Emergency nursing: the Institute of Hygiene’s performance during the brazilian civil war of 1932

Objectives: to analyze and describe the São Paulo Institute of Hygiene’s performance, now the School of Public Health of the Universidade de São Paulo , in the training of emergency nurses during the Brazilian Civil War. Method: descriptive, historical-documentary study. Results: ministered from July 13 to August 31, 1932 to 383 students, in five classes, with an average of ten days of class. The discipline First Aid to the Wounded of Trenches is highlighted and was ministered by the nurse Iracema Niebler. At the end of the course, the students graduated and made up the List of Nurses of the Barracks Battalion of São Paulo. Conclusion and implications for the practice: the Institute of Hygiene’s performance in the training of civilians in emergency/war nurses revealed the institutional political alignment with the revolutionary movement of 1932, as well as the historical rescue of one of the first initiatives to train hands-on nurses assist in emergency situations during the most emblematic brazilian Civil War of 1932.


INTRODUCTION
Health School) of the Universidade de São Paulo (FSP-USP) 11,13 . In the same period, the Brazilian Nursing presented important movements for the consolidation of the professional category. In 1923, the School of Nursing of the Brazilian Department of Public Health (DNSP -Departamento Nacional de Saúde Pública) was created in Rio de Janeiro State, symbol of modern Nursing. Three years later, by Decree 17.268, dated March 31, 1926, the school was renamed Escola de Enfermeiras D. Anna Nery, considered official in Brazil through Decree 20,109 of 1931, as a standard of equivalence for the rest schools until the year 1949, with Law 775/49. 1926 was also marked by the founding of the Associação de Enfermeiras Diplomadas (Association of Graduate Nurses), the current Associação Brasileira de Enfermagem (ABEn) 14,15 .
In São Paulo, since the beginning of the 20 th century and reproducing the movements of the category at the national level, the nursing practiced, for the most part, by hands-on nurses, gradually promoted training initiatives based on modern nursing. For example, the Nursing Course of the Hospital Samaritano (1894), the Nursing Course of the Hospital São Joaquim (1908) and the Nursing Course of the Red Cross (1912) 16 . The aforementioned courses preceded the foundation of the first Escola de Enfermeiras (Nursing School) of the Hospital São Paulo (EEHSP), with activities started on March 1, 1939 17 .
Thus, considering the reverberation of the impact of this nationwide conflict, in addition to the mobilization of São Paulo society, above all by the accomplishment of the numerous courses of civil training in "hands-on nurses" for direct care for the wounded, especially promoted by the Institute of Hygiene, which at that time sought its affirmation as an educational institution, in the same way that the Brazilian and São Paulo Nursing struggled to assert itself, was questioned: "How was the Institute of Hygiene's performance in the training of "emergency nurses" during the Brazilian Civil War?" The initiative of the study was supported by three perspectives: 1-The documentation's novelty, despite the few competent studies in which the Nursing work in the Brazilian Civil War was analyzed, was analyzed, there were no available studies that approached the specific phenomenon proposed here 9,10,18 ; 2-The currentness and magnitude of the issue, since wars, whether world wars 19 or civil wars, the latter usually stemming from internal conflicts in several countries, are constant objects of investigation. Especially because such conflicts, throughout history, have made hundreds of thousands of victims around the world; 3 -Necessity of the historical rescue of fragments related to the formation of the São Paulo Nursing identity and its institutional relations, from the beginning of the 20 th century 16 .
Therefore, the objective of the present study was to describe and analyze the Institute of Hygiene's performance in the training of "emergency nurses" during the Brazilian Civil War.

