|Anna la Torre, Università Statale di Milano, Italy and Universitat Autònoma Barcelona, Spain||The UKAHN Bulletin|
|Volume 10 (1) 2022|
‘The fascists must worry about the health of the race because they will make history with it.’ declared Mussolini in his speech at the Augusteo on November 9, 1921, heralding a theme that would recur throughout the entire history of the soon-to-be-established regime. In fact, fascism, a political movement that originated in 1919 and remained in power in Italy from 1922 to 1943, immediately left its mark on nursing, in the pursuit of control of the population, institutionalisation and, above all, eugenics. Mussolini, Il Duce himself, undisputed leader of the fascist dictatorship, often emphasised the pre-eminent role of doctors in Italian society, reaffirming the essential nature of their work with regard to public health. In his 1927 Ascensione speech, Mussolini stated that ‘In a well-ordered state, care for the health of the populace must come first. Therefore, we must strictly monitor the fate of the race; we must take care of the race.’ This message was understood perfectly by the medical profession which immediately took action, both in research and in the development of a complex network of welfare institutions to pursue eugenics and protect the birth rate and the family, at home and in the colonies. Thus, to lend greater individuality and prominence to his ideas on health and morality, it became a priority for the fascist regime to create organisations such as the Opera Nazionale Maternità e Infanzia (ONMI) [National Organisation for the Protection of Maternity and Infancy] for educational, social and health protective purposes; the Opera Nazionale Dopolavoro (OND) [National Afterwork Club] aimed at education and, by implication, health education; and the Opera Nazionale Balilla (ONB) [Fascist Youth Organisation] for the physical and moral education of youth.
Also included in this context were a series of targeted nursing initiatives or, as they were described in the 1937 edition of the Enciclopedia Moderna Italiana under the heading ‘Social legislation’, initiatives for the ‘elevation’ and ‘regulation’ of the auxiliary work of the healthcare professions. In particular, ‘Noteworthy are the laws for the elevation of nursing (15 August 1925) and for the regulation of the auxiliary arts of health professions (23 June 1927) as well as for the increase and perfection of health resorts, hospitals and summer camps (law of 29 January 1934).’ In fact, the first Italian law concerned the regulation of the nursing profession was officially recognised during the Fascism-regime. Thus, boarding schools were established, where the exclusively unmarried female students were required to reside and where, at the end of a two-year course, they might obtain a diploma as a professional nurse. An additional year was required to gain certification for management duties, or to choose to become visiting nurses, with a degree from schools specialised in medicine, public health and hygiene and social welfare.
Women, as the only students admitted to the new training schools, therefore became legally responsible for nursing care, a concept that was also enshrined in law in 1940; entitled ‘Job descriptions of professional nurses and nursing associates’ it emphasised that ‘Professional nurses have powers of an administrative, organisational and disciplinary nature in the hospital ward to which they are assigned, while the tasks of nursing associates are technical in nature and always under the supervision of the professional nurse’.
However, assigning such levels of responsibility to nurses and visiting nurses, created a difficult and ambiguous relationship between the female gender and a fascist regime full of complexities and contradictions. On one hand, the fascists disapproved of all social practices related to the empowerment of women – from voting rights to working outside the home, to birth control – while also seeking to eradicate behaviours directed toward the affirmation of individual interests that underlie women’s demands for autonomy and equality. On the other, in an attempt to boost Italy’s economic might and mobilise all available resources, including women’s reproductive capability, the fascists, inevitably, ended up promoting the very changes they were trying to prohibit. This dichotomous relationship between fascism and the female gender is often also highlighted in the party’s own propaganda, but above all within the historically gender-based relationships of power, like that between nurses and doctors.
The earliest research into the history of women during the fascist era dates back to the mid-nineteen-seventies in the work, for example, of Maria Antonietta Macciocchi or Piero Meldini. Noteworthy research was also undertaken during the nineties on women’s professions and the portrayal of women in propaganda and in the mass media of that period, in particular the work of Victoria De Grazia. With widespread illiteracy (that of women was around 25% in 1921), the regime invested heavily in mass communication, starting with women’s magazines, like La Rassegna femminile italiana by Elisa Majer Rizzioli, or l’Almanacco della donna fascista, and nursing publications, such as the journals of the professional associations, or the publications of party affiliates. A recent study conducted at the Tor Vergata University of Rome used text-analysis software (Iramuteq) to examine the text in articles published from 1935 to 1938 in the only nursing magazine of the day: L’Infermiera Italiana [The Italian Nurse], official organ of the fascist union of nurses. However, to date, there has been no survey of how the healthcare professions were represented in the medical journals of the era. To be able to highlight the opinions of the medical profession and the fascist propaganda about the nursing profession, the objective of this research is therefore the analysis of articles and images of nurses during the period in question through the reading of the official journal published by the Italian association of physicians and surgeons.
