Abstract

This article focuses on the perception of nursing as a low-prestige occupation in the 19th century. The history of nursing produced by professionals in the area supported this understanding. However, the profile of the enfermeiro-mor (head nurse), a position in the Santas Casas, demonstrates that the nursing profession was present throughout a broader social spectrum. The authors support the hypothesis that the typical negative assessment is based only on the more visible patient care activities. The presence of the enfermeiro-mor exemplifies the limits of a generalization of the social undervaluation of nursing. The conclusion is that the generalized assumption that nursing was only about basic health care is not acceptable.

Key words:
History of nursing; History 19th century; Almshouse

Introduction

This article emerged from puzzlement and curiosity caused by research projects about the 19th century history of health in Minas Gerais, projects that involved a broad survey of public and private sources. Among the main actors described in this documentation, we highlight, in this article, the enfermeiro-mor (a role similar to that of the current head nurse). This role is present in the statues of the Santas Casas¹1 Abreu L. O poder e os pobres: as dinâmicas políticas e sociais da pobreza e da assistência em Portugal (sec. XVI-XVIII). Lisboa: Gradiva; 2014.^,22 Correia FS. Origens e formação das Misericórdias Portuguesas. Lisboa: Livros Horizonte; 1999. from Portugal and from the Brazilian state of Minas Gerais. These statutes indicate that the enfermeiro-mor was the person in charge of hospital assistance, with the aid of the other nurses in the institution; however, their role was much more than simply assisting the diseased. The enfermeiro-mor coordinated activities such as administering medication, wound dressing, diet management, and other essential actions, that is, they had all the managerial responsibilities of a hospital administrator³3 Leone J. O cargo de Enfermeiro-Mor e sua possível origem. Boletim Clínico dos Hospitais civis de Lisboa 1960; 24(2):233-238..

The curiosity that emerged from those documents stemmed from the interest in understanding who was this character in the context of 19th century assistance, since some of the roles attributed to them are outside of the scope usually attributed to nurses. The puzzlement, on the other hand, originated from the fact that nursing history largely pus these professionals under a negative light, often characterizing them as unprepared, socially inferior, and not representative of good moral standards⁴4 Paixão W. História da enfermagem. Rio de Janeiro: Livraria Julio Reis; 1979.^,55 Oguisso T, Campos PFS, Moreira A. Enfermagem pré-profissional no Brasil: questões e personagens. Enfermagem em Foco 2011; 2(Supl.):68-72.. The role of nurses was seen a low-prestige one, especially when the nurses in question were not domestic or religious workers. In these cases, participants were seen as good persons, practitioners of abnegation and charity, especially those associated with care for poor diseased people⁵5 Oguisso T, Campos PFS, Moreira A. Enfermagem pré-profissional no Brasil: questões e personagens. Enfermagem em Foco 2011; 2(Supl.):68-72.. This is an example of what Nelson calls “building a pathway of virtue”, where moral and ethical frameworks are seen to add more value to the nurse than the technical knowledge expected from them.⁶6 Nelson S. A imagem da enfermeira - as origens históricas da invisibilidade na enfermagem. Texto Contexto Enferm 201; 20(2):223-224.

Literature about the history of health, including that on the history of nursing itself, is full of unflattering judgments on nurses, up to the end of the 19th century. Critics to these professionals go from the practices used by nurses up to the knowledge these practices were based on, often involving their moral conduct. The lack of prestige of the profession meant it attracted unqualified, undisciplined, unreliable people, feeding to the negative evaluations of nurses and their occupation⁵5 Oguisso T, Campos PFS, Moreira A. Enfermagem pré-profissional no Brasil: questões e personagens. Enfermagem em Foco 2011; 2(Supl.):68-72.^,77 Santos Filho L. História geral da medicina no Brasil. São Paulo: Edusp/Hucitec; 1977.. An example of this is the classic book História Geral da Medicina no Brasil (Complete History of Brazilian Medicine), by Lycurgo Santos Filho, a 432-page book that dedicates little more than one of its pages to nurses. The term is used to refer to “any individual who took care of the diseased and wounded, at their homes or in hospitals - where they worked in nursing wards...”. In regard to those who worked in this field, Lycurgo states they were from a “lower social class, mostly illiterate, ignorant of the simplest rudiments of the Art”. Regarding their qualification, he states: “once hired to assist a diseased person, anyone - man or woman - could learn its practice, and then, pretentiously, acquired the reputation of knowledgeable in nursing”, concluding: “The experience was their teacher”⁷7 Santos Filho L. História geral da medicina no Brasil. São Paulo: Edusp/Hucitec; 1977.. Russel-Wood⁸8 Russell-Wood, AJR. Fidalgos e filantropos: a Santa Casa de Misericórdia da Bahia, 1550-1755. Brasília: Editora da Universidade de Brasília; 1981. states, in regard to the Santa Casa de Misericórdia in Bahia, that except for physicians and surgeons, “the rest of the team in the hospital could not boast about their knowledge of medicine” (p. 220). The only demands from nurses were that they were white and were not “tainted by Jewish blood” (p. 220).