METHOD
This is a descriptive, historical-documentary study of a qualitative approach. Studies that use the qualitative method

Institute of hygiene during the Brazilian Civil War
Marques MCC, Brasileiro DF, Fraga FD are understood here as those that deal with the subjective and relational level of social reality, being treated in the perspective of history, the universe, meanings, motives, beliefs, values and attitudes of social actors 20 . The research shares the thought that the study of the past is only relevant when it is in the service of the present, so much that we have sought support in the theoretical framework proposed by Breihl 21 , especially considering that historical research must propose a re-reading of advances of sciences of health and the individual and collective contributions of its actors.
The documentary corpus researched is part of the "Collection of the Revolution of 1932", which compiles the collection of the  25,1965. After formalization of the institutional authorization, all 420 documents of the collection were submitted to digitalization and organization in a digital database, which allowed instant access to each digitalized document.
Then, the pre-analytical procedure was started with the individual reading of the entire digitized collection and final selection of 92 documentary pages, which, in consensus, the three researchers judged to be pertinent in relation to the circumstances that involved creation, and later developments of the Emergency Nursing Course.
After selecting the 92 documents, participants characterization of this course began through application of relative frequency and absolute values. Then, the qualitative analysis was started, in which excerpts were selected, following criteria of pertinence and similarity, allowing the findings to be organized, categorized, described and discussed based on relevant and available scientific literature.
As it is a research with documentary sources available, it was not necessary to submit the project to the evaluation of the Committee of Ethics in Research with Human Beings 22 . However, it was decided to preserve the secrecy regarding identity of participants of the course, using abbreviations in front of excerpts that mentioned full names of participants.

Efficient Nurse Collaborators -the profile of volunteers
Emergency Nursing Course classes, also called War Nursing Course, started and finished between July 13 and August 31, 1932, and were organized by the Institute of Hygiene of São Paulo. The course was taught at the Institute of Hygiene, in five editions (1 st -July 13 to July 22; 2 nd -July 18 to August 2; 3 rd -July 27 to August 5; 4 th -August 8 to August 17; and 5 th -August 22 to August 31), with an average of ten days of classes, from 09:00 to 11:30 and from 14:00 to 17:00. There was exception on weekends, with classes formed as participants were voluntarily recruited by Cruzada Pró-Infância (Childhood Crusade), Justice Battalion, Medical School of São Paulo, and Institute of Hygiene.
In addition to the numerous volunteer lists, the press collaborated in the mobilization and naturalization of transformation of civilians into war nurses. As they romanticized such practice, they also legitimized it, divulging it as essential to reach the aspirations proposed by São Paulo, as the excerpt below: "No one is ignorant of what the nurse represents in a blood hospital on a battlefield. Her humane and unhappy work in caring for wounded soldiers, their self-denial and heroism for almost at times even gives life; all of this makes nurses the most efficient contributors to the victory of a cause." 23:1 Thus, 383 students enrolled in the five editions of the course (1 st -106, 2 nd -100, 3 rd -87, 04 th -56 and 5 th -34), the majority composed of women that is 312 (81.5% ), with a mean age of 26 years, a mode of 21 years old. The youngest was 14 years old, she a student of the first course, while the oldest, 52, was a seamstress and student of the third course.
The most common occupations performed by these students were related to domestic service, being more frequent in the third course, represented by 35 (49.3%) of the 71 female students. Teaching was the second most common profession, in general, being more frequent among students of the first course represented by 25 (24.3%) of all 103 women enrolled. Other students were dentists, typists and civil servants. Two employees of Instituto do Café de São Paulo obtained authorization to participate in the 2 nd edition of the course, issued by the president of the aforementioned organ, as described below: "We acknowledge receipt of your letter no. 58, dated 19th of this year, in reply to which we are pleased to inform you that, in response to your request, the President has agreed to waive their duties at these Institutes, Miss M.A.A.M and N.O.C, in order to be able to follow the nursing course of that institution. Sincerely yours." 24:1 As for the 71 (18.5%) men enrolled in the course, participation gradually increased, but remained discreet, reaching balance in its latest version, since in the first edition were enrolled 03 (2.8%), in the second 13 (13%), third 16 (18.4%), fourth 22 (39.3%) and fifth 17 (50%). Most of the men were merchants, as well as some students from the Medical School of São Paulo, such as the case of two 20-year-old students attending the fifth edition.
After defining the classes that would compose each edition of the course, theoretical and hands-on classes were subsequently started, following a pre-defined standardized program content divided into two parts, the first one related to seven disciplines predominantly biological and the second strictly nursing, which will be described below.