Thanks to the research conducted by the University of Rome, it was decided to use the lexographic software called GATTO (Gestione degli Archivi Testuali del Tesoro delle Origini), created as a tool for the construction, management and interrogation of the corpus of texts that forms the basis of the Opera del Vocabolario Storico della Lingua Italiana (Historical Vocabulary of the Italian Language).The analysis carried out to date focused on the journal, La Federazione medica, published from 1921 to the first four months of 1932, and its replacement title, Le Forze Sanitarie, published from May 1932 to 1943. With publication schedules that varied from semi-monthly to quarterly, it was possible to read approximately twenty years of publications, numbering about 240 issues. No issues for the whole of 1921 or from May to July 1943 were available and, within the years viewed, some issues were missing. The exploration of texts was conducted at the library of the Catholic University of Milan, the National Central Library of Florence and the library and archives of the Archivio centrale dello Stato in Rome. Future research plans include viewing other medical publications from the period, specifically L’Avvenire sanitario, a weekly magazine of political, jurisprudence and health news, established in 1907 and printed in Milan; La Difesa sociale, a health, welfare and nursing magazine active from 1922 to 1947; and La Difesa della razza, a semi-monthly journal, published from 5 August 1938 to 20 June 1943, whose editorial board was made up of renowned doctors and scientists.
Compared to the association of the nursing professions, which was established in 1946, the doctors’ association was established by royal parliamentary decree in 1910. As fascism came to power, the associations were gradually replaced by unions tied to the regime, being definitively suppressed by law in 1935. The transformation of the images and content in the journal offers disturbing evidence of this historically verified transition to the fascist regime. Above all, the change is clearly identifiable between 1925 and 1926, when the infamous leggi fasciatissime, a series of rules of law, were issued, launching the metamorphosis of the legal system of the Kingdom of Italy into a totalitarian regime. In 1934 came the birth of the Empire and the glorification of Italian victories; in 1938, the deplorable racial laws and the alliance with Hitler; and in 1940, when Italy entered World War II. The name of the journal itself changed in May 1932 from La Federazione medica, which encompassed the regional associations in a single association, to Le Forze sanitarie, with a powerful military connotation, clearly signalling the new militaristic trend. This change, explained by Professor Eugenio Morelli, the new editor, ‘is due to a desire for power and constant escalation, a name that expresses the desire for a great leader, our Duce, who, in peacetime and in war, by approving its title, approved the program’. The results were collected into three large groups diversified between professional nurses, visiting nurses and with a look at male nurses as well. Professional nurses are analysed both in their image in magazine advertisements and in the texts of articles. The findings so far are presented here in four sections: Nurses in advertising, Nursing as an Art, Visiting Nurses and Male Nurses.
Nurses in advertising
Compared to the countless number of articles examined in the two journals, articles about nurses and nursing in general were few and far between. More significant, however, is the extensive use made of images, both photographs and illustrations, of nurses in advertising. Indeed, compared to just three photographs in which Red Cross nurses appear at official functions – such as the gathering of doctors in piazza Venezia in Rome, the speech of the Duce to doctors and the opening of the academic year at the La Sapienza University of Rome (appearing respectively in issues in 1932, 1935 and 1939) –adverts for the sale of drugs, medicines and sleep remedies teem with their images.
The original graphic design of the La Federazione medica was austere and typical of a medical journal. The editorial treatment of nurses still conveyed a belle époque image of women, not as sensuous but young, sweet, smiling and dressed in patterned uniforms – shapely uniforms and lace-trimmed caps, more like those of a maid than a nurse. Three adverts in particular recur: in one, the smiling ‘signorina’ medicates the sore of a grateful patient; in another, the nurse’s face seems to project out of the O in the name of the medicine; while, in the third, the image of the woman is dwarfed by the words, Calm, Tranquillity and Sleep, and visually conveys the message that the nurse received the medicine from the hands of the doctor, while in the background the patient sleeps peacefully in their bedroom.
The journal underwent another graphic transformation in the nineteen-thirties that aligned it to better represent the new needs of the regime, with increasingly extensive displays of party symbols, typefaces with crisp, slanted contours, faraway gazes, and the typical futuristic postures which lead into the future with figures that seem to be in motion. The image of the sweet young woman is replaced by the beautiful, noble image of the Italian Red Cross nurse who steadfastly accompanies the victorious Italian army on all of its colonial campaigns and throughout WWII, or the nurse with a uniform more similar to that of a rural housewife who, with a side-glance, stands alongside (but obviously of lesser stature than) the young surgeon and elderly hospital doctor.