Among the attributions of the nurse, from the colony to the end of the empire, Santos Filho lists: administering medication at the right time, sanitizing, providing company, aiding the patient in needs such as baths and feeding, and cleaning the room. He exemplifies this using the regulations from the Santa Casa in Campos, which lists, as tasks of the nurses, the opening and closing of the doors, receiving shrouded corpses, brooming the wards, making beds on Sundays, and cleaning the wards on Saturdays. Finally, he observes: “they were more similar to janitors than to nurses as we understand them today”⁷7 Santos Filho L. História geral da medicina no Brasil. São Paulo: Edusp/Hucitec; 1977..

What he refers to when he mentions nurses “as we understand them today” is what the historiography of the profession classifies as “modern nursing”, a profession based on rational, standardized, rigid precepts, supported by scientific information and hierarchy. This concept was based and consolidated with the emergence of professional education schools, institutionalized, and recognized as a standard. In international history, these schools were associated with the figure of Florence Nightingale, while in the history of nursing in Brazil, Anna Nery was the name associated with said schools. Nightingale and Nery were well-to-do women, who emerged as central characters in the history of the profession, giving value and prestige to the position of nursing⁹9 Cardoso MMVN, Miranda CML. Anna Justina Ferreira Nery: um marco na história da enfermagem brasileira. Rev Bras Enferm 199; 2(3):339-348..

Going back to the characterization of the nurses and their practices in 19^th century Brazil, we would like to highlight two issues relevant to our research. Firstly: they had practical knowledge, which did not require special characteristics or abilities, or specific knowledge; therefore, the profession was accessible to all. Secondly: the activity suggested a certain subservience, especially when the “care” was not mediated by a familial or fraternal relationship with the diseased, but by the market and the need for survival.

The perception of the nurse as little more than a janitor is long-lasting in the historiography of the profession, especially considering that, in many situations, it was true. In the domestic environment, where family bonds suggest a more affective relationship, caring for the diseased was mostly the responsibility of women, who were especially identified with the idea of embracing and assisting with care. In the public sphere, with the exception of religious practices, exercising this role meant working to make ends meet, accepting the orders of the physicians and the whims of the diseased.

The ads divulged on the press allow us to have a certain perception about the practitioners of nursing in the 19th century, especially considering the newspapers of the capital of the empire, which was the most attractive work market at the time. The most common requirements for nurses, demanded by those who could hire them, were experience, moral qualities, and ability, in addition to willing to accompany the diseased in trips outside of the court. For those who wanted to work in the field, other attributes were highlighted, including abilities with letters and numbers, willingness to provide, simultaneously or not, other curative functions or even more general roles, including domestic and administrative ones, as the following example shows: “A young man with much experience, both in pharmacy and in nursing, who knows how to read, how to write perfectly, and arithmetic, who wants to find a place outside of the court, or even in a farm outside of the province...”¹⁰10 Ferreira LO. As guardiãs da saúde: representações e características socioculturais de enfermeiras domésticas do Rio de Janeiro, 1880-1910. RMT 2022; 12:1-17.2020.. It is true that some managed to achieve a good reputation in the exercise of nursing, however, the profession was not always a choice. On the other hand, it was not uncommon for disturbances and ill behavior to be reported, caused by those one would expect to zeal for order and quiet. This can be noted in the dismissal records of the soldier Delfino Ribeiro de Freitas “who was the nurse of the smallpox lazaretto”, requested in 1862 to the Chamber of Uberaba (Minas Gerais, Brazil), since he continuously “became drunk, with unruly acts in the nursing ward, [which is why] I judged prudent to remove him from such a position”¹¹11 Jornal do Commercio 1860; 15 out..

These examples indicate how broad and diverse was the universe of nursing practitioners throughout the 19th century. In Portuguese, the word entered dictionaries only at the end of the 19th century, when the terms infirm, infirmity, nursing ward, and nurse were only mentioned. The imprecision still persists, as the term is defined in two different manners: 1) a person who graduated in nursing or who works as a professional nurse; 2) anyone who cares for the diseased¹²12 Houaiss A, Vilar MS. Dicionário Houaiss da Língua Portuguesa. Rio de Janeiro: Objetiva; 2001. p. 1144.. These definitions are opposed, as only one indicates there is an educational level required to authorize the practice.

