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NURSING CARES GIVEN TO THE SUFFERERS FROM SYPHILIS IN THE HOSPITAL DEL ESPIRITU SANTO OF SEVILLA (SPAIN) AROUND THE YEAR 1600. BOOKS AND DOCUMENTS [1]

LOS CUIDADOS ENFERMEROS PROPORCION ADOS A LOS ENFERMOS DE SIFILIS EN EL HOSPITAL DEL ESPIRITU SANTO DE SEVILLA (ESPANA) EN TORNO A 1600. LIBROS Y DOCUMENTOS

Antonio Claret Garcia Martinez

Universidad de Huelva

aclaret@portalhiades.com

1. Introduction

Sexually transmitted deseases (STDs), particularly syphilis, were intensely present in Europe since the end of the 15 th century and during the following centuries, generating an abundant specialized literature [2] , seeking to understand the disease and to cure it, or, at least, to alleviate their terrible effects. For this purpose, hospitals were built almost exclusively dedicated to the treatment of the so-called ‘buboes illness’, where the known remedies at the time were applied and there were experiments in new ones carried out, with greater or lesser success, as the case may be [3] .

Increasingly complex treatments applied required a specialized health workforce who could adequately develop the entire process of diagnosis, cures, and caring of the sick. Physicians, surgeons, pharmacists, and nurses were responsible for controlling the entire evolution of the patient process, since this one entered the hospital until he/she came out of it [4] .

So, this study seeks to determine the level of training that nurses working in the most important Spanish hospitals reached towards the year 1600 in the treatments applied to patients with STDs (sexually transmitted diseases), particularly syphilis, provided in the new hospitals erected in the main Spanish cities, especially in Seville.

2. Sources: documents and books

In 1589, works began for a new hospital in Seville (Spain): the Hospital del Espiritu Santo. Its construction had as its purpose the regrouping of already existing small hospitals in the city since the Middle Ages that, with the passage of time, had ceased to be functional and whose income and sources of funding had considerably decayed [5] . The progress of science and medical studies was transforming the vision of illnesses and, as a consequence, the treatments that were applied for many of them [6] .

For this study we have used the bundles 2C, 3 and 3bis, containing the Constitutions of the Hospital del Espiritu Santo, adopted in April 26 th , 1590, in Seville, and other financial documents related to the hospital kept in the Archive of the Diputación Provincial de Sevilla [7] .

We have also used two nursing treatises created in the first half of the 17 th century, and which collect the work that nurses should develop for the implementation of their treatments to patients with syphilis. These are Instruction de Enfermeros (“Instruction of Nurses”), composed by Andres Fernandez, a nurse belonging to the Congregation of the Obregones Nurses, and whose first edition was printed in 1617 [8] and Directorio de Enfermeros (Directory of Nurses), by Simon Lopez, completed in 1651 and preserved as a manuscript in the library of the Universidad de Salamanca [9] . Both treatises were drawn up by nurses and were a result of the personal experience of its authors, who worked for many years in the Castilian hospitals, so they are especially useful to get to know the real work carried out by nurses at the time; they are, therefore, very different from other merely theoretical treatises, which collected concepts and medicinal compounds, but of which we have no certainty that they were actually applied in hospitals; these two, on the other hand, were.

In addition to the mentioned Instruction of Nurses and Directory of Nurses, it is of obligatory consultation to learn more theoretical knowledge of surgery and its application to the sexually transmitted infections the book written by the greatest surgeon of the Hospital Anton Martin in Madrid, and brother of the Hospital San Juan de Dios, Mathias de Quintanilla [10] , Breve compendio de cirugia (Short Compendium of Surgery), published in the year 1683, although in fact the work had been completed years before. The brothers of this hospital order had already specialized since the first foundations in the middle of the 16 41 century in the medical and surgical treatment and the nursing care of the buboes [11] .

With regard to the mentioned Hospital del Espiritu Santo in Seville, it keeps a rich and interesting documentation that reports on many aspects of its operation during the more than two centuries and a half of its existence. Part of these documents came from small hospitals which were integrated into this one from 1589 (documents that date back to the 14 th century), and the other part was generated by the new hospital from the moment its construction began: properties, tributes, donations, chaplaincy foundation, and a long etcetera [12] . Among the consulted documentation, we highlight the Constitutions of the hospital, expenses books, and admission and discharge of the sick books, being all of them used in the present work.

Along with this, the Archive of the Hospital del Espiritu Santo of Seville and the treatises of nursing documentation offer an excellent view of the nursing work in the treatment and care provided to patients who suffered this terrible disease of the “buboes illness”.

3. The nursing work environment: characteristics of a hospital dedicated to the treatment of syphilis

The Hospital del Espiritu Santo in Seville was dedicated to the treatment of the so known as “buboes illness”, an expression grouping various sexually transmitted diseases and, especially, syphilis. This was a serious and socially reprehensible disease to the morality of the time, by fundamentally being acquired through sexual relations.