Nursing as an art
Three of the articles examined contained topics specifically about nurses. The first, which appeared in issue 5 of May 1927, written by the editor, Dr. Arnaldo Fioretti, entitled ‘Approval of boarding schools’, extols and explains the creation of an official, nationally-recognised educational training program. The author emphasises the fascist policies and writes: ‘Education and training are essential, like that implemented today through the regulation stipulated by the Ministry of the Interior and that which the candidates and those who are being instructed can receive comprehensively in the existing boarding schools.’
The article reports the need for more trained lay nurses, rather than the religious nurses who, since the last century, had worked in hospitals, often in administration and inspection, but who had not had any specific training. It says: ‘Doctors must rely more heavily on professional nurses who, compared to the venerable Suore della Carità [Sisters of Charity], are better educated and trained for their job. Education is now a must when caring for the ill’ and again, ‘The position of the nurse is raised above that of the most marvellous and noble Suora di Carità, to the level of the auxiliary caregiver, alongside the doctor.’ But in order to reinforce traditional hierarchies it emphasises this work should be undertaken ‘…as a silent and attentive collaborator, with no pretence of intervening’.
Nursing was defined as an ‘auxiliary art’ until 1934, the year in which the consolidated health law was enacted which listed professional nurses among the health professions. Nevertheless, in an article of the same year, published in issue 4, Amilcare Delfini conformed to the previous definition and wrote, ‘Nursing is an art’. Even though it is not cited as a quotation, the exact wording of the sentence above is striking as it is one of the most well-known quotes by Florence Nightingale. But the author added, ‘[it is] a difficult art, that requires hard work and great knowledge’. In the same article, Delfini stated that ‘nurses must be well-trained – as in some countries around the world, without presuming it to be analogous to that in the United States or in England, where I have personally seen competent, highly skilled nurses –no longer uneducated, inexperienced and lacking any method’.
These concepts are abundantly reiterated in an article that appeared in issue 7 April 1939 written by Editor Raffaele Bastianelli and entitled ‘Nurses and the care of the sick’. The article begins by urging all Italian women to embrace this profession, inviting them to follow the noble example of Her Majesty the Empress Queen of Italy and Her Highness the Princess of Piedmont, both volunteers with the Italian Red Cross. Thus, the author compares, without distinction, the professional nurses with the volunteer nurses who, even under fascist legislation, had different roles and training. In fact, the professional nurses attended a two-year course at the above-mentioned boarding schools and were allowed to work in all settings, while the ‘ladies’ of the Italian Red Cross attended a course lasting from six to nine months, were allowed to work only in military settings and followed the Italian army in all its battles and this, probably for the fascist doctors’ union, was undoubtedly a greater virtue.
Bastianelli’s article begins with an act of persuasion and states: ‘I am confident that the best means of persuasion is to speak the truth, in order that the duties, the burdens and the satisfactions that come with this career be known, so the decision can be made with full knowledge of the facts.’ Surprisingly, however, in the same article, the author cited an absolutely unexpected perspective for the times, describing nursing as ‘the expression of an accumulation of knowledge and experiences so great and varied that it constitutes a separate job of its own, extremely wide-ranging and difficult to perform well without special training and without special qualities’. Thus, in a way, he saw it as an independent profession that included a broad spectrum of skills and is engaged in many different work environments.
In describing the qualities required, the author mentioned the known religious calling but adds the capacity for critical thinking and decision-making:
For this profession, as for all professions, it is an error to think that anyone can practise it. A calling and aptitude must be coupled with an attraction for the profession and vast knowledge. The school curriculum provides elements that open the eyes to the art of observation, but the ability to observe cannot be acquired, it can only be deepened or sharpened with constant work.
The irreplaceable role of nurses is thus reiterated:
In today’s world, care of a seriously ill patient or performing surgery – with all its attendant possibilities and dangers prior to and after the surgery – is unthinkable without the involvement of the nurse, a role that can even save a life with the prompt identification of a menacing danger and with the appropriate response, in collaboration with the doctor. The qualifications I mentioned as crucial for exemplary care of the ill are many and not easily found, which means that the profession of caring for the ill is not a manual task but rather a spiritual, technical and intellectual one.