Epidemiology of war -the troop's health is the guarantee of victory
Disciplines of the first part of the content were taught by The discipline Epidemiology of War, elaborated and taught by Francisco Borges Vieira, deserves to be highlighted by its originality in the singular context of the course. It sought to disseminate a hygienist conception of intervention (military hygiene), whose classes were divided into three subcategories (1 -Epidemiology and Communicable Diseases, 2 -Military Recruitment and Sanitation, and 3 -Sanitation of Facilities). Francisco Borges Vieira proposed a hygiene interface with the battlefield and his fighters, since he considered that "The troop's health is the guarantee of victory" 25:3 .
The first subcategory emphasized issues related to the history of world wars, etiology of communicable diseases, individual and general prophylaxis, transmitting animals (mosquitoes, fleas, ticks, bedbugs, flies, rats, dogs and horses) and the main diseases that would affect the troop, as pointed out in the quotation below: "In all meetings of men, the spread of epidemic diseases becomes easier, thanks to several factors. This danger in time of war is much greater than in times of peace. All troops who fought at the beginning of this century saw the armies decimated by diseases, such as exanthematic typhus, smallpox, cholera, plague, typhoid, disintegrates, etc., with their victims being often superior to those produced by wounds." 25:1 The second subcategory addressed concepts of recruitment and sanitation of the troop, such as ideal selective measures (age, height, weight, chest perimetry, vision, hearing), physical and mental examination, personal hygiene rules, bathing and dressing military), bowel care, health education, soldiers' nutrition, physical exercises and walking (feet, heart, work in progress), illustrated by the excerpt below: "One measure that soon imposes itself is that of medical examination in admission to military life. It has this measure for a double purpose; if, on the one hand, it aims only to allow the army of individuals physically fit for the harsh military life, on the other hand, and this is its main health aspect, to look for the rigorous examination, to verify if it does not have a communicable disease." 25:1 The third subcategory emphasized issues of sanitation of facilities such as tents, barracks, camps, trenches and blood hospitals, which contained rules to be adopted by soldiers for water intake, waste treatment destinations, human excreta and animals, as well as rules on the proper preparation of emergency facilities, taking into account the knowledge of characteristics related to humidity, ventilation, dust and confinement conditions, as mentioned below: "One of the factors of disease spread in armies, as we said at the outset, is the crowding, overcrowded accommodations, which make the possibility of transmission closer. Therefore, sanitation should not be neglected due to the convenient destination of feces and urine, disinfection of drinking water, constant removal of waste that attracts flies, also disseminating." 25:2 Also worthy of mention is the discipline called Notions of Pathology, which contemplated teaching exclusively to male students, about notions of prophylaxis of venereal diseases, with a hands-on internship followed by Professor José Maria Gomes at the Associação Comercial de São Paulo (Commercial Association of São Paulo).

War Nursing
War Nursing had nine subcategories of content, taught by nurse Iracema Niebler, who was aided by teaching supervisors, such as Maria Rosa de Sousa Pinheiro, Grasiela Marques Leite, Noêmia Ippolito, among others ( Figure 1). According to the image, in the facilities of the Institute of Hygiene, Iracema Niebler, uniformed as a "registered nurse", taught a nursing technique class, handling a mannequin to a room full of students, aided by three monitors dressed in white (standing), one at the left end, the other at the center and another at the right end of the image.
In the seventh subcategory, First Aid to the Wounded in the Trenches, the general rule was to deal with all types of injuries, as well as specific measures for various types of injuries such as head, chest, abdomen, lower limbs and fractured upper limbs exposed. In situations of injury to lower limbs with exposed fractures, it was advised to follow the general rule for all wounding and taping, immobilizing limbs with improvised triangles or splints (tree branches, etc.) and providing water and food at will to the injured.

Institute of hygiene during the Brazilian Civil War
Marques MCC, Brasileiro DF, Fraga FD The topic "hemorrhage" was classified in the classes as internal and external, of arterial, venous or capillary origin, always oriented that during the period of external hemorrhagic events should perform indirect compression with a garrote or tourniquet, which should be improvised with stone, bandage, brace, triangle, a pencil or a plump stick.
In addition to the theoretical description, there were drawings that carefully illustrated first aid techniques (Figure 2), to be performed by war nurses, which included presentation of cotton-based materials to be used (patches, triangles, bandages), besides different techniques of immobilization and compression of shoulder, skull, arm, buttocks and legs.
After completing the theoretical study, the hands-on internship began, which lasted an average of three days and was carried out in groups composed, on average, of ten students, who presented themselves systematically at Hospital Santa Catarina, Hospital Alemão, Santa Casa de Misericórdia and at the Polyclinic. At the end of the internship, a final exam was carried out to evaluate the performance of the students, who subsequently graduated in formal ceremony at the Institute of Hygiene, as can be seen below: "Yesterday at the São Paulo Institute of Hygiene the ceremony of oath and certificate delivery to the 3 rd group of girls and boys who attended the Emergency Nursing Course, taught by that institution, was held yesterday at the Institute of Hygiene of São Paulo. Professor Paula Souza, Director of the Institute, opened the session, which gave the floor to the chief's nurse, Dr. Iracema Niebler, who with words of exalted civility and brasilidade, exhorted the new nurses to good practice, assisting wounded or civilian soldiers who lacked them, and pointed out to them the heroic figures of Anna Nery, who provided such excellent services in the campaign of Paraguay and patroness of the Brazilian nurses and Florence Nightingale, the "lamp lady" of the Crimean War." 26:1 In the ceremonies of diplomacy, the "Oath of the Emergency Nurse", by Iracema Niebler: "Before God and the Nation, I swear to São Paulo, to carry out care with honor, nobility, dignity and loyalty, to the wounded Brazilian soldier on the battlefield and to the civilian who needs it." 27:1 Once they graduated, the emergency nurses were able to provide assistance and were sent to the Paulista Barracks to compose the list of nurses, who would be headed by Dr. João Rebelo Neto, as well as the auxiliary doctors: Francisco Ourique, Passos Cunha, Honório Dias Soares and Faustino Ferreira Gomes.
Many of the registered nurses worked during the conflict, so much so that the São Paulo Defense League, on September 24, through a formal document sent to the General Superintendency of Transportation, stated that one of the former students was providing assistance services to soldiers. Soon, his family needed authorization for free transit of official cars. Other evidences of the unfolding of the performance of these participants can be verified through the evidence of participation in the course under analysis, formally issued by the Directors of the Institute of Hygiene after the year 1948, as can be seen in the following excerpt: "I certify, for the due purposes, that Miss O.R.B followed the 3 rd War Emergency Nursing Course, carried out by the former Institute of Hygiene of São Paulo, during the Constitutionalist Revolution of 1932, as recorded in the archives of that division, having afterwards, the Hospital "Alemão", today called "Oswaldo Cruz", and later to the Santa Casa de Misericórdia (Blood Section where the wounded from the near front of the capital were transported), in order to lend the nursing services." 28:1

DISCUSSION
The course under analysis legitimized the ideological alignment of the Institute of Hygiene, which struggled to assert itself autonomously in the field of health education with the interests of the government and the São Paulo elite. This movement took place against the interests of the Provisional Government, given the relevant link between the Institute and the Faculty of Medicine of São Paulo, and the first, from its foundation to the year It was crucial for São Paulo, especially for the fragility of the insurgents, to bring together as many volunteers as possible. In a single combat front of the South, the difference was of ten thousand men in favor of the federal troops, besides the relation of distribution of automatic weapons of war, one for each 03 federal soldiers, against one for each 50 soldiers of São Paulo 3 .
Thus, volunteers were recruited through organized civil groups, such as the Childhood Crusade, the Liga das Senhoras Católicas (freely translated as Catholic Ladies League), the Justice Battalion, the Medical School of São Paulo, the Institute of Hygiene, etc., which promoted the enlistment and provided food and lodging for. 3 It is mentioned that advertising strategies, with focus on the mobilization and recruitment of volunteers, were implemented by the mass media to the elitist. Strategies based on the discourse of authority, competence and paulistanidade 5 , so much that one of the most publicized posters was of a solemn nurse, with the left finger cocked, right hand on the thorax (left side), that said: "Paulista: I've already done my duty. What about you? 3 ".
The Civil Enlistment and Propaganda Department used the press as an ally, extolling the social role of the nurse figure, sensitizing civilians in order to transform them into war nurses, especially considering that the owner of the newspaper O Estado de S. Paulo, Júlio de Mesquita Filho, was one of the enthusiasts of press engagement in the 1932 War 3 .
In the face of the numerous training initiatives of war nurses (Blue Cross, Red Cross, Black Legion, etc.), it is considered that the course of the Institute of Hygiene trained a considerable number of hands-on nurses. Especially when compared with the group of 168 volunteers from the Provisional Government who held the "First Aid and Hands-On Nursing Course", given by the EEAN during the same conflict 18 .
Despite being a hands-on course, there was a notable female participation, that is, 308 (81.2%), a trend observed even on other voluntary fronts, such as the participation of 70,000 women in sewing workshops 5 , as well as numerous volunteers linked to Blue Cross, who worked on the delivery of medicines to the homes of the wounded of war and services of correspondence/ information between combatants and their relatives 3 .
Although the training in Emergency Nursing allowed ruptures in the traditionalist and paternalistic discourse that affirmed the place of the woman, it contributed to keep it within the frame of the supposed natural vocation for the profession 30 , and naturalized the woman-care relationship. Such a statement is made because the State could name the course only as a "hands-on course of lifeguards" and accept volunteers of both genders, but preferred to use the archetype of the "nursing profession", although it faced an imagistic-discursive structuring, above all by the institutionalization of education (Decree 20,109, June 15, 1931) and adherence to new concepts, was permeated by eugenic and elitist influences, so much so that admission to official nursing schools was hegemonically white and favored social strata 9, 31 .
The performance of the five courses with training of hundreds of "war nurses", between July 13 and August 31, was a shocking event in the process of legitimacy of the Institute of Hygiene against the society and medicine of São Paulo. The fact that the first course began after only five days of the outbreak of armed conflict, according to the documentation researched, a process of organization, both of institutional structure and of highly complex pedagogical and scientific contribution, demonstrates a mobilization that preceded the beginning of the war of 1932. According to the documentation researched, it is questioned: Was there a prior planning for a fully structured course, with teaching staff and teaching aides, as well as meticulously organized theoretical and hands-on content?
The research seems to point to a positive response, as well as to the previous non-disclosure, considering the knowledge of information and actions that, known to the opposing side, could anticipate reprisals or even an armed invasion.
Disciplines of the first part of the content introduced students into concepts of Medical Science, with an emphasis on hygienist conception, permeated by knowledge of Physiology, Microbiology, Histology and Pathology, where, with due proportions, they resembled the courses taught to educators by that Institute from 1926 onwards 29 . The same happened, considering the grade of disciplines of Emergency Nursing, taught by Blue Cross, under the leadership of Professor Raul Briquet, who approached notions of Surface Anatomy, Bacteriology, Elementary Medical Nursing, Surgical Nursing, Pathology and First Aid to the Wounded 3 .
Classes of Venereology, exclusive to men, as advocated, can be justified by the high prevalence of syphilis, as well as other venereal diseases (soft cancer, gonorrhea, among others) in that period, being one of the diseases that most affected the fighters in the trenches of the 1932 war 5 . Since the 1910s, in the Navy of Brazil, educational and prophylactic measures were disseminated in order to combat this aggravation, considered a hindrance to the project of a modern Brazilian nation that craved 32 .
In Epidemiology of War, it was identified the influence of hygienist concepts and disciplinalization of bodies 33 , purposely prepared by Francisco Borges Vieira, professor responsible for the Epidemiology section of the Institute of Hygiene and who, since 1931, was the Director General of the State Service Sanitary. Throughout his career, he published numerous epidemiological studies, including with Gastão Fleury da Silveira, also professor of the course under analysis 29,34 .
Nursing disciplines focused on exposing concepts and information for the training of exclusively hands-on workforce, so that students would be able to work in field hospitals, being strictly enforcers of basic techniques, besides procedures related to hygiene, handling and care of surgical materials. As well as actions related to patient care in situations of imminent risk of death, usually undergoing surgical procedures, and injured in the trenches, as illustrated by Figure 2.
The participation of Iracema Isabel Niebler, a nurse trained by the EEAN, linked to the Institute of Hygiene since the early 1930s, was outstanding, since she taught in many other courses carried out by the institution, such as those of health educators, being, until the year 1949, responsible for supervising them 35 36 .
The accomplishment of the hospital hands-on internship as the last requisite before the conclusion of the course, besides allowing the performance of theoretical knowledge learned, also sought to accustom students with that space of care, where they would probably act, whether in the capital or in the countryside. Public and private hospitals, in every state of São Paulo, had about 2,000 beds to care for the wounded, which, at first, might seem to be sufficient. However, in comparison with the number of hospital visits in the North Front trenches, it seems to have been insufficient, since, according to some sources, 1,006 hospitalizations were carried out during the conflict, of which 588 were wounded, including 77 wounded by grenade and 75 by firearms 3 .
At the end of the training, the graduation ceremony of students, the oath, seems to have been a request of Iracema Niebler, mainly for being a nurse graduated by EEAN. Emblems and rituals (headdress, veil, lamp pass, oath, etc.), along the history of Brazilian Nursing History, were part of the daily life of educational institutions, supposedly under religious and military influence, in order to transmit and reinforce predicates such as hierarchy and discipline 37 .
This study, even with the limit imposed by the researched documentation, especially regarding the setting of effective participation of emergency nurses in caring for wounded on the battlefield (post-training), pointed to a training process of success in front of the institutional project. Some records allowed approximations to this question, mainly due to the high number of requests and certifications of proof of participation in the course under analysis issued after 1948.
Requests were motivated by the interest of instructing cases addressed to the Committee on Article 30 of the Transitory Provisions of the State Constitution, dated July 9, 1947 38 mainly after 1948, when Law 211 of December 7, 1948 was sanctioned. This Law regulated the advantages granted by the aforementioned Article 30 Commission to the active participants of the Constitutionalist Revolution of 1932, which included preference for entry into the public service, internal promotion to public officials, donation of lots of up to 50 hectares for those who wished to dedicate themselves to activities rural areas, among others 39 .

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE
The execution of the War Nursing course, carried out by the Institute of Hygiene, characterizes its participation in the Brazilian Civil War. The performance in the preparation of volunteers exposed its position of alliance to the movement and the institutions of the São Paulo science, besides legitimizing and strengthening its role in the training of health professionals included in the modernization project of São Paulo.
Although the course started its activities during the conflict, it is believed that there was a planning about its accomplishment, that was conditioned to the outbreak of the conflict, given to the logistics, personnel mobilization and structuring of theoretical and hands-on content.
The state of São Paulo used nursing (a profession that began to assert itself in that period) as a mechanism for institutionalizing and rationalizing care practices necessary for its effective combatants and civilians, allowing students, typists, housewives, etc., were "mobilized by civic duty" and transformed into "war nurses". It is not wrong to say that such an initiative contributed to affirmation of the profession in the midst of the' São Paulo society.

Institute of hygiene during the Brazilian Civil War
Marques MCC, Brasileiro DF, Fraga FD