself (31).


The history of nursing

The History of Nursing found a new element in Spain due to the fact that the instruction of this discipline has a very recent university acknowledgment in Spain (32, 33). We may remember that in the Spain from the 18th century, the necessity of sanitary treatment had been expanded, but it had a strong lack of elements with a precise formation in the University. The necessity created the workers to attend them, subordinated doctors without those studies at the University, which will be many in Spain and the different Latino-American countries. It was about the common called ministrants, doctors with no qualification (34) trained during the practice with professional doctors and who acted as health-assistants or as popular healers (romanticism) and they will have their unification in 1845 in the Spanish legislation. During 1857 the Basis for the Public Instruction Law, known as Moyano's Law because of the name of the minister that supported it, established the creation of the so called "assistant", that grouped the previous, plus chiropodists, dentists (until 1877) and birth assistants.

In this evolution, "assistants" and "midwives" will form their associations, and will act at hospitals and in the new-born public health. According to the new rules set in France and other countries some years before, in 1915 was created in Spain the Nursing Degree; nurses gathered Assistants (men), Nurses (women) and Midwives. In 1953, as the regulations hadn't developed, a unification of these three professionals with the birth of the Technical Health Assistants. Eventually, since the first half of the eighties, the final integration in the University will change the old Technical Health Assistants into Nursing Graduated (32), and that has been recently changed, with the application in Spain of the remodelling of the European Space of the Higher Education, into Nursing Grade.

In the last years the development of the History of Nursing shows its presence and its own power in relation to several topics. The fact of a recent development of the own history of Nursing and its link to the university instruction influences on the fact that the perspective of the illness and the ill person is present in many analysis. In this sense, the studies about the History of Nursing can be mentioned, as they start with primitive conceptions or actuations or pre-professional, to reach the modern models of care. In this line we remark relevant contributions such as the ones by Eseverri(35), Santo-Tomás(36), Siles (37), Hernández Conesa (38), Hernández Martín (39), o García y Martínez (40).

Another element that shows the development of the historical view of the Spanish Nursing is the one of the regular celebrations along the time of the different editions of the National Conferences of History of Nursing, similar to the ones of Medicine. These are the same conferences that contribute to the elaboration of a History of Nursing in its different areas. A significant example is found in the publication of the different contributions to the Conference of History of Nursing that was carried out during the year 2008 in Almería(41).

We should enhance the rise and the consolidation of some regular publications or specialized journals in Nursing, whose pages gather information related to the historical analysis about the improvements of knowledge or the professional and the evolution of thought. We refer to publications such as Index of Nursing or Hiades, taking into account in the former the scientific exactitude and the concern for the factor "impact of journals" (42), while the second incorporates in the Net a bibliographical lineup that is very useful in relation to the History of Nursing (43).

All these elements influence, with no doubt, in the fact that nowadays the History of Nursing in Spain has a quite significant bibliography (44).

The bibliographical review lets to point at some of the main lines of research that have been developed during the last years.

- Development of the regional or local studies that, in some occasions begin with studies of cases carried out from the local files of the 17th and 18th centuries. Among these works we can enhance analysis about Autonomous Communities, like Castilla-La Mancha(45), or in the case of provinces the study about Badajoz (46).

- Analysis of "internal" literature of the nurses' collective, especially from the professional journals of Nursing, mainly published as ways of expressions in some of the Spanish provinces during the 19th and 20th century. By means of these journals and bulletins many current sanitary problems are filtered, together with the situation of the professionals. Among all these contributions, Álvarez Nebreda(47,48) catalogues can be enhanced.

- The important line of research is the one related to the fact that the nursing profession has been feminized. among the several contributions in this regard, it can be mentioned the so named volume in which the contributions in the Congress of the History of spanish nursing of Almería are gathered, with the support of Lozano Peña about women in the charitable establishment of Granada in the modern age, the one by Segura Graíño about women and the recovery, the one by claret and García Martínez about the contribution of carer women in the sanitary assistance, or the one by García Pardo about women and assistance during the 15th and 16th centuries in almería(41).

- On the one hand, the hospitals considered as sanitary act units with works such as the ones carried out by López Terrada (49) y de Gallent Marco (50). On the other, not only are analysed the facts of attention, care, dietetics, but other aspects referred to the formal structure or even to artistical issues are also revise, all this integrated in the concept of assistance architecture, and where we can find a good example in the monograph by Cambil Hernández (51).

- The image of the profession is presented in the Art and the graphic representations, like the study from the stamps of the representation of the Spanish Nursing (52).



We tend to think that this analysis lets to trace a general view about the evolution of the History of Health in Spain. As we have pointed out, there exists a significant tradition in that regard which starts in the 16th century, but during the Illustration period, in partial scientific and medical actions, it would recover part of the lost field in the previous century. Also, the research in the History of Health started at the beginning of the 19th century, and from its beginning it acquired the same dominant characteristics until three decades ago: The History of Health was the History of Medicine; especially it focused its attention on the protagonist of the professional doctors.

The social changes, the historiography and the weight of the experimented transformation in the research in other European countries and in the United States supported that this outlook of "technical period" seemed old. There was a movement from the personal History to the social History, in the sense that the society became the true protagonist of the attention since the incident of the illness. In this way in Spain, above all since the eighties of the 20th century, a social conception of the History in the sanitary topics started to develop.

Finally, in the analysis we gather the role of the health professions which are not new, but they are professionally emerging. This presence which is not only auxiliary, but it is strictly professional, with university formation, has led to the fact that in other countries, Nursing (as the most significant example) has started to be the object of research. An attention of the care and the presence of Nursing that has focused on its presence along the History, in local and regional cases, and also in aspects related to its rise, development or professional representation during the 19th and 20th centuries.



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