The Constitutions of the Hospital del Espiritu Santo show the concept of “hospital dedicated to the treatment of syphilis” of the moment: a complex architectural space organized in various departments; some of them for the regular stay of patients and, others, for the administration of certain highly specialized treatments and requiring remote and upgraded rooms, and other facilities that provided the necessary administration for the operation of the hospital: kitchen, stores, pharmacy, and various rooms for the accommodation of the staff and the management activities; the Church shall be added to all this. In relation to the spaces dedicated to the treatment of patients, the Hospital del Espiritu Santo provided the following layout:

1. Four elongated rooms with beds for the sick during the admission period.
2. A high room for the “sweats”.
3. A room for them to “dribble” with these “sweats”.
4. A room for patients undergoing a meal plan.
5. A particular and isolated room with an exit door to the outside, for 12 beds, to provide medicine and anointments for the people of quality, living in their homes and who came to receive the treatment.
6. A high room to cure sores and tumors and pains originated by the buboes.
7. A room for the convalescence [13] .

This same structure was for men and for women, in two separate sick bays: In this hospital only buboes, sores, and contagious illnesses generated from them must be cured, even if they are thought incurable, both men and women, and not other illnesses.

4. The nursing work in the Hospital treatment of syphilis

From the 16 th century, medical science began to search for the origin of diseases beyond the concept of inherited divine punishment of the medieval world. The response to this new vision of the concept of disease was the search for new and more effective remedies which relieve the suffering of patients who suffered from them. To this contributed significantly the new plants brought from the New World, unknown in Europe, and which represented the basis of quite a few new medications, more effective in the treatments prescribed by doctors [15] .

Primarily for syphilis [16] were applied remedies based on two predominant currents at the time: first, that of the “herbalists”, supporters of therapies based on the use of plants; the second one, much more aggressive, the power of the “metalists” or defenders of anointings and baths of mercury, introduced as a novelty by Paracelso (hence this phrase became known at the time: “a night with Venus and a lifetime with mercury”, alluding to the sexual origin of the disease and its treatment on the basis of this metal) [17] .

These treatments required adequate facilities and increasingly qualified nursing staff [18] , who knew how to administer the medicinal compounds and the different techniques that were applied. The distribution of sick bays and the remaining units of the Hospital del Espiritu Santo in Seville, and also the characteristics required to the nurses in the constitutions of this same hospital should be understood in this context:

1. The work of the major nurse is of great importance since it is on him that most part of the curing process and caring procedure depends, and because of this it shall be paid special attention to the confident character of the same. He/she must have the jurisdiction within all the sick bays and nurses, distributing and managing what the others must do, pointing out the others where they must proceed regarding these Constitutions and the order given by the administrator.

2. It must be looked to it that he/she is a practitioner in medicine and surgery and, not being so, at least is a decisive person to prove good quality with the physician and the surgery of the illnesses of the sick and their effects, being capable of handling the sudden cases that would happen at day and night [19] .

Syphilis was feared and hated, because it was considered, in addition, a disease that came from sin, from the practice of lust and, frequently, of adultery, apart from the lack of control in sexual relationships. Thus, it must also be understood that the Hospital del Espiritu Santo in Seville had a secluded room with a direct exit door to the outside where the sick important persons of the city could enter with discretion to receive the treatments without having to do it by the main entrance, and thus avoiding the established protocol for the admission of patients.

The need to build specific hospitals for the treatment of this disease responded to the considerations listed in the abundant scientific literature that was circulating at the time. In this way, in the treatises written by nurses, such as the aforementioned Instruction of Nurses, there were published extensive references to this pathology, with an emphasis on the knowledge that nurses had to acquire and the care that they provided [20] . All of this can give a better understanding of the operation of the Hospital del Espiritu Santo in Seville.

The treatment of syphilis required, especially, the coordination of different health specialists: doctor, surgeon, apothecary, and nurses, involved throughout the process of treatment and cure of disease. Particularly active was the intervention of the surgeon and it is observed in the salary he received in the Hospital del Espiritu Santo, the highest of all: 666 “reales” and 22 maravedies, higher even tan that of the administrator of the Hospital and the physician [21] .

The importance of the surgeon in hospitals of syphilis is highlighted in the work of the father Mathias de Quintanilla, which was designed for the training of practitioners, devoting a large number of pages to the disease: description, signs and symptoms, transmission, medical treatment, measures, and nursing care. It is a posthumous work, brought to light by a disciple and with a prologue that pointed out to whom it was intended:

This is the fact, that the Most Reverend Father Quintanilla, driven by the charity of his personality and profession.; and also handing down some rides and surgery canons for the work of the practitioners of this college who studied it in the Hospital of Madrid, he wrote a handbook I keep (...) [22] .

Already in his first chapter entitled “Treatise of Gallic disease”, it mentions the non-epidemic nature of this pathology:

(...) and thus we say that syphilis is not epidemic of the plague as it does not depend on a common cause, which is the air, but common because many suffer it, transmitted by contact to one another (...) [23] .

The treatment or “cure” of the buboes, according to the author, should be conducted either in spring or in autumn, with warm air, and rested on four pillars [24] :

• To order the way of life (suitable diet and adapted to the age, complexion, and the patient’s condition, being better chickens and cocks, hens, sheep, kid and veal, all roasted; vegetables -borage, endive, lettuce-; drinks -the best “bramble water” or lignum vitae-; moderate exercise and sleep; continued evacuation of the belly and, if it could not be done, use enemas).
• Remove background humours using bloodletting and purging, and sometimes syrups, as many times as it is necessary.
• Remove the joint cause, which are these said humours, using the spiderling plant, the bramble, lignum vitae (also known as palo santo or guayacan [25] ), and quicksilver (also known as “mercury”), in quantities suited to each patient.
• Correct the poisonous and hidden in the living parts.

The Spanish large hospitals applied, at least since the 16 th century, complex treatments for serious illnesses, so the demands for training of the hired nursing staff were growing and growing. At the Hospital del Espiritu Santo in Seville, at the beginning of the 17 th century, a male major nurse and three male minor nurses in the rooms for men, and one female major nurse and two female minor nurses in the room for women. At certain times of the year, spring and autumn being the most suitable periods for the management of the treatments for syphilis, the number of nurses was reinforced in relation to the number of patients receiving the therapy [26] .

The treatment of syphilis was made through the strict application of different therapies based on three fundamental principles: The administration of medicaments. Evacuation of bodily humours in various ways. Diet adapted to the disease.

The adequate coordination in the implementation of these three principles, based, in the case of the buboes illness, on experimental knowledge of the effects of new medicines and the balance between the evacuation of bad humours and proper food intake, providing improvements in the health of the sick. Throughout this process, the adequate involvement of nurses was essential, they who were responsible for following the application of therapies and the coordination with doctors, surgeons and apothecaries, daily explaining the evolution of the patients.

Instruction of Nurses collects precisely therapies applied, their techniques and medications. In this sense, the work stands out for its didactic features and clarity of ideas and concepts exposed. Andres Fernandez explains to nurses the medicaments that were used in the therapies, the available instruments, the parts of the body where they had to be applied, and the most suitable techniques to do so, ending with the reasoned exposition of the most suitable diet for the sick throughout the process of their illness.

4.1. The administration of medicaments

Three were the routes through which medicaments were administered to patients with syphilis: the topical route, by means of ointments or dressing; orally, with the taking of various medicinal substances: and through the respiratory route, through inhalation of vapours. One of the goals of this treatment was to cause the gradual elimination of the illness through the evacuation of toxic substances accumulated in the body through “sweats”. Instruction of Nurses deals widely with all about these sweats, how to trigger them, when, with what medicines, and other aspects to get them more effective [27] .

The nurses took part in the tasks required at each of the stages of die treatment and were directly involved in all of them. Therefore, they had to be connoisseurs of all the techniques applied in hospitals. Instruction of Nurses dedicates the whole chapter 31 and the last one to the “buboes illness”: Chapter XXXI. On the doctrine to be followed by the nurses who help and cure the buboes affected patients [28] . This work circulated throughout Seville and other Spanish and American cities, and was used not only by nurses, but also by surgeons and other healthcare professionals, in such a way that it was frequently among the books purchased by them [29] .

4.1.1. The topical route

Skin manifestations of syphilis, in the form of ulcers, pustules and skin rashes, as well as the internal effects (depending on the phase in which the patient was), headaches and fever, were treated with medicaments through ointments on the skin, which received the generic name of “unctions”. It was of utmost importance that the nurse would take care of getting the right conditions for the application of the ointment. It was necessary to get a suitable enviromnent room temperature, controlling flows of air and closing doors and Windows; to manage the unction with its proper technique, with the anointing of the prescribed substance in the parts of the body; to administer the subsequent care, washing the patient and facilitating his/her rest. They should, also, completely cover the patient with clothes to provoke sweat. They had to meet the predictable side effects such as nausea and vomiting, diarrhoeal evacuations and many others which were present, providing an appropriate diet to the symptoms and medicines administered.