In the history of medicine, similarly to that of nursing, general perceptions on the profession would only start improving during the 19th century, as religious workers became a part of hospital assistance. Later, during the turn into the 20th century, nursing work became more consistent, as the first schools of professional education were created. Where does the enfermeiro-mor fit in nursing history? Why is this category so seldom discussed in the elaboration and diffusion of a memory of the profession? We propose the hypothesis that, as the history of nursing unraveled, its facet known as “modern nursing” has become its focus. This facet is characterized by science-based knowledge, supported by institutionalized education, distinguishing itself from the knowledge acquired through practice and associated with a set of abilities and qualities difficult to measure from a rational perspective, such as charity, solicitude, abnegation.

Moreover, as a certain image of the past is formed, leading for the discipline to focus on this aspect of nursing, certain attributions more closely related to assistance stand out, and other activities associated with hospital administration are forgotten, despite being so relevant to current nurse education⁶6 Nelson S. A imagem da enfermeira - as origens históricas da invisibilidade na enfermagem. Texto Contexto Enferm 201; 20(2):223-224.. The issues raised here are in accordance with discussions that put into question a revisionist bibliography focused on myths and interpretive keys common in the past, which were highlighted in the final decades of the 20th century. Certain studies, dealing with arguments that involve key-concepts such as modernization, professionalization, autonomy, and altruism, in addition to demands from therapeutic changes and their processes, pressures of a pre-industrial job market in transition, and the proposal of several systems - including some which were previous to that established by Nightingale - have been collaborating to show the important movement of changes and tensions in the setting of assistance to the diseased in the 19th century, a movement which originated the British Lady-Nurse rather than being a result of her existence¹³13 Helmstadter C, Godden J. Nursing before Nightingale, 1815-1899. Surrey UK/Burlington USA: Ashgate; 2011.^,1414 Mortimer B, McGann S. New directions in the history of nursing: international perspectives. London: Routledge; 2005..

Methodology and sources

This research has a historical methodology, seeking, through document research and criticism, data that can corroborate the alternative interpretation suggested here. In this exercise, we access a broad range of literature, consolidated in years of investigation in the field of health historiography, from which we select certain titles and authors. Our sources include regiments and statutes from Santas Casas, as well as reports, publications and newspapers form the 19th century, researched in the Public Archive from Minas Gerais (APM), in the Center for the Memory of Nursing (CEMENF/UFMG), in the Center for the Memory of Medicine (CEMEMOR/UFMG), and in the Digital Journal Sector of the National Library, using as search terms the words nurse and nursing.

About nurses and nursing

Nursing is a hierarchical professional category. Today, the nurse is surrounded by nursing technicians, but at certain points in the 20th century, the nursing team also included nursing auxiliaries and nursing aides, which were workers with a lower educational level. Classic narratives in the history of nursing highlight that the work of these professionals was molded into the current practices by Florence Nightingale (1820-1910), an unquestionable reference for modern nursing and its historiography¹⁵15 Costa R, Padilha MI, Amante LN, Costa E, Bock LF. O legado de Florence Nightingale: uma viagem no tempo. Texto Contexto Enferm 2009; 18(4):661-669.. In the second half of the 19th century, Nightingale structured nursing work and attention to the diseased around the figures of the Lady Nurse and the Nurse. This stratification, in addition to organizing the different levels of the profession, which was seen as a key for its optimal exercise, was also associated with a social separation, since the Lady Nurse was from the richest and most educated parts of society, while nurses were generally from less privileged classes. This hierarchy lasted for some time, and still, today, those on the top of the nursing pyramid are responsible for administrative roles, while direct basic care is the function of less graduated/specialized nurses and other subordinates¹⁶16 Soares A, Porto F. Nem Lady, nem nurse: a manager nurse no cenário hospitalar no Rio de Janeiro. Rev Pesq 2009; 1(2):124-131..

The competences of the nurse according with the National Curricular Guidelines for the graduation course include: Nursing Attention in Human Health Care; Health Education; Professional Nursing Development; Investigation/Research in Nursing and Health; Teaching in Middle-School Level Technical Professional Education in Nursing; Management/Administration of Nursing Care and Nursing and Health Services. This article is interested in the competence Management/Administration of Care, involved with the planning, organization, and ordering of human resources, material conditions of the work force, and of the infrastructure of the nursing work.¹⁷17 Brasil. Ministério da Saúde (MS). Conselho Nacional de saúde. Resolução nº 573, de 31 de janeiro de 2018. Diário Oficial da União 2018; 6 jun. These functions are certainly more sophisticated today, but managing care has, historically, been a responsibility of nurses. Nonetheless, the administrator nurse, nowadays referred to as manager nurse, is not often discussed in studies focused on pre-professional nursing, that is, the practice of nursing before nursing schools were created⁵5 Oguisso T, Campos PFS, Moreira A. Enfermagem pré-profissional no Brasil: questões e personagens. Enfermagem em Foco 2011; 2(Supl.):68-72..

The concept of professional nursing presupposes a formal learning process based on systematized teaching, with a curriculum established by a regulatory act, a diploma and a specific title. In Brazil, this process started at the end of the 19th century, when the provisional republican government created, via Decree No. 791, from 1890¹⁸18 Brasil. Coleção Leis do Brasil. Decreto 791, de 27 de setembro de 1890 [Internet]. [acessado 2021 jan 19]. Disponível em: https://www2.camara.leg.br/legin/fed/decret/1824-1899/decreto-791-27-setembro- 1890-503459-publicacaooriginal-1-pe.html
https://www2.camara.leg.br/legin/fed/dec... , the Nursing School, as part of the Hospício Nacional de Alienados (National Hospice for the Insane, previously known as Hospício Pedro II). People from both genders were admitted, as long as they were 18 years old or older, knew how to read, mastered the four basic arithmetic operations, and had a certificate of good customs. Students spent at least two years as interns in the school, learning basic medicine, hygiene, and hospital administration. We would like to emphasize the fact that hospital administration is one of the subjects this school focused on, reiterating the fact that this is one of the basic roles of a nurse’s profession¹⁹19 Escola Profissional de Enfermeiros e Enfermeiras. Dicionário Histórico-Biográfico das Ciências da Saúde no Brasil (1832-1930) [Internet]. [acessado 2022 jan 7]. Disponível em: http://www.dichistoriasaude.coc.fiocruz.br/iah/pt/verbetes/escproenf.htm#ficha
http://www.dichistoriasaude.coc.fiocruz.... .

As opposed to the schools that followed Anna Nery’s (1923) standards, which were exclusive for young, single, well-schooled women, preferably normalists (that is, who attended what were called “normal schools” at the time). This meant that the nurses came from a higher socioeconomic levels¹⁰10 Ferreira LO. As guardiãs da saúde: representações e características socioculturais de enfermeiras domésticas do Rio de Janeiro, 1880-1910. RMT 2022; 12:1-17.2020. when compared with those in the schools from the 1890s, which accepted both men and women. In 1942, the Nursing School changed its name to Escola Alfredo Pinto²¹21 Moreira A. Profissionalização de enfermagem brasileira: o pioneirismo da Escola de Enfermagem Alfredo Pinto (1890-1920) [tese]. São Paulo: USP; 2003., and started following Anna Nery standards. Despite the institutional character of the Escola Alfredo Pinto, the scarce formation at the end of the 19th century had not changed the perceived association of nursing with precariousness and ignorance. This would only be overcome with the emergence of professional nursing and its patroness, Florence Nightingale, whose recognition and prestige came after the Crimea War, and were consolidated with the creation of a nursing school in the Saint Thomas Hospital, in London¹⁵15 Costa R, Padilha MI, Amante LN, Costa E, Bock LF. O legado de Florence Nightingale: uma viagem no tempo. Texto Contexto Enferm 2009; 18(4):661-669.^,2222 Mascarenhas NB, Melo CMM, Silva LA. Gênese do trabalho profissional da enfermeira no Brasil (1920-1925). Esc Anna Nery 2016; 20(2):220-227..

In this period, Nightingale elaborated Notes on nursing: what it is and what it is not (1860), work where she established the main precepts for the new nursing. In addition to the well-known basic activities, related with immediate patient care, such as administering medication, applying poultices, and sanitizing wards and patients, new, more general tasks were added, such as caring for the sanitary facilities, ensuring the wellbeing of the patient, silence, good air circulation, good illumination, preparing and administering proper diet, in addition to periodically patrolling the wards. The nurse needed to do more than just carry out, inspect, and supervise these tasks. Their responsibilities included administration and guaranteeing that there were sufficient conditions to care for the diseased. This effort to centralize the management of the care of the patient puts into sharp focus the role of the Lady Nurse, person responsible for planning the actions, coordinating the servers, and making decisions²³23 Nightingale F. Notes on nursing: what it is and what it is not. London: Harrison and sons, Brokseller to the Queen; 1860..

In Brazil, the precursor of this new nursing was Anna Nery. Similarly to Nightingale, Nery also worked in a war (in Paraguay), standing out as she adopted efficient measures to care for patients as she organized and administered the routine of nursing wards. Despite not promoting practical changes in the nursing practiced around the country, her actions sufficed for her name to be chosen as that of the first school born under the banner of modern nursing in the country⁹9 Cardoso MMVN, Miranda CML. Anna Justina Ferreira Nery: um marco na história da enfermagem brasileira. Rev Bras Enferm 199; 2(3):339-348.^,2424 Peres MAA, Aperibense PGGS, Bellaguarda MLR, Almeida DB, Santos FBO, Luchesi LB. Reconhecimento a Anna Justina Ferreira Nery: mulher e personalidade da história da enfermagem. Esc Anna Nery 2021; 25(2):e20200207..

In Minas Gerais, in the 19th century, there are no exponents in this regard, and the state provided little information on nursing during the imperial period²⁵25 Teixeira VMN, Silveira AJT, Marques RC. De práticos a enfermeiros: os caminhos da enfermagem em Belo Horizonte (1987-1933) [tese]. Belo Horizonte: UFMG; 2012.. However, the profession is mentioned in the press, in public documentation, or in regard with the health institutions in the period, which included two military hospitals, two sanatoriums, one hospice, and 42 Santas Casas or Casas de Caridade. In addition to these, there were provisional structures, hospitals and nursing wards administered by the public powers or privately, created in a period of epidemic crises²⁶26 Silveira AJT, Marques RC. Panorama da interiorização da saúde no território provincial de Minas Gerais: as Santas Casas do século XIX. In: Ferreira LO, Sanglard G, Barreto MR, organizadores. A interiorização da Assistência: um estudo sobre a expansão e a diversificação da assistência à saúde no Brasil (1850-1945). Belo Horizonte: Fino Traço; 2019.. In this scenario, the enfermeiro-mor, object of this reflection, was born.

The enfermeiro-mor in Minas Gerais

The statutes of some 19th-century Santas Casas from Minas Gerais mentioned the role of enfermeiro-mor, who was responsible for hospital assistance. Their role, focused on the management of the care for the diseased, is seen as a legacy from the Portuguese organization of hospitals, fruit from a restructuring that reduced the power of the prelates and increased that of the Crown, that is, a movement of hospital centralization with lay administration, which started with the creation of the Hospital de Todos os Santos in 1504¹1 Abreu L. O poder e os pobres: as dinâmicas políticas e sociais da pobreza e da assistência em Portugal (sec. XVI-XVIII). Lisboa: Gradiva; 2014..

The regiment of this hospital established that it would be directed by a provider, who would be aided by a vice-provider, an auditor, a treasurer, a scribe, a clerk, and a chemist. The provider was responsible for supervising the employees and guaranteeing that the needs of the diseased were taken care of. The regiment also included the enfermeiro-mor, who was responsible for treating the diseased with zeal and compassion. This person should be a “caring and well-to-do man with no shame upon him”²⁷27 Queirós PJP, Almeida Filho AJ, Almeida MA, Santos TC, Pereira MB, Pereira PF. O cuidado e o bom serviço dos enfermeiros em 1821. Rev Enferm Ref 2018; 6(16):95-106.. In mid-19th century, under the administration of the Santa Casa Sisterhood in Lisbon, an election was held to choose those to occupy the Management Board and to replace the Provider, whose functions were assumed for the person elected, a “noble, honored and well-to-do men, to be henceforth called enfermeiro-mor”³3 Leone J. O cargo de Enfermeiro-Mor e sua possível origem. Boletim Clínico dos Hospitais civis de Lisboa 1960; 24(2):233-238.^,2828 Regimento do Esprital de Todo los Santos De El-Rey Nosso Senhor De Lisboa, Que Deu El-Rey D. Manuel no ano do senhor de 1504. Lisboa: Laboratório Sanitas; 1946.. Until the enfermeiro-mor ascended into managerial positions, the term “nurse” appeared discreetly in regiments, with “upper nurses” responsible for specific functions, such as organizing the activities of “minor or small nurses”, who were responsible for health care activities and others determined by their supervisor²⁹29 Bulcão E, Cantante AP, Almeida B, Peixoto MJ, Pereira O, Oliveira LA. Hospitais portugueses entre os séculos XVI e XVIII: de hospitaleiros a enfermeiros. Temperamentvm 2019; 15:e12666..

Since the enfermeiro-mor was a “brother”, he should accept the requirements to enter the brotherhood. These “qualities” included, according with the statutes of the Santa Casa in Ouro Preto, being free and emancipated, 21 years old, well-mannered, with decent means of survival, who could provide the brotherhood with personal services and monetary aid³⁰30 Governo Provincial. Lei 1.811, de 12 de outubro de 1871. Lei que approva os estatutos da santa Casa de Misericórdia da cidade de Ouro Preto. Noticiador de Minas 1871; 28 dez., edição 0372, p.1..

The first reference to an enfermeiro-mor was found in the 1816 compromise³¹31 Coelho RS. A organização da assistência médica na Santa Casa da Misericórdia de São Joao del Rei há 150 anos. In: Instituto Técnico em Saúde. Esboço Histórico do Hospital. Belo Horizonte: Fundação Belo Horizonte; 1972. p. 83-94 of the Santa Casa in São João del Rey. Founded by the hermit Manuel de Jesus Fortes under the name “Casa de Hospital e Caridade” in 1783, it became the Santa Casa de Misericórdia in the 19th century, receiving provisions from D. João VI, who gave it all prerogatives of the Santa Casa de Lisboa³¹31 Coelho RS. A organização da assistência médica na Santa Casa da Misericórdia de São Joao del Rei há 150 anos. In: Instituto Técnico em Saúde. Esboço Histórico do Hospital. Belo Horizonte: Fundação Belo Horizonte; 1972. p. 83-94^,3232 Franco R. O modelo luso de assistência e a dinâmica das santas Casas de Misericórdia na América Portuguesa. Est Hist Rio de Janeiro 2014; 27(53):5-25.. As per custom, its regiment indicated that the Administrative Board should be occupied by brothers elected by the members of the brotherhood. The main role was that of Provider, a “nobleman of authority, prudence, virtue, representation, age [older than 40 years old], so the other Brothers can recognize him as a head, thus obeying him more readily”³³33 Arquivo Nacional. Mesa de Consciência e Ordens, Compromisso pelo qual se rege a Santa Casa da Misericórdia da Cidade de São João d'El Rey, em virtude da Provisão Régia de 21 de outubro de 1816, Códice 638.. In addition to assisting the poor and diseased, he had other roles in the brotherhood: services, caring for orphans and widows, receiving maidens, providing wakes and burials. In its 40th chapter, the Compromise indicates that there should always be a enfermeiro-mor, elected by the administrative chairs, who lives “in the Houses of the Hospital, and, during the ordinary service and administration of the house, does everything a Provider must, so he can better and more often attend to the obligations of the Brotherhood of Mercy, and the Hospital is never without a superior”³³33 Arquivo Nacional. Mesa de Consciência e Ordens, Compromisso pelo qual se rege a Santa Casa da Misericórdia da Cidade de São João d'El Rey, em virtude da Provisão Régia de 21 de outubro de 1816, Códice 638.. He could also work as the treasurer of the hospital, as the 5th paragraph of the same chapter, “[being] required to give account to the Board every Thursday about what the Provider and the other Brothers do in the Hospital, the state of things under his supervision, so he can receive the orders which seem appropriate”³³33 Arquivo Nacional. Mesa de Consciência e Ordens, Compromisso pelo qual se rege a Santa Casa da Misericórdia da Cidade de São João d'El Rey, em virtude da Provisão Régia de 21 de outubro de 1816, Códice 638..

From the 25 titles and 152 articles that are part of the Regiment of the Santa Casa at São João del Rey in 1826, ten made reference to the enfermeiro-mor. In the structure of the Board, formed by 13 members, he is the 4th, below the provider, the board scribe, and the treasurer.

His important position on the Board means that his chair cannot be occupied by an unqualified individual. The profile of the occupants of this chair can be determined in a note published in 1887, in a newspaper in São João del Rey, regarding the “citizen Francisco de Salles Souza Vieira, inspector of the 7th. block and owner of the Hotel Salles, ex-administrator and nurse in the Santa Casa de Misericórdia of this city for 15 to 16 years...³⁴34 O Arauto de Minas. Ao Público. São Joao del-Rei, 24 de abril de 1887, p.3..

The obligations of the enfermeiro-mor included daily visits to the wards; accompanying medical visits, and guaranteeing they took place at the right time; surveying the diseased about the quality and cleanliness of food; punishing servers when there are complaints that they are not serving well; “politically” warning paid workers about how to fulfill their duties; “all which has an immediate connection with the health of the diseased is a responsibility of the enfermeiro-mor, and from him are expected zeal and care resulting from love for Mankind”³¹31 Coelho RS. A organização da assistência médica na Santa Casa da Misericórdia de São Joao del Rei há 150 anos. In: Instituto Técnico em Saúde. Esboço Histórico do Hospital. Belo Horizonte: Fundação Belo Horizonte; 1972. p. 83-94.

Once again, we see that the roles of supervisor and auditor of other direct assistance workers are emphasized, and the enfermeiro-mor must warn and punish other workers, external or “of inferior quality”, showing the hierarchy within the hospital. The nurses were required to: obey the orders of their superior, live inside the hospital, have a notebook at hand where they could write everything down, inform any events to the surgeon, give the patients remedies at the right time, alternating in this role with the surgery assistance in severe cases; they were capable of bloodletting, scarify, cupping, and applying caustic fluids and leeches, in addition to applying poultices, unguents, liniments, ointments, and receiving paper, quills, and candle wicks. In addition to working as surgery aids, nurses also had other attributions: transporting severe diseases on stretchers; calling the surgeon or physician to attend the diseased who were under the risk of death; sending to sound ten strikes of the chapels bell; replicating the bell to call the chaplain when administering the sacrament was needed; preventing foods, beverages, and remedies from entering; and guaranteeing that lunch was served at 9 a.m. and dinner at 3 p.m.³³33 Arquivo Nacional. Mesa de Consciência e Ordens, Compromisso pelo qual se rege a Santa Casa da Misericórdia da Cidade de São João d'El Rey, em virtude da Provisão Régia de 21 de outubro de 1816, Códice 638.

Once again, the press shows what the regiments expected from the enfermeiro-mor, or from a nurse administrator. In an issue from August 12, 1888, the newspaper Diário de Minas published a report from the Santa Casa de Caridade in Pitangui with important information, as it described the hospital personnel, starting with the nurse director, followed by a nurse, a server, a cook, and cleaning worker. The report also presented the names of those in the role of provider, vice-provider, treasurer, and board members, but makes it clear that the person who stays in the hospital and directs the work is a nurse³⁵35 Diário de Minas. Publicação a pedido, Juiz de Fora, 12 de agosto de 1888, p.2..

In the Statute of the Santa Casa de Ouro Preto, published in 1871³⁰30 Governo Provincial. Lei 1.811, de 12 de outubro de 1871. Lei que approva os estatutos da santa Casa de Misericórdia da cidade de Ouro Preto. Noticiador de Minas 1871; 28 dez., edição 0372, p.1., the enfermeiro-mor is presented as “the most graduated aide of the physicians in the sanitary service of the nursing wards, and of the Chaplain in the religious service; and substitute proxy in the economic services”³⁰30 Governo Provincial. Lei 1.811, de 12 de outubro de 1871. Lei que approva os estatutos da santa Casa de Misericórdia da cidade de Ouro Preto. Noticiador de Minas 1871; 28 dez., edição 0372, p.1.. His subordinates included “all employees indicated by the Provider and Proxies, and the indication aide of the Board”. In regard to their administrative and assistance activities, the Statute of the Santa Casa de Ouro Preto shows little difference from what was mentioned elsewhere: making sure all activities regarding the sanitization and organization of nursing wards were fulfilled, as well as the determinations prescribed by physicians; auditing and defining a practical hierarchy of all other employees, servers, aides, and nurses; accompanying medical visitation, attending to their instructions; surveilling the evolution of patients, informing the physician of all relevant occurrences, in addition to calling them when needed; administering dangerous medicine; caring for more delicate wound dressings on men, requiring from a female nurse to do the same for diseased women; controlling all events within the nursing wards; avoiding the circulation of people and external products; being “more cautions and careful so the diseased are treated with all care and charity by nursing aides, regardless of their class”³⁰30 Governo Provincial. Lei 1.811, de 12 de outubro de 1871. Lei que approva os estatutos da santa Casa de Misericórdia da cidade de Ouro Preto. Noticiador de Minas 1871; 28 dez., edição 0372, p.1..

Once more, we have administrative activities superposed with assistance activities. Those activities were relatively more complex, demanding someone with the domain of specific knowledge and a recognized authority. The role of instructing, distributing, and auditing the service of the aides, nurses, and servers in nursing wards reiterates the idea of having a person of a superior status managing a subordinate nursing network.

These administrative actions can also be evidenced by the press, who would occasionally publish news involving the activities of the enfermeiro-mor. In 1870, the newspaper Noticiador de Minas published an announcement signed by the enfermeiro-mor from Santa Casa de Ouro Preto, informing that he was the responsible, in the Administrative Board, for receiving all the amounts owed to the institution, and requesting all debtors to pay the bills owed due to treatments in the wards or medicine dispensed in the pharmacy²⁹29 Bulcão E, Cantante AP, Almeida B, Peixoto MJ, Pereira O, Oliveira LA. Hospitais portugueses entre os séculos XVI e XVIII: de hospitaleiros a enfermeiros. Temperamentvm 2019; 15:e12666.. In addition to their role as treasurers, they were also responsible for dealings with the justice, and for the zeal needed to guarantee order and solve conflicts in the hospital environment. This is why the enfermeiro-mor from the same Santa Casa de Ouro Preto was responsible for notifying police authority about an occurrence involving a worker from that institution. In September 1871, Eziquiel Correia dos Santos was accused of asphyxiating a patient in their bed, a crime witnessed by all other patients hospitalized there. When asked about the fact, the enfermeiro-mor Antônio Justiniano alleged that the crime took place under the previous administration, and he had no information in this regard. He added that, considering the information gathered about the situation, the death was due to a strong diarrhea, although the patient was under strong medication at the time. The news spread around the newspapers in the following days, and the enfermeiro-mor was responsible for providing clarifications to the press and police authorities³⁶36 Santa Casa de Misericórdia de Ouro Preto, 6 de julho de 1870 - enfermeiro-mor Antônio Justiniano da Costa Cabral. Noticiador de Minas. Ouro Preto, edição 221 de 13 de agosto de 1870, p.4.. Other references stand out within the documentation, showing here and there how the actions of the enfermeiro-mor extrapolated the universe of direct assistance, as he assumed roles whose nature was completely different, including the administration of services, spaces, and people, in addition to being the spokesperson of the institution in public and juridical courts, and managing resources and conflicts. This role would certainly not be occupied by individuals as unruly and lacking in civility and intelligence, as those who form the image created about this role and its practitioners. As the bibliography indicates and the sources suggest, the universe of nursing practice, in the period that became known as pre-professional, included a number of roles and characters, and to emphasize a single one would be to interpret them in a reductive manner.

Conclusion

As we attempted to demonstrate here, even without a specific recognized formation, it is possible to perceive there was a complex setting of characters and roles in the scope of curative hospital institutions during the 19th century, both in Minas Gerais and in the rest of the Empire. In addition to physicians and diseased persons, life in the hospitals included providers, enfermeiro-mor, pharmacists or chemists, nurses, and servers/aides. Nurses were not limited to the activity of assisting and curing the diseased; they could also occupy positions necessary for the good administration of these institutions. As the enfermeiro-mor figure shows, the “art” of nursing went much farther than assisting the diseased, involving other essential aspects of hospital work.

The history of nurses in the 19th century, mere “servers” or not, still requires further investigation, especially in the case of Brazil. The scenario where the profession of nursing is seen as a second-class activity, it should be said, is a counterpoint which values characters-symbols of modern nursing, raised onto a place of prominence due to their alleged pioneer role in the adoption of rational and efficient measures to care for patients and their ability to organize and manage the routine of nursing wards.

This work did not attempt to investigate the very well-known issues in regard to the care provided to the diseased throughout the 19th century, especially regarding hospital assistance. Problems involving material difficulties, such as resources to maintain space and activities, a scarce number of workers, and even conceptual issues, such as the understanding about the disease process and available alternatives for intervention. As the studies about hospitals emphasize, until the end of the 19^th century, these were not exactly spaces to achieve a cure, but to embrace the diseased and mitigate the suffering of those who had no one to care for them. This work does not deny this reality, instead showing other aspects that are not always emphasized when the actors in these spaces are discussed.

If actors and activities associated with hospital care at the time have significant differences in regard to our understanding about these spaces and practices, certain elements that indicate a greater permanence or proximity can also be observed. This is the case of the administrative tasks that were the responsibility of the enfermeiro-mor. The proposition explored in these pages is that, as the past is mobilized to construct a history of the profession, the choices of nursing historiography in regard to what should be its focus have almost always been related to one of the sets of competences expected from these professionals, especially those that help demarcating a turning point, that is, a moment after which a new reality is in place. As the revisionist studies mentioned earlier emphasize, nursing history has also been written by winners.

We attempted to demonstrate here that, even without a specific recognized formation, it is possible to perceive there was a complex setting of characters and roles in the scope of curative hospital institutions during the 19th century, both in Minas Gerais and in the rest of the Empire. In addition to physicians and diseased persons, life in the hospitals included providers, enfermeiro-mor, pharmacists or chemists, nurses, and servers/aides. Nurses were not limited to the activity of assisting and curing the diseased, also assuming positions necessary for the good administration of these institutions. As the enfermeiro-mor figure shows, the “art” of nursing went much farther than assisting the diseased, involving other essential aspects of hospital work.

References

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