The concepts encapsulated in this final phrase are utterly modern because, for the first time, nursing is referred to as a profession when, as mentioned earlier, it was never included among these. It was always defined as an auxiliary art and to be defined as an intellectual pursuit, to be pursued only by those in possession of a university degree, was very new.
In 1938, the winds of war were already in the air and articles about military healthcare, professional training for emergency surgery and speculation about the need for them began to feel increasingly serious. The topic of mobilisation appeared in issue 3 of 1939. The article stated that, in the case of national necessity, and in a hypothetical state of need, retired nurses and those who had to resign due to marriage could be reinstated and employed in the cities where they lived to aid and care for the populace in case of catastrophe.
As had been done for the professional nurses, the establishment of schools for visiting nurses was authorised in 1925 with the creation of the specialised schools of medicine, public health and social services that organised the specialisation course work for their training. Admission to the one-year course was only granted to those students who already held a diploma to practise in the nursing profession. Once qualified, in addition to being engaged in cities, in summer camps and in tuberculosis sanatoriums, the visiting nurses went into the homes of citizens to view and make note of the health and hygiene conditions in which the nuclear families lived and to find educational and health-promoting solutions for each individual setting.
The visiting nurses held considerable power over those in their care. In the report/medical histories they completed on each visit, along with the questions about the state of the family and its financial condition, were questions that asked if anyone was hospitalised in a sanatorium, for details of unemployed persons in the family, anyone recalled for military duty, any national awards/honours presented to family members. There was even a section of the form entitled ‘Moral situation of the family’ and another called ‘Health and hygiene conditions’. Generous space was provided for recording personal impressions in the ‘other information’ box. Thus, the visiting nurse was a true functionary of the political regime. An unfavourable report by a visiting nurse could give rise to disciplinary measures and repressive actions if details were mentioned that might be cause for investigation. Not surprisingly, in a note by the Milan welfare office, the role of the visiting nurse was described as ‘an extremely delicate responsibility and of significant political gravity’. The authors of the Forze sanitarie were well aware of this role. In an article, ‘Visiting nurses’ by Dr. Arnaldo Lusignoli, that appeared in issue 9 of May 1939 and which appeared in a column headed ‘Social medicine’, visiting nurses are referred to as ‘an essential category for protection of the race, in which the fascist woman plays a key role’. They are described as true professionals with delicate jobs, unlike the hospital nurses who had to acquiesce to the doctor. The visiting nurses were independent and skilled in their jobs and paid more for their work, given their more worthy profession. Specifically, Lusignoli says:
The task of the visiting nurse is truly worthy but also insensitive they must always seek out and find the homes inhabited by the devil and evil and, with a gentle yet determined manner they must persuade those who are often reluctant to participate in the visit, the treatment, the isolation, the surveillance. They must teach the practical rules of hygiene, of prevention, those rules that all too often are not followed, through indifference or ignorance or malevolence of the heart and soul, contradicting the true belief of our Duce.
As mentioned above, the professional nursing diploma was open only to unmarried women who had attended the two-year boarding-school program. In support of this fascist party initiative, an article entitled ‘Sull’istruzione tecnica del personale d’assistenza maschile negli ospedali italiani’ [On the technical instruction of male nursing staff in Italian hospitals] was published in issue 4 of the Federazione medica in 1928. In this article, the author and editor, Franco D’Alessandro, head physician of the Catanzaro Hospital, raised a question that he (hypothetically) had been asked, ‘Why is it that in Italy there are numerous schools for training female staff to care for the ill and there is not even one similar school for the training of male personnel?’. Starting with this question, D’Alesssandro praised the decision to limit the professional diploma to women because, as he himself noted: ‘given their mental constitution and social position, they are most suited to a job that requires the eradication of their own personality in the face of human suffering’ but he added that ‘it is no less true that not all the jobs of nurses can be performed by women and that, therefore, the male presence is indispensable’
According to the author, the greatest problem was the category itself because, in his opinion, male nurses ‘are farmers and failed labourers for whom the rough work in the fields or factory is too burdensome and who are attracted, the former by the mirage of urbanisation, and the latter by a job with sure pay even if not overly lucrative’.
A major problem, to which he adds that:
The large and medium-sized hospitals themselves provide technical training of the [male] nursing students with academic and practical courses that should have been two years in length, to allow the right to participate in the competitive exams but were, taught, in fact, less than fifty lessons each year, typically, by hospital nursing staff. The coursework is modelled on the female version. In fact, the above-mentioned courses are held intermittently, tied to the need for staff to fill in where needed. It is often true that the urgent need to fill the voids and the scarce number of [male] students force the examining committees to make do with tests that do not afford proof of completed coursework.
In addition to this, the author emphasised that often the lessons were excessively theoretical and not practical and thus the ‘impossibly ignorant’ students failed to learn anything and were therefore, also incapable of working. Things were even worse in terms of conduct, a point over which the author expressed his deepest remorse. Indeed, he wrote:
The opportunistic mentality that motivated the young man to enrol in the nursing course, more often than not, makes him emotionally labile with lukewarm interest. Those who have experience with the ill and with hospital wards know that quite often the patient has more need for moral than material support and that an impatient or rude gesture is more offensive to an ill person than to a healthy one.
With the approaching likelihood of war, the tone taken with male nurses also changed. Indeed, in a possible war scenario, the expectation was that they would be the ones most heavily engaged, thanks primarily to their large numbers in the armed forces. The image reproduced in issue 6 of 1939 differs distinctly from that painted by D’Alessandro. The illustration shows several male nurses/litter-bearers with serious but reassuring faces who, alongside a doctor in civilian clothes, are attending to a wounded person in a clearly urban setting after a bombing raid. The accompanying article, written by Prof. Eugenio Diretti, also softens the tone regarding the male nurses; he reported on the staff shortages but also wrote:
I do not intend to disparage a commendable class that has every right to my esteem and admiration who are carrying out one of the most difficult and dangerous jobs, for which they are not always fairly compensated. The fault for this must fall upon an organisation – which we must now have the courage to acknowledge as such – that is antiquated. If male nurses in the hospitals cannot be replaced by female nurses, then the selection and training processes must be reviewed. Less anatomy and physiology and more comprehensive practical experience and, if need be, wartime medicine.
The evolution of the status of nurses during Mussolini’s twenty-year period of rule is an interesting study as an example of the fluctuations, ideological contradictions and changes in this profession and in the regime. Analysis of the photographs and words used in articles, including the topics themselves, has shown that, even while the position of female nurses was consistently downgraded, medical literature considered a trained and educated nurse to be valuable. Nurses were required to have acquired a safe, shared method, possess balanced critical thinking and experience.
Although Catholic nuns had been the protagonists of nursing from early nineteenth century onwards, and even if the Italian Church and the Fascist party were linked through the Lateran Pacts (1929), the articles analysed for this study highlight the desire from doctors to be helped by lay professional nurses with more training than nuns. These considerations lead us to think that nuns were unprepared for this job and that they were employed in assistance duties, in addition to the managerial and financial aspect of hospitals. In addition, this research has highlighted the nature of the work of visiting nurses, emphasising their social and political importance. These aspects appear to be suppositions and considerations that deserve further investigation. Furthermore, regarding the work and preparation of male nurses, the medical literature does not deviate from the fascist initiative to exclude men from nursing schools, as well as expressing misgivings about the preparation of men and their ethical motivation for undertaking nursing work.
The research presented in this article is part of a larger project that aims to analyse the evolution of professional nurses during the fascist regime in Italy. This project is a part of the PhD I am currently undertaking at the Autonomous University of Barcelona in Spain. In the course of my studies, I have consulted a wide variety of sources (scientific, literary, public and personal) and multiple perspectives that will allow me to do justice to a very complex and elaborate subject. The research will not only focus on one aspect of the evolution of nursing, but will take into account political, social, financial and institutional topics such as legislative background, institutional structure, and policies. I will also consider the social and public images of nurses and their personal experience by analysing narratives in diaries, letters and memories. Primary and secondary sources will be undertaken in libraries and archives, especially in Italy.
In conclusion, this reading, although partial, of the medical-political literature of the period has brought to light and recognised some little-known and new aspects regarding the interest and desire of the medical profession for an intellectually, scientifically and technically-prepared category of nurses, compared to previous research on the same subject. This new research is leading to a rethinking of the history of the power relationship between doctors and nurses, one that, despite the time that has passed, still has not completely vanished and is woefully still relevant today.
The author gratefully acknowledges the following translators for their invaluable assistance: Massimo Carlo Maria Tintori and Jana McCloskey-Gholikhany.
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 Raffaele Bastianelli ‘Assistenza agli infermi e le infermiere’, Le Forze Sanitarie, organo ufficiale del sindacato fascista dei medici e degli ordini dei medici, IX/7 (1939- XVII E.F.), 345-63
 It would be sixty years before this status of nursing was officially acknowledged in Italian law, when finally, in 1999, the auxiliary designation was eliminated and nursing was listed among the intellectual professions.
 Anonymous, ‘Attività sanitarie in caