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NURSING CARE GIVEN TO THE PLAGUE INFECTED PATIENTS IN THE HOSPITAL GENERAL OF MADRID (SPAIN) IN THE 17 th CENTURY

CUIDADOS ENFERMEROS OFRECIDOS ALOS ENFERMOS DE PESTE EN EL HOSPITAL GENERAL DE MADRID (ESPAÑA) EN EL SIGLO XVII

Manuel Jesus Garcia Martinez

Universidad de Sevilla

mjgmlO@us.es

Introduction. Objectives

Man is a changing being through time, a historical animal, and this has led to differently understand the constant reality of the human disease in different cultures and in different times, said Professor Lain Entralgo [1] . This is especially shown in situations of disasters, natural disasters or major epidemics that have endangered the very existence of the human being in the world he inhabits.

The importance of epidemics, including plague, by its far-reaching consequences for the population (high mortality, economic crisis, hunger. ...), justifies the emergence of a growing number of studies that approach it from different points of view in our days: medical, demographic, economic, ethical, religious, literary, etc. [2]

In general, it can be said that Europe has suffered intermittently the scourges of this epidemic from the mid-1300s onwards, disappearing in the first half of the 18 th century. After the very serious spread in 1348, during the second half of the 14 th century four big waves occurred. In the first half of the 15 th century, although less generally, three other waves took place, strongly appearing again throughout the second half of the century. For the European territory, between 1450 and 1500, more than 1,000 affected places have been mentioned; from 1501 to 1550, about 1,500; from 1551 to 1600, the amount rises to 1.775. Since then, it descends notably to detect only 173 from 1601 to 1650. Similarly, for some large cities such as Paris or London, there is a resurgence of the plague in the course of the 16 th century [3] . In Spain, the last three waves of plague before its final disappearance at the end of the 17 th century, although already very distant from each other, were 1596- 1602, 1647-1654 and 1676-1685, being the first the most serious one for Castile [4] . Since its entry in Santander in 1596, coming from the North Sea [5] in a boat that had left the port of Dunkirk, the famous Rodamundo, the plague was spreading slowly through towns and villages from Northern Spain (Galicia, Asturias, Palencia, Valladolid, Madrid, Toledo), and it even reached Murcia. Practically, the plague was eradicated in Western Europe in 1720-1721, when the last great epidemic of Marseille ended, a plague which did not affect the Spanish peninsular lands [6] .

Throughout history, and as a result of this interest awaken by the so called “bubonic plague”, “pestilential disease” or “black death”, between the 15 th and the 18 th centuries, a large number of texts were printed which were intended to meet and fight the epidemic. Even in our days we find this interest in the plague is present, finding writers who, in lais novels, historically recreated it and brought it to the screen with great success, showing us the terrifying atmosphere of this disease called “black death” for some of the symptoms presented, and that devastated whole towns and villages from antiquity until the end of the Modem Age.

All of these books included descriptions, treatments and health measures seeking to alleviate, in some way, the terrible effects of these epidemics. But nothing was known of the causative agent and the way to combat it, since it was not up to little more than a century ago, in 1894, when it is discovered by the Franco-Swiss doctor Alexandre Emile John Yersin. Nowadays, the plague is considered as one of the oldest recognised zoonoses, caused by the bacterium yersinia pestis, whose name was given in honour of its discoverer. The vector of the disease is the rat flea (xenopsylla cheopis). It is usually transmitted to human beings through the bite of infected rodent fleas or by inhaling droplets expelled by the coughing of an infected person or animal (for example, domestic cats); the latter constitutes what is known as the pneumonic plague, which could spread quickly [7] .

These treatises resorted to official medicine, religion, and popular beliefs; everything was valid but little or nothing could be done when the disease had already been contracted. Thus, in the Tratado de la peste, y fiebre pestilente. (Treatise of the plague and pestilent fever), composed by Dr Geronimo Basilio Beçón and published in Zaragoza in 1655, described the plague as follows: “The plague is a venomous disease of the heart, deadly, really severe and contagious, sprang from a poisonous contagious with every substance, total enemy of the heart, whose functions it suddenly and completely destroys, introducing harmful accidents of any kind.” [8] In all these books, composed by physicians and surgeons in the 17 th century, we find this concern to find the causes and treatment of this disease, but they do not reach their scientific reality yet [9] . It is important to remember that the conceptual framework in which the pathology will apply in the modem world -sixteenth, seventeenth and eighteenth centuries- runs between the fight for survival of the old traditional Galenism, which would still be maintained until the 18 th century, and the disease as it is now understood according to what the senses inform about it -empirical pathology, Sydenham-, to a mechanical view of the human body -iatromechanic pathology- or according to the organismic design and chemistry of that body - iatrochemistry pathology [10] .

Nevertheless, and despite that abundant medical literature, we find a significant lack in what refers to works that highlight the role played by one of the professionals working in hospitals and who was responsible for the administration of care: the nurse [11] .

From the 17 th ,century some treatises composed by nurses are known (lay and religious nurses) which had as its main objective the training of nurses working in hospitals, in the army, the navy, in prisons, and in the private houses. Among them, basically two stand out: the manuscript Directorio de Enfermeros (Directory of Nurses) [12] , written by the nurse Simon Lopez and completed in 1668, and Instrucción de Enfermeros (Instruction of Nurses) [13] , a work composed by the Minima Congregation de los Hermanos Enfermeros Pobres, known as “Enfermeros Obregones” (Obregones Nurses). This last publication saw six editions between the 17 th and 18 th centuries, as well as its translation into Portuguese. These are works which include the experience of its authors at work as hospital nurses and therefore possess a high testimonial value. These treatises describe the functions carried out by nurses, the techniques they employed, the knowledge they possessed in the various fields of knowledge -Anatomy, Botany, Pathology, and Physiology-, and deeply reflect the developments that were being experienced about the care provided in the Spanish hospitals of the time; they meant a progressive break with the medieval world.

The responsibility of care, treatment, and cure of the sick in the hospitals fell on various health professional groups of high qualification, mainly doctors, surgeons, and apothecaries. Alongside them, a figure that existed since long time ago, but with little known and clear role and duties, was gradually taking definite shape throughout the 16 th century; we are talking here about the nurse. It was in this century when this figure develops more clearly, receiving new and more specialized functions for which it was necessary to improve their levels of theoretical and practical training to meet the growing needs they faced up in hospitals in matters of disease and health at the beginning of the Modem Age [14] .

The development of medicine and science in general, and its practical application demanded that this part of the staff, the nurse, knew and applied the set of techniques and care the most frequent diseases of the time required and that the medical science began to investigate and learn [15] .

The objective of this study is to get to know the care given by nurses to patients infected of plague and those diseases called “pestilential” admitted to the Castilian hospitals in the 17 th century.

Material and method

In carrying out this work, the following sources have been used as documentary and bibliographic:

• Constituciones del Hospital General de Madrid. (Constitutions of the Hospital General of Madrid) 16 th - 18 th centuries.

  They included the work, tasks, and functions developed by the staff working in this hospital, highlighting that of the Obregones nurses. The first news we have are dated December 6 th , 1589, and bear the title “[Constituciones] Para el Régimen del Hospital General y para servir a los pobres y su curación, desde el año de 85 y renobada sus Constituciones el año de 5 por Don Juan de Layseca y Albarado, Decano del Real Consexo y Cámaras de Castilla, en sus Juntas que todos los jueves tenían en diferentes Casas agregadas a dicho Hospital [...]” ([Constitutions] for the Regime of the Hospital General and to serve the poor and their healing, since the year 85 and being their Constitutions renewed on the year 5 by Don Juan de Layseca y Albarado, Dean of the Real Consexo y Camaras of Castilla at the Meetings they held every Thursday in different houses added to the Hospital [,..].” [16] Equally preserved are the Constitutions of the Hospital General of the years 1611, 1705, and 1780.

• Constituciones y Regla de congregaciones y órdenes dedicadas al Cuidado enfermero (Constitutions and Rules of congregations and orders dedicated to the nursing care)
• Constituciones y regla de la Mínima Congregación de los Hermanos Enfermeros Pobres, Dispuestas y ordenadas por Ntro. Pre. y fundador el Venerable Bernardino de Obregon, escritas de su mano y manda sus hijos las observen y Guarden. En Madrid por Francisco De Ocampo. Año de 1634. (Constitutions and Rules of the Minima Congregation de los Hermanos Enfermeros Pobre, arranged and sorted by Our Pres, and founder, the Venerable Bernardino de Obregon, written from his hand, and he orders his sons observe them and comply to them. In Madrid, by Francisco De Ocampo. Year 1634). There is a second edition of these Constitutions of the year 1689.
• Tratados docentes enfermeros redactados por enfermeros .(Instructional treatises for nurses written by nurses).
• Instruccción de Enfermeros (Instruction of Nurses), composed by the Obregones nurses [17] . The book incorporated another text about the “good way of dying” entitled Tratado de lo que se ha de hazer con los que están en el artículo de la muerte, sacado de diuersos libros espirituales. Con privilegio. En Madrid, En la Imprenta Real. Año M.DC .XXJ ’ (Treatise of what has to be done to those who are at death’s door, taken from various spiritual books. With privilege. In Madrid, die Real Print. Year 1625).
• Directorio de Enfermeros, y artífiçe de obras de caridad para curar las enfermedades del cuerpo. Con la prática de sauer aplicar las mediçinas que ordenan los médicos con el mejor arte y méthodo que ai en ella,, compuesto por el enfennero Simon Lopez (Directory of Nurses, and the architect of charitable works to cure the diseases of the body. It includes the practice of knowing how to apply the medicines ordered by physicians with die best art and method in it, written by the nurse Simon Lopez) [18] .

The analysis of these sources has allowed us to see die work carried out by the nurse, both in normal situations of everyday life and special cases of epidemics, as it is the case of plague or pestilential diseases, during the 16th and 17th centuries.

The nursing work in hospitals during the epidemics of plague in the 16th And 17th centuries

When the plague was spreading through a given region, a terrible juncture was felt, characterized by the harmful effects that led to the long-lasting and persistent crisis of subsistence, appearing scarcity, deficiency, and shortage of food, all of which caused a high mortality [19] .

At the end of the 16 th century, from 1596, the plague epidemic affected a great part of Spain, leaving a very large number of deaths in its wake. Historian Colme- nares, one of those who narrated those effects on the population in the capital of Spain, Madrid, and its surroundings, described the symptoms of the disease in the following way:

“[...] active, malignant and contagious illness; it lits in choleric constitutions, so abundant in Spain, with scabs or tumours, and anthrax in groins, throats, and arms, quick and irregular pulse, with sweating and vomiting, all of them signs of noxiousness and contagion [...]”’ [20]

The situation in cities suffering from the illness during those years had to be terrible, taking severe measures of all kinds (health, economic, legal, etc.) to combat it or, at least, mitigate its impact. These measures included the following:

1. Banning “all meetings or competitions, comedies, schools, and even sermons.”
2. Notifying neighbours about the arrival of the illness and its consequences.
3. Placing hospitals outside the city. In the case of Madrid: “the hermitages of Santa Lucia. Santa Catalina, and the plagues, to the East; and the Hospital of San Lorenzo, to the West. The Hospital of the Convalecientes was also working, being in the process of its building at the moment.”
4. The Hospital General de la Misericordia and the Hospital de los Desamparados were kept within the city for non-affected patients.
5. In terms of clothing of the health staff (surgeons, barbers, and any worker of the hospitals), it was decreed that they were dressed in “leather or buckram to provide some resistance to the contagion”, although an explanatory note specified that such a measure was not very useful: “Note. Leather dress is not perfect at times of plague for not becoming infected, but it is rather exposed to receive and keep the contagion [...].”
6. At sun setting, in squares and streets, lighting “bonfires of juniper, fragrant wood brought by sea from the Sepulveda mountains; and everyone shall bum incense in their homes.”
7. Abundantly providing the drugstores “and doctors’ public wages shall be increased.”
8. That the deceased were buried “within six hours after their death.”
9. Burning the bedclothes from infected houses in the designated places.
10. “That everyone considered that this damage and such a widely spread plague called for general care and love with the afflicted and tried to soothe the divine wrath with actions of penance” [21] .

This set of measures, mainly in public health [22] -whitewash houses, clean and disinfect houses and streets as well as coins, gold and silver jewellery with vinegar and putting them in the oven’s heat...-, would help reduce the deadly effects in case of epidemic of plague or of diseases at the time considered as of pestilential nature, the croup or “angina anthrax” and the “typhoid”.

When an epidemic of great magnitude was declared, virtually all health centres accepted the infected, so the recommendation or prohibition for certain hospitals of not seeing them was not always observed, as it was the case of the Hospital General of Madrid in the epidemic of 1599, in which the Obregones nurses practiced during the last third of the 16 th century until the end of the 19 th . On August 6 th of that same year, the founder of the Congregation, Bernardino de Obregon, died while taking care of a patient infected with the plague with his own hands [23] .

In these tragic circumstances, we can imagine the difficulty to find staff to work as a nurse or caregiver in hospitals, having been documented cases of health staff (doctors, surgeons ...) fleeing from such dramatic situations, even being prosecuted by justice so that they complied with their professional obligations. In the Constitutions and Rules of the Obregones nurses, one of the points the aspirant should swear to enter the Congregation and then exercise as a nurse was as follows:

“Q (uestion) 5.You have already seen, Brother, more or less, what the Brothers have as practice and obligation, that is to cure or serve the poor sick, day and night, all diseases, of any quality and condition, although be it the plague, do you dare doing it? A. Yes, I do, with the help of God, and the good doctrine of Your Mercy” [24] .

In a different part of these Constitutions, describing the obligations that the Obregones nurses had, he said:

“The fourth vote is hospitality, promising to serve God and heal the poor sick, all the days of your life, both in hospitals and prisons, armies and navies, in whatever kingdom and place where obedience thus sends you although there is the plague or other contagious illness” [25] .

And, finally, on this same point, the Constitutions collected that refusing to attend a patient infected with plague could result in expulsion from the Congregation [26] .

Some of the general measures applied in those centuries to combat the plague, as well as the difficulties known to exercise the health professions, one might wonder: what was the work developed by a nurse at a hospital in the 17 th century? What care did he/she administered to the patients affected of plague? To try to answer these questions, it is necessary to refer to the nurses’ treatises above mentioned. Directorio de Enfermeros and Instruction de Enfermeros, composed in the 17 th century.

“Directorio de Enfermeros” and the care administered by THE NURSE IN AN EPIDEMIC OF PLAGUE

In relation to the professionals giving care. Dominguez-Alcon notes that the training of the caregiving staff during the period 1531-1820 becomes progressively apparent, something which materializes in the edition of books and manuals that include differentiated content according to those to whom they are aimed (nurses, midwives...) [27] .

One of these books, the manuscript Directorio de Enfermeros, dedicates seven chapters to the subject of the plague, those from 100 to 106 [28] , including the work to be developed by the nurse in the hospital [29] and the public health measures that should be taken for its prevention and for avoiding its spread. We have divided the nurses’ work in four groups:

Care and measures to treat the air conditions inside and outside the hospital

The nurse was responsible, during the months of cold weather, for the air purification of the hospital wards: elimination of stenches and their causes. To do so, they burned various aromatic herbs such as laurel, juniper, cypress, rosemary, and pennyroyal mainly, or the use of other substances such as incense, bálsamo de gota (drop balm). The pornos were also employed [30] , a kind of balls made with different ingredients, normally aromatic:

“[...] and, thus, the nurse must make sure with all his/her good practice that in the places, rooms, passages, sick bays, corridors, offices, and everywhere the stench is present, laurel, ash tree, juniper, mastic, cypress are burnt; this is for the trees. About the herbs, common rue, rosemary, sage, savin, savory, myrtle, lavender, topped lavender, thyme, pennyroyal, and many other fragrant things. Of the aromatic ones, the complex and the simple ones, as well as pills, joss sticks, incense, benzoin, styrax, drop balm, and others that the physician can invent and order, burning one or the other at different times. The pomas, well-seasoned and placed on small braziers with embers, are very good to correct the air and they last as long as you want, taking into account that all of these things, or most of them, cannot be used in hot weather, apart from the pomas” [31] .

This preventive measure was advised for all houses, hospitals, convents, streets, squares, and yards, given that it was “a very necessary precaution and medicine.” [32]

In times of plague, it was of prime importance to fight the stench and its causes because they were synonymous with putrefaction or decomposition of organic matter; they were especially important, emphasizing that in towns or villages there should not be “stinking places, latrines, fish houses, dunghills, drains [33] , lakes or large pools with stagnant water, rotten vegetables and fruits, and dead animals”; and the reason given was “because all this helps and gives more strength to the corrupt air, leading to a high risk for the population” [34] .

The pomas, designed to prevent the spread, were made of metal, usually silver, or, if it was not possible, of juniper wood, a large lemon, or a pippin [35] , also large. They should be round and holey, about the size of a cowbell. After making the holes in the lemon or pippin, through them they introduced cloves and cinnamon sticks, previously wet in water, and pink vinegar, and if possible, in addition, some beads of amber or musk. All spiced with roses, violets and water lily carnations’ powder, called “river figs”, pouring citron and lemon seeds and shells mixed with tragacanth sap [36] previously soaked in water and pink vinegar. Finally, a little bit of laudanum was added, making poma”

During cold weather, (cold constellation in the Spanish of the time), the poma was done with powders of benzoin [37] and styrax, cloves, cinnamon, nutmeg, amber, and musk, as the doctor prescribed.

In the warmer months of the year, what Simon Lopez called the hot constellation, the work of the nurse to combat the plague focused primarily on air ventilation -by opening windows and doors-, clotlung ventilation, and cleaning of sick bays and rooms, “disinfecting” them with pink vinegar mixed with water or “those who can’t do it, with common vinegar [38] and water”. After sweeping and washing sick bays with fresh water, it was recommended to spray the walls and floors with a solution consisting of five or six parts of water and one part vinegar, being advisable that the curtains were porous or made of canvas. Also very useful was to include those plants in the room and place a “washbowl of sedge” [39] or, in absence of this, the powders of the same mixed with strong white vinegar. This cleansing was extended to the objects present in the sick bays, such as spittoon or bedpans and, in general, everything that could cause stench. From this, one can notice the growing concern over hygiene issues.

All these measures would be ineffective, states Simon Lopez, if the many objects and belongings that had been in direct contact with infected person were not tin-own out, “the filth of the plague-infested” [40] , as the nurse called them.

For this purpose, great holes must be opened in the ground to put all these objects in (clothes, dirty bandages, gauzes, used plasters, and other objects) and the organic matter (sputum, vomit, blood, urine, and excrements), creating as many layers as necessary.

Everything that had to do with the plague-infected people who died in hospitals was really important. Simon Lopez also deals with the subject and teaches the procedure to bury the dead.

Simon Lopez completes the measures with a set of practices that nurses and other people should apply every day in times of epidemic: personal hygiene measures and means to establish a proper distance separation with the sick and those suspected of having the disease. These measures range from “rinsing the mouth many times a day with water and white vinegar”, in the said proportion of 6;1, as much the person could bear; “always taking with him/her a clean cloth or new wet sponge in water and pink vinegar, or common vinegar if not possible, to apply it to the mouth or nose when the person was in contact with the patient”; “introducing cotton wicks in the nose, previously soaked in amber or musk” [41] ; “keeping the distance with the patient to avoid breathing in the exhaled air of the sick”; “make sure to be careful not to breath in the exhales air of the patient” [42] .

Other recommended practices were to massage the heart several times a day with an ointment of three or four drops of Mathiolo oil and the same quantity of good white wine, putting on top a bit of red taffeta or a loose silk skein, also red, previously softened with your fingers [43] . It was also advised not to buy clothes or belongings from places suspicious of the presence of the disease, in order to prevent the infection.

Finally, measures of psychological type: how to avoid the gaze of infected patients: “Do not look at them at the face, or stare at them, as we say, because it is very bad” [44] .

Altogether, they represent basic but necessary hygiene measures from the medical point of view, which were based on past experiences transmitted through the uses and habits more than on the basis of a scientific knowledge of the disease.

Care and dietary measures for the treatment of the plague

Dietary measures played an important role in the nursing work. These measures were directed both to the infected and those “in danger” of getting infected, and were based on “good rule and in the use of some of the manuals, remedies and good maintenance, and moderate drinking.” [45] The book is a true dietary treatise. The nurse Simon Lopez advised for infected patients that meals should be few, of quality, and easy to digest. Meat occupied an important place in this scheme and he recommended ram, hen, capon, partridge meat, chickens and cocks, young rabbits, kid, veal, young birds of the wild pigeon, quail, and other mountain birds, being these preferred to the water birds.

As for the meat preparation, to grill it was preferred rather than to cook it. In the stew, vegetables of the type of borage, savory, sorrel, and spearmint were recommended. Lemons, bitter oranges, sour grape juice, and parsley cooked with elder vinegar or common vinegar are good for the sauce that accompanied the roasted and cooked food.

At the beginning of meals, it is advised to eat fruit, such as fresh cherries, plums, sweet limes, sour oranges with sugar, and a mixture of sweet and sour pomegranates. And for dessert, both after lunch and dinner, roasted pippins were good, as well as roasted quince and sweet pears. Among the canned food, it was recommended the pear, quince, black salsify, cilantro comfit or red roses, depending on the time of the year.

Simple dried figs were considered to be very good for the chest and lung and were thought to be medicinal for the plague, bad moods, and the poison, because, among other effects, they facilitated the digestion [46] . The use of these foods in Castilian hospitals follows a long tradition which has its roots in the classical world. Simon Lopez states that figs were eaten since ancient times, and so mentioned it Pliny and Mithridates. King of Pontus, and the same idea was later used by Pompey. As an antidote. Mithridates used a recipe based on figs, walnuts, common rue, salt, and wine. Subsequently, this result would be equally recognized by Arab doctors such as Rasis.

Melons were also recommended, but not the irrigation ones; they should be fragrant and sweet, not green, mature, or “overripe because these have already began to rip”, also advising against those sown on an infected or watery land, “because that will be eating the plague.” [47]

And, in terms of a type of food as basic as the bread, and based on a motto by Avicenna and Galen, it was recommended that the bread they ate was were baked the previous day, well-seasoned, and that “the wheat used to make it were first cleaned of any strange tiling and not harvested in a pestilential year.” [48]

In relation to the amount of food, moderation was always mentioned, not to fill the stomach in excess, especially at dinner, which should start with a salad made from parsley, borage, chicory, and purslane, with a bit of spearmint. Capers were also good for salads and could be mixed with the previous one. To bring herbs into the stew, this meal could be accompanied by herbs of marjoram, sage, sorrel, scabious, bugloss, and lemon balm. If they wanted to make a salad with the last mentioned plants, these should be stewed with some oil and pink vinegar or elder, and sugar.

Those who felt “well and with appetite” could dine half a chicken or half a stewed wild pigeon’s young bird, or a fricassee, and for those who were weaker, the recommendation was a dinner based on fresh, sucked out or boiled, peeled, stewed with pink vinegar or elder, and sugar.

Water [49] should also be controlled, especially in times of plague, and as an integral part of the diet. It was recommended to boil it with salsify or bugloss root, adding a slice of cinnamon. Golden water was specifically advised in tins disease; for the healthy ones, it was advised to add half or one ounce of lemon or pink syrup, or to previously eat a scabious root or three tablespoons of quince jelly or sour grape juice.

And, for those who had lost their appetite, as a consequence of the disease, it was allowed to eat fish of the type of a small trout (or lancurdia), bermejuela, Iberian nase, plaice, sole, or crayfish (the last one was particularly suitable for those infected with the plague). All this was prescribed to whet the appetite.

Along with the wide range of foods recommended for patients infected of the plague, Simon Lopez collects some dietary contraindications in times of epidemic, like not eating cucumbers, figs, early fresh or greens figs, peaches, or fresh grapes.

Citing medical authorities, as the doctors Zamudio, physician of the Royal Chamber, and Lazaro, one of the prologue writers and censor of Directorio de Enfermeros, both doctors who operated during the plague in 1598. Simon Lopez gives a list of disapproved food, as the tamed oxen, which are considered “to be the same as the plague”, water birds and, in general, all kinds of cured meat and fresh goat, sheep, lamb, hare, rabbit, and deer meat.

With regard to breakfast, Simon Lopez recommends a “breakfast preventive of pestilence”, based on the intake of fresh or canned cherries, juice (orange, lemon, or sour pomegranates), sponge cake or two or three bites of good bread. As for the canned food, he specifies that the flower of borage, bugloss and black salsify were excellent, as well as putting into the mouth a cinnamon stick or cider peel, lemon or leaf of common rue, as the physician or the season prescribed (hot or cold) [50] .

The list of foods is wide, which allowed administrators of hospitals the choice depending on the time of the year that the epidemic was taking place and the acquisition of resources depending on availability and price.

Care aimed at the psychological and spiritual support of the nurse assisting an infected

If the arrival of an epidemic of plague in a place caused terror among the population, the fear the staff that assisted in the suffered hospitals should be indescribable. Therefore, the implementation of a series of measures was necessary to maintain and even encourage the mood of the nurses, who were the ones who bad a major and frequent physical proximity with the sick.

Simon Lopez devotes several paragraphs to this aspect: preparing the mood of nurses in the situations they were going to experience in the next few months, until the epidemic passed (though these recommendations were also addressed to all those who had a plague-infected patient in his care) [51] .

In this context and time, psychological help had a distinctly religious and spiritual character. Simon Lopez prepared nurses in a double direction: strength of body and also of spirit, both of them needed to deal with the disease; the rigorous implementation of all the hygiene measures exposed, together with a good breakfast intake to meet with the demands of the hard day’s work and strengthen the body to better confront the disease, which was really close to them. Psychological guidelines had a strong spiritual charge and were directed to the strengthening of the faith as the best means to achieve God’s help: “banishing all fear and apprehension of being infected, because God looks after those who do it in the name of love, and he will not avoid helping them, as he is able to free us from these and other major illnesses and dangers of what our little faith make us fearful and sceptical, so God helps us.” [52] Simon Lopez insists in the need that, when dealing with the care given, the nurse shall do it with complete conviction, with confidence in himself and in God, without hesitation, having “faith in his Glory” as his the best “breakfast” to start the day:

“And, this way, he must encourage and lift the spirits of his fellows, because starting with a sense of revulsion, few faith and fear of being infected, he must not enter the organization because, in this way, it will be true that he will be infected; let us put ourselves in the hands of God to enter the service with valour to serve the infected because He will also trust us and free us from being infected, if that is His will”” [53] .

Terror was greater in those situations in which the spread of infection was really fast: “when it is the air which is infectious and corrupt, the infection is really fast and, as has been said, in an instant it plays its role and kills many people, and fleeing from this danger is very difficult.” [54]

The scientific knowledge of the 17 th century was very limited and, when the epidemic occurred was of much virulence, Simon Lopez certainly knew that little could be done to fight it, with the exception of the given measures to try to alleviate it; for this reason, he warned that the best remedies were the spiritual ones. These were the first to be applied “by putting ourselves in the hands of God.”

These psychological treatments with a strong religious and spiritual base were well organized. A general confession should be made, together with acts of contrition and prayers. The narrations about the spread of the epidemics of plague throughout Europe were creating a whole set of popular beliefs that quickly circulated through all the places and marked the way of living the infectious disease and confront her.

When medical treatments do not give the expected results, the human being has resorted (and still does) to the relief of superior forces, whether in the field of religion or of magic. Either way, this set of psychological measures proposed by Simon Lopez helped to withstand the hard days of confinement in the hospital both to the infected and the “clean” patients, promoting an atmosphere of devotion that was extensible to the rest of the city.

Other measures and recommendations

All the measures proposed by Simon Lopez joined other general ones, also applicable during those periods in which there was no spread of the plague, but that had to be maximized in these circumstances. Hospitals, which were originally designed as spaces for health recovery, were considered especially feared centres in moments of contagion.

The measures against the spread of the plague at hospitals should also take into consideration other aspects of the patient, such as the safe elimination of bodily fluids, excrements, saliva, and mucus. It was thought that the lack of elimination of them could lead to the aggravation of the disease: “the stomach must be in a good condition because the retention of excrements is very harmful.” [55] In addition, in the event that the patient could not pass a motion daily, the nurse should use an external aid [56] or enema every three days, or as the doctor prescribed.

Rest and exercise were also important, and both must be moderate. Physical exercise was recommended when it was hot and it should be taken in the morning and fasting, after a light breakfast, and could be increased after two hours; in winter, it was recommended to take exercise in the afternoon, five hours after the sick had eaten [57] .

Another set of hygiene measures was aimed at cleaning the clothes, both the personal ones with which the patient had been admitted and those used in the beds, baths, and other. In order to avoid infection. Chapter 30 is dedicated to this issue, highlighting the importance of changing clothes and sheets of the patients and those suffering from “acute illnesses”, among which was the plague, a practice little or non-extended at all in the 17 th century. This chapter justifies such a measure: “Notice how necessary it is to change clothes and sheets to those suffering from acute diseases.” [58]

Simon Lopez tries to eradicate the practices used in hospitals from long ago, tenuous and causing harmful effects on the health [59] , among them, dressing a healthy person with a shirt before giving it to the sick in order to warm it up and make it more pleasant to the touch. To eliminate the moisture from clothes, Simon Lopez proposed as follows:

“There is a common thought, as Dr Lázaro states in his censorship, which is not easy to eliminate, that clothes and sheets to be changed to these patients must be worn by a healthy person because, in the end, he soils them and the patient needs them clean, and to remove the damp they could have there is the option of using fire and pills or other aromatic things” [60] .

It describes in detail how to change the bed linen and clothes, the time at which they should do it and the most appropriate techniques for those cases in which the patient presents difficulties of mobility. Very important were the measures to be taken in the own room of the hospital, keeping windows closed and heating it to prevent the sick from cooling, detailing the required staff to do it right: a nurse and an assistant.

Other texts prepared by Spanish nurses in the 16 th centur\ also emphasized this. Thus, the rules Bernardino de Obregon (1540-1599) -founder of the Minima Congregation de los Hermanos Enfermos Pobres, popularly known as Obregones nurses)- wrote in the mid-sixteenth century, state it for convalescent patients:

“Those admitted will be noted down in a book and, when any of them suffer a relapse, he/she will be placed next to the sick bay where he/she will be cured, that day, month and year, and the same for those stated by the physician, after properly having recovered, because when their relatives come to ask after their health, it can be said what has been done to them.”

Change their bed linen, pillows, clothes and white clothing at their tables at least three times a month, if not every week, because the best medicine to heal the sick is cleaning everything and the charity and good condition of their nurses [...]” [61] .

The experience of Simon Lopez as a nurse in Castilian hospitals for more than 25 years had given him the deep knowledge of the daily work in the same, from his organization and its administration, to the treatment of the more varied diseases.

Nursing care in pestilential diseases in Instruccion de Enfermeros

In the Instruction de Enfermeros treatise, we also find the work carried out by the nurse before infectious and epidemic diseases, what was called “of pestilential nature”. Among these, the “croup” [62] and the “typhoid” [63] were highlighted, causing epidemics and a high mortality. In relation to the croup, the Obregon nurse Andres Fernandez, author of the treatise, includes the measures and the care given, which we will describe below.

First, the nurse recommended the sick gargling with different substances: pink vinegar, barley water and sugar or pink syrup, milk and sugar, or other compounds. Health education was important: teaching the patient how he/she should correctly carry out the technique:

“The nurse will administer a drink, the poaching the physician had ordered, and affirmed in bed, lifting the head to face the sky and opening the mouth to gargle, until he loses breath, and then the process will be repeated, gargling again as before, so that the patient do it three or four times every hour, taking care not to swallow the liquid because it contains egipcíaco ointment and other things that are not convenient to digest. And, just in case the doctor shall command to take juleps (kind of drink made with distilled water, syrup and other medicines) or water with sugar, it will be ordered to first gargle, not to swallow some of the materials of the croup” [64] .

After gargling, and if the patient had sores in the throat, the nurse should carefully heal them to do no harm:

“When dealing with these sores it must be done softly, so that, although it is the scab is peeled off, it is not removed, but only to apply the remedy on top and wait for nature to do its effects, helped by the remedy because, in another way, the part becomes irritated and the patients feel like choking and so it very quickly starts again” [65] .

In addition, the nurse applied oil ointments in the throat with chamomile, chicken fat...., orplasters made of a decoction of mallows, chamomile, swallows nests, beans flour and barley, among other substances. It was really good, said the author, the ointment of orange blossom butter mixed with sweet almond oil or chamomile. Together with the previous treatments, the nurse also performed ligatures, which could be of three types: soft, ordinary and painful or by garrotte. For each of these treatments, the nurse explained in detail how the technique should be performed. Thus, these ligatures were as follows:

“These ligatures must be done on the flesh of the arms and of the thighs in this way. If the ligatures must be soft, they will be like this. The nurse will take a plait or thin rope and tie it in the middle of the fleshy part, six fingers above the knee, which is the thigh, and with a half-knot, the nurse will gradually tighten it by pulling from both ends of the cord” [66] .

In these “pernicious” or infectious diseases, requiring complex and varied treatments (bleeding, enemas, ointments, ligatures, etc.), it was important that the nurse knew how to correctly manage them and in the order indicated, so that the result of the treatment was the expected. Throughout the pages of the treatise, there is a great insistence on the methodical work of the nurse:

“Doctors often order many remedies together, such as the ointment, bleeding, julep (kind of drink made with syrup, distilled water and medicines), soaked cloths, enemas, early eating; it seems to be convenient to say which one of those remedies will be first, so that it is all for the good of the patient and so that the nurse can properly work [...]” [67] .

All of the above was equally applicable to other diseases considered “pestilential”, as it is the typhoid case. The nurse also insisted on the importance of hygienic measures such as, for example, changing the clothes of the infected patient (bed linen, clothes, etc.). The author describes it in the following way:

“And because we have started dealing with cleaning, now we will talk about if, in the pernicious diseases such as the smallpox, typhoid and malignant fevers, it will be good to change the clothes if they are dirty, and the answer is positive because the clothes are soaked with the infected vapours resulting from the suffered temperature and, if those clothes are later used for a healthy person, it will not be strange that they infect the healthy person, it is very obvious, isn’t it?” [68] .

And, finally, together with care, the nurse did not forget the diet, stating what was beneficial or harmful for the sick in these pathologies:

“And, because there are patients with such a lack of appetite, we state which foods can be given to each genre of sick and the most common things that should be observed: for those patients suffering from typhoid, anthrax, erysipelas, open wounds, they should not be given parsley, except when there is no other option, for being hot and having elements which can be added to the pernicious mood and the blood, and it would increase; to those patients, lemon juice or sour grape juice and, best of all, it is the lemon, as the sour grape juice is an astringent” [69] .

By way of conclusion

The several outbreaks of the plague occurred in Spain during the 16 th and 17 th centuries gave rise to an abundant medical literature about this disease, which was widely disseminated throughout the country. In these documents, medical treatment, public health measures, and measures of other kind were collected to be applied in hospitals, but little or nothing was said about the work carried out by the nurse.

As documentary sources for the work done by nurses in the 16 41 and 17 th centuries, we highlight as of great interest: the constitutions of hospitals, the constitutions and rules of institutes dedicated to the care (Obregones nurses. San Juan de Dios brothers,...), manuals and nurses treatises written by and for nurses, and different documentation generated in the same hospitals.

Among the training treatises written by nurses and aimed at the training of nurses in the 17 ll ’ccntury, two of them stand out: Directorio de Enfermeros, by Simon Lopez, and Instruction de Enfermeros, by the Obregones nurses.

The authors of these treatises collected throughout his works, in a didactic manner, its tasks and functions, as well as the care and measures to manage patients admitted to hospitals in case of plague or other diseases of pestilential nature, such as the croup and the typhoid; the nurse acted on the environment (air purification, water,...), dietary’ measures, measures aimed at the psychological and spiritual support of the nurse, and other various measures (importance of the rest of the sick, measures to avoid infection, etc.)

These works ultimately allow us to know, as few historical sources can show it, the actual state of the hospital health system in Castile in this century and, in particular, such a concrete episode as it was the epidemics of plague.

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