While it was usually the apothecary who prepared the medicines (the ointment among them), it was recoimnended that the nurse knew them and, above all, that he/she knew the techniques for its application. The administration of the ointment, due to the external manifestations of the disease, with wounds and pustules of all kinds and throughout the body, depending on the stage of the disease was particularly sensitive to the treatment of syphilis. Here it required well-trained nurses, since they had to calculate the appropriate dose of the ointment or plaster that was depending on the physical characteristics of the patient. Thus, in terms of the amount of ointment to use, it implied proportions that the nurse should know:

If the nurse wants to know more or less the quantity’ of ointment to apply to every sick person, I say it must be two ounces if the person is big and, if the person is small, it will be the nurse s decision and, sometimes, if the patient is underage of a pregnant woman, or the patient suffers from temperature, the physicians would advise one ounce and a half of the quicksilver ointment and half an ounce of the pink ointment, so as it is not so strong [30] .

In terms of the proportions to apply, Instruction of Nurses indicated the following: joints, shoulders, arms, elbows, wrists, hands, hips, sciatic bone, ankles, knees, feet and its soles, and other proportions where there were pains. The spine is being run with the fingers, smearing with the same ointment up to the nape, and has to be applied softly without scrubbing in all the scabs [31] . It is important, insists the nurse, to take into account not to apply the ointment on the testes, groin, belly, chest, and kidneys, except where in any of these parts there are the concerned scabs.

The time in which the ointment should be conducted was indicated by the doctor, though it is most common in the afternoon, four or five hours after eating, with doors and windows closed in the room, and if it was winter, widi some small brazier of embers inside, always Wood embers, never charcoal embers, for being hannful for the sick, all this in order to get a friendly atmosphere.

The ointments applied by nurses were prepared based on plants and animal products -or based in mercury (“Quicksilver”). Andres Fernandez contains a large number of ointments or plaster, used by prestigious physicians of the moment such as Dr. Pedro de Torres, physician and surgeon of the Queen.

Take green dressing of Galen and apply it through the skin as you decide [32] .

Ointment for the sufferers of buboes, almost consumptive. Take refreshing ointment of Galen, three ounces; quicksilver dissolved in sweet almond oil, one ounce; prepare the ointment to your discretion [33] .

Syphilis. Take pig fat without salt, one pound. Marciaton ointment and of Aragon, one ounce each, and another ounce ofmagna theriac. Quicksilver dissolved in the fat, eight ounces; marshmallow plant and agripa ointment, one ounce each; vine shoot ash, four ounces; laurel oil, two ounces; myrtle oil and liquid styrax, two ounces each; incense and mastic, both powdered, halfan ounce each; prepare an ointment to your discretion, mixing it with a spatula until the quicksilver is folded into the mixture [34] .

Another ointment. Take pigfat, four pounds; laurel oil, one pound; vine shoot ash, four ounces; myrrh, mastic and incense, one ounce each; magna theriac, one ounce and a half; quicksilver, one pound; prepare to your discretion [35] .

The diversity of ointments used in hospitals responded to the different effects they caused in the sick, according to the nature of the illness, its age or time of the disease. Whenever some of them failed, others were applied.

In the handbook Directory of Nurses, Simon Lopez teaches the nurse to apply an ointment to “the buboes sick”, taking part in it the mercury:

Rough ointments, given the case that physicians order to make them in some occasion but, generally speaking, the rough ointments are made with the mercury ointment in the buboes diseases [36] .

And for the treatment of the buboes or inguinal tumours, advises Simon Lopez:

But, if the dry nibs made on the groin come from the buboes, an ointment will be made (while the physician is on his way) with the following liniment because it calms the pain and resolves a lot: hen fat and iris and camomile oil, half an ounce each, will be enough to make the liniment [37] .

To treat the skin manifestations of syphilis, sores and pustules, they also applied steam baths through the technique of the “stove”. This consisted of introducing the sick in a kind of wood barrel, leaving out only the head or other parts of the body, according to medical prescription. Once inside, the sick were given vapours from the combustion of different vegetable or mineral substances during the prescribed time and depending on the physical conditions of the sick. In the words of Andres Fernandez:

Way of using the stoves. T he stove is made of sieve wood arches, almost as a coverage for a chest, seven feet long, well arched so that it is narrower on the area were the sick’s feetwill be. In this part, a board a handspan long shall be hammered into it, were the brazier with embers will be placed.

When the sweat is wanted to happen (always fasting), 250ml of bramble water must be ready, very hot. First, the sick will feel it; he/she will have the whole body on a hot blanket which shall be between the mattress and the sheet. There the sick will lie naked.

Out of consideration, the ends of the sheets shall be folded around the sick and, be it a woman, for further respect, she can be covered with a sheet until she is covered with the stove and it be taken from her from an end. When the sick is uncovered, he/ she will drink the hot water (previously said), as much as bearable; then, the stove is put an, on it, a sheer and some blankets to keep the heat. On the board of the stove will be burning a light fire, hoping the sick is not breathless in the process. On the head there will be a towel and a blanket to keep the heat. When the sick is well covered with the stove, the sheet will be removed and he/she will have a towel to clean the sweat, and a person who will be cleaning his/her face from time to time. This way, the sick will be sweating for one hour and a half or, be it thin, an hour. The quantity of sweating applied to the sick will be established as the needs require it.

Once the time has passed, the feet will be removed from the stove and the sick will keep the sheet and the blankets for half an hour mote, well covered. After that, he/ she will receive clean and hot clothes and sheets to take the sweated ones, and with the care expressed in chapter 28, in warnings 5 and 6, the sick can eat half an hour later. If it is possible, always roasted, chicken or ram with raisins and almonds, never eating anything sour [38] .

4.1.2. The oral route

Since the 16 th century different medicaments were used orally for the treatment of syphilis. The nurse should know them and administer them according to medical prescription: the decoctions, syrups and electuaries, pills and powders. All of them made with a variety of vegetable, animal, and mineral substances, according to the pharmacopoeia of the time and the experience of nurses in their daily work in the hospitals. Among the decoctions. Andres Fernandez recommended for syphilis those made with guayacan and bramble. Due to its frequent use and importance. Instruction of Nurses carefully explains its composition and preparation, as well as its administration to the sick.

HOW WILL NURSES KNOW THE GUAYACAN AND THE BRAMBLE. WHICH IS THE BEST ONE.

First, the guayacan must be taken from the trunk, not from the branch, smooth and without knots; its bark must be yellowish, with a lot of filling, tending towards black y heavy. You will know if it is old and less valuable if the bark is easily removed. The bark is the best part of the guayacan. The bramble must be tick, purplish, that when it is broken, there is no powder coming out of it and one can handle it without it losing its bark. This is the newest and best one. The spiderling plant must be heavy and with knots, without woodworm [39] .

A broad relationship of syrups, powders and pills was also provided by the author for the cure or alleviation of the buboes illness.

4.1.3. The respiratory route.

A good number of medicinal substances were applied by the respiratory route through the use of incense. Andres Fernandez advised that, if given aromatic smoke [40] [41] , this was to be of rosemary flame and not of smoke, and the time needed with this sweat was three hours in summer and four in winter. Later, it came the cleaning of the mouth of the patient affected of sores with a swab and water of barley and sugar and, sometimes, when the mouth was badly damaged, with egipciaco’”’.

Also Andres Fernandez dedicated a large section of his treatise to explain to nurses the technique to get the sweats through the incense. The author confinns that he is not in favour of these treatments by their experience, in particular those made with “cinnabar pills” or similar because, although they have a good effect and show large samples and health principles, I have seen in many who have taken them a very bad end.

Sweats from incense. There are other kinds of sweats which some give as incense, with cinnabar pills and other similar things. And, while I am not very fond on this because, although they have a good effect and show large samples and health principles, I have seen in many who have taken them a very bad end, truth is that those experienced in the matter do not give them but in desperate cases, where they do not find any other remedy. I will explain how it must be done and, being the case, the sick must be alone because of the bad effect of the smoke on others. Because of this, in agreement with other physicians, I made this process disappear from the hospital I was working in. There are many who disagree with these incenses, the pharmacist Juan Fragoso, together with Pedro Paulo Perea, Gabriel Falopio, and Ambrosio Pareo; and it not my aim to defame these medicaments, but to tell what I fell and have experienced for those who use them, to do it with caution and after using other means; this is why I say they give them to desperate diseases to those who do not improve with other remedies. Below I describe many of them for you to choose the one which best suits you and better adjusts to your discretion, and the way nurses must use them [42] .

At the beginning of the 17 th century Andres Fernandez already warned of the harmful effects of the use of mercury in medical treatments, having personally experienced for many years these therapies with adverse results in patients.

The way of proceeding of the nurse to apply the incense was to introduce the sick in a kind of ‘cage’, whose creation is shown in the treatise, and to well cover him/her with blankets to keep the smoke. A brazier was lit containing the cinnabar pill or what the doctor ordered, and must remain in this position for no more than half an hour. The author narrates it in the following way:

The way of healing must be with a more or less high stool, with a hole as a means of drainage, where the sick must seat, and a wooden cage with a board on top which, broken in the middle, makes a parallel shape to that in the stool (the hole) for the sick to sit inside de cage with his/her head coming out of the superior hole and the rest of the body inside the cage. The seat must be five square feet and must have four pieces with its latches: in one of them there must be an opening with two doors through which the sick can go in and out, and the cage must be well covered with blankets so that the smoke cannot come out of it. Before the sick goes inside, a brazier must be placed under the stool with few embers and these must not be very bright to avoid the sick to get burnt or whatever is put inside. Under the cage, lifting the blankets a little bit and taking care for the heat not to come out, the pill will be added into the embers, and then covering the sick and his/her head with a blanket.

The nurse must be aware that the sick cannot be inside for more than half an hour the strongest one, while the more weak patients must be less that this period of time since, though it may seem a very slight cure, if they are not looked after they faint, so they are left almost dead [43] .

With all this, the medicine of the time used a number of techniques and medicinal compounds for the administration which provided with very different results depending on the circumstances of the sick and the seriousness of their state.

4.2. Evacuation of bodily humours in various ways

The elimination of malignant humours generating diseases was another of the main sections of the therapies of the time. Andres Fernandez warned:

And sweats or ointments must not be applied without the previous bowel movements by syrups and purgatives, when because of weakness, bleeding cannot be applied. And it is good to, when the time and the diseases thus allow it, leave the sick to rest two or three days and then purge it to continue with the sweats, which will be ten between purge and purge. And, after this, purge them again to throw away all the bad humours. And this is in accordance to the procedures of the physicians with whom I have been, well experienced in the healing of this disease [44] .

Bleeding [45] , purging [46] and sweating were therapies applied in the treatment of syphilis; the first one consisted of the extraction of certain amounts of blood; the second one consisted of the bowel movement, to make more effective the effects of the administered medications, and the third one was to cause perspiration.

Nurses should carefully monitor the administration of one or another and its coordination with taking the medications orally, topically, or by a respiratory route. The medical prescription provided the proper order and care the nurse should take on their correct distribution and application.

The objective of most of these treatments, were they ointments, taking medicaments or incense, was to cause a profuse sweating, so the patient should remain covered and sheltered. In the cited manual, the nurse is taught to properly develop this work, explaining in detail all the manoeuvres that should be carried out, both to cover the sick and to release it from the coverage:

Way of covering them. The way of covering them will be, to those with the sweating, put them in a proper blanket, between the mattress and the sheets, and cover them with two more blankets and release them from their clothes and give them a quarter of litre of bramble or guayacan water to drink, hot, as hot as possible, and being the sick lying, make him/her tuck his/her legs in a Little bit and stretch his/her hands with the tips of the fingers on the forehead reaching the roots of the hair to create an arch and thus suffer the heat. Then, the sick must be covered with the blankets according to the weather, so that the heat is not released and, on the contrary, to those with ointments, make them stretch their arms facing down and, being lying, cover their face so that he cannot breath very heavily and the air cannot go in [47] .

And, regarding the number of blankets that should be used, it was left to the “wisdom of the good nurse”, which was to evaluate the weather and the individual characteristics of the patients.

Once administered the treatment and the proper time passed, and the goal of sweating achieved, the nurse came to uncover the sick who had received the ointment, an operation that should be carried out in the room where they had to convalesce. To those who had received the administration of the guayacan and the bramble, they were uncovered following the rules described in detail in the book.

The “sweating room” and the “dribbling room” referred to in the Constitutions of the Hospital del Espiritu Santo in Seville were an essential part of all of the treatments received by patients suffering from syphilis, as well as the places where more aggressive therapies were applied in the process of healing. In this way, the Constitutions of 1590 tried to organize the newly created hospital based on scientific and functional criteria.

4.3. Diet adapted to the disease

Since ancient times, Greek and Roman physicians dealt with the importance of feeding on the preservation of health or in the recovery of the same. This long tradition, maintained to a certain extent in the medieval centuries, took a new form with the humanism and scientific advances. Nursing treatises make continuous references to this issue and stress the importance of the diet in the whole process of recovery of the patient [48] . The treatment of syphilis is no exception to this rule.

The strict observance of fasting before receiving certain therapies, such as purging, bleeding and enemas, was of prime importance to the doctors and it was the work of the nurse to monitor its compliance.

Also, once received the therapies (ointments, medicaments, vapors, etc.), the intake of certain food was recommended or advised. Thus, after taking the ‘Holy wine’:

This medication shall be used not in cold weather; vinegar, sour food, fruit or vegetables shall not be eaten during all the time it takes, which will be twenty days, interpolating [49] .

The adequacy of the power to the treatments applied to the sick was a continuous concern both for doctors and nurses. Due to their (the nurses’) closeness to the patients, they could better ascertain the effects the diet produced in the sick and inform doctors of the results, by proposing an alternative to the usual diet:

“As for eating, it must be made in accordance with the physician. And, although physicians order raisins and almonds to those with sweating, and also sponge bread, it is necessary to pay attention to the discretion of the nurses. And, being thin, the best option is to give them roasted chicken or; at least, roasted ram and not another kind of meat unless it is feather; I have known opinions about giving muffin type bread to those with sweating because it is easier to digest, though it must be of good quality and with not a lot of yeast as the ones sold at the market. And, when the sick stops dribbling and does not suffer from pains in the stomach, physicians use to order to continue with the ointments for two more days to change the humours.

To those receiving ointments because of swollen mouths, give them a good hen clear soup with nothing sour or any other substance. Being thin, the soup must be cooked with the breasts and, if not, porridge with flour and honey. And being they so thin they faint, give them a soup with wine before the ointment”.

Andrés Fernández always warned young nurses on the need for observation to improve the delivery of care [50] .

As a result of the already said and taking into consideration the abundant and interesting works being developed in Spain, especially about the History of Nursing, we disagree with the medicine school of thought which regards hospitals as healing centers in the modem sense of the concept in the second half of the 18 th century. See, as an example, Michael Foucault, who states “The hospital, as a therapeutic instrument, is a relatively modem concept which dates back to the end of the 18 th century. Around the year 1760, a conscience of the hospital as an instrument dedicated to the healing of the patient is created, and this can be seen in a new practice: the visit and the systematic and comparative observation of hospital (...)”. At least, in Spain, this change arrived some centuries before, and already in the second half of the 16 th century we can see signs of this new situation and, surely, many Spanish hospitals treated and cured according to processes of methodical observation and procedures. The study of hospitals dedicated to the treatment of syphilis, to the techniques and the specialized health staff, as it is the case of the Hospital del Espiritu Santo of Sevilla, shows this idea.

5. Final concluding reflections

The medical practice experimented, from the 16 th century onwards, with various substances and compounds in order to achieve more effective treatments in the fight against the disease: syphilis. Its practical application provided knowledge about the therapeutic results and its effects. The nurses were, fundamentally, those who enforced the different treatments and followed more closely the evolution of the sick, hence they were increasing their demands in die field of training, especially in large hospitals, more specialized and with more resources. Through the study of care in the disease of syphilis of the 16 th century and the beginning of the 17 th century we know the tough, hard, and specialized work carried out by nurses in their treatment. Treatises for the training of nurses that circulated in Spain and America from the 17 th century show the high level reached by an important part of the nurses, primarily those who exercised in large hospitals.

Therefore, since the 16 th century, we observe in Spain that nurses began the long process of professionalization, which can be seen in the fight for increased wages, the definition of a specific body of knowledge, the creation of ethical codes and behaviour, and the consolidation of prestige and social recognition. Long and arduous tasks which will meet their most significant advances at the end of the 19 th century and throughout the 20 th century with the establishment of nursing institutions (schools of nursing) and centres of training and achievement of academic titles (the universities). It was the “long way of the nursing professionalization.”

Appendixes

1

Rules and constitutions of the Hospital del Espiritu Santo (Sevilla, 1590)

(ADS, Espiritu Santo, Bundle 2C)

/lr Rules and constitutions which, Mr Rodrigo de Castro, Cardinal of the Basilica de los Doce Apostoles, Archbishop of Sevilla, member of our King’s Counsel, ordered and advised to preserve in the Hospital del Espiritu Santo of this city, which is one of the two remaining by brief from His Holiness and provisions from His Majesty. They are as follows, ordered by common sense and agreement by the most expert and experienced doctors of this city, by the adimistrators of its hospitals and by other experienced people, also including the most convenient relations of the mam hospitals of this Kingdom and out of it.

What must be kept in tire administration of the Hospital del Espiritu Santo, the ministers who must be there and their roles is as follows (...).

/13r Head nurse and other nurses

1. The role of the head nurse is highly relevant because on him depends most of the healing process and welfare of nurses, so this person must inspire great confidence and must be in charge of all the infirmaries and nurses, distributing and monitoring what must be done, telling each nurse what to do according to these constitutions and the order given by the administrator.

2. The head nurse must practice medicine and surgery and, if this were not possible, at least, the head nurse must be competent in the relationship with the doctor and surgeon in relation to the diseases of the sick and their consequences, and must be able to help in the sudden cases that occur during day and night.

3. Diseases normally bring discontent and desperation, and the poor sick who come to the hospitals tend to be difficult to treat and correct in their behaviour, so it is really important to seek charity and love in the head nurse and this, at the same time, must assure that the other nurses and servants, and he himself, treat the patients with great love and patience and, even if they are given cause, the must not use the wrong words or treat them with surliness and, if some of them got carried away, the same person must confess it to the administrator to receive the appropriate punishment and even be despised if there is no possible correction. However, this does not mean that there will be no punishment for those nurses who overdid it and were disobedient, and they would be punished as the administrator considers.

4. The head nurse must be given an inventory of all the beds in the infirmaries and of the bedclothes, tables, benches, tablecloths, clothes for the poor and all other elements of service available in the infirmaries.

5. All the beds in the infirmaries will be noted down on /13v a list in a most visible place in the infirmary, organized by order and number, and it is the head nurse’s responsibility to write down or order to do write down the name of the sick at his/her admission in the hospital, including in it the day, month and year of admission and, on the discharge or death of the patient, the name must be erased so that it is easily possible to know the number of patients being treated and in which beds they are.

6. The head nurse must accompany the administrator, doctor and surgeon to the reception of patients and a minor nurse must be in charge of taking the patient to confess with the priest, have his/her hair cut and get undressed in the allocated room for this purpose or where it is convenient at the moment, and the patient must be given clean clothes and slippers, then showing him/her the bed where the healing will be done and the number of the same.

7. The person in charge of the clothes must receive those of the patient by the order given in the title and, be it necessary, he will give the order of washing the patient’s feet.

8. The head nurse must accompany the doctor and surgeon in their visits, and must note down in some charts consigned for the same purpose the numbers of beds and the food prescribed to each of the patients and the time it must be given to them, as it is not necessarily at the same time the other patients eat.

9. The head nurse will also note down the bleedings, syrups, purgatives or any other medicine or remedy prescribed by the doctor and the surgeon in the order and at the time agreed, taking a special care and vigilance to do it in the way they ordered.

10. Once the visit is finished, one of the priests will accompany the head nurse and they must take the book or chart where lunch or dinner were noted down to count the portions of hen, chicken or ram, ratatouille, almonds, panatela (a type of big and slim sponge cake) or any other kind of food or diet, writing in a piece of paper or logbook how many portions of each type of food must be administerd in the following way.

/14r 11. One pound and a quarter or ram for every three portions and for four portions of poultry meat.

A hen for two portions. A chicken, not being prescribed by the doctor, can be given to the discretion of the nurse. Once noted down, the person in charge of the pantry will be summoned and ordered to keep what is prescribed, and the cook must be told to receive it and cook it for the time thus prescribed.

12. The meals shall be given all together at the time prescribed and there will be a table for the same purpose. The priest and the head nurse will distribute the food to each patient according to the notes from the visit and referring to the number assigned to the beds. The administrator will help, as well as the other ministers, to organize what was ordered to ingest, and the person in charge of the pantry will note down this meals and the portions.

13. The administrator, together with the doctor and surgeon, and in agreement with the head nurse, will advise the number of patients that should normally be treated, increasing or decreasing this number according to the sufferers and the diseases.

14. The administrator will assign, in agreement with the head nurse, one of the minor nurses the task of keeping count of the sufferers, sorting those who shall eat together in the table assigned for them and all the necessary elements for the service. This minor nurse will bring the food and make their beds, and will keep the infirmary clean.

15. Minor nurses must hold the responsibility of sweeping the infirmaries, distributing themselves among the beds assigned to them and keeping them clean and neat, making the same beds, at least, twice a day, one in the morning and one in the evening after dinner.

16. A minor nurse will attend to the plates and porringers, which must be made of pewter, as well as to the glasses, tablecloths, knives and salt-cellars.

/14v This minor nurse will have a sideboard or table to set all this and the head nurse will put him in charge of it. The minor nurse will also take the responsibility of lighting the infirmary lamps with some perfume on them so that there is no stink, and this will be made every morning, prior to the doctor’s visit.

17. Each minor nurse must give each patient the necessary utensils to eat and must clean everything, and when the patients finish and stand up, the minor nurse shall put them their slippers and clothes on, helping them to lift themselves and directing them to their beds, then taking the utensils to wash them.

18. All minor nurses must go to the kitchen and to the pantry to bring the food and the pitcher with water to the sideboard, and they must go to the place assigned for the distribution of the same and give the portions to each minor nurse in his charge. These minor nurses must open the recipients and do everything necessary for the service.

19. Three minor nurses must be on call every night, distributing them according to their shifts and alternating them so that the one who is not on call is on call the next day.

20. There must be a sweeper who keeps the place clean and helps in everything necessary for the services given, also assisting the cook.

21. After sunset and after the ringing out of the bells to tidy everything up, nobody must walk in or pass through the infirmaries if it is not necessary, and those on call must take special care on being silent so as not to disturb the sufferers.

II

HOSPITAL DEL ESPIRITU SANTO (SEVILLA) OCCUPATIONSAND SALARIES (ADS, Espiritu Santo, Bundle 2C)
Occupation	Salary (reales*)
Administrator	588
Priest	196
Assistant Priest	166
Doctor	488
Surgeon	666
Head Nurse (male)	96
Apothecary	132
Charge of the pantry	120
Nurse 1 (male)	48
Nurse 2 (male)	48
Nurse 3 (male)	48
Hospital porter (male)	48
Cook	120
Cook Assistant	80
Mother nurse	56
Mother in charge of clothing	56
Hospital porter (Mother)	56
Nurse 1 (female)	48
Nurse 2 female)	48

* Old Spanish currency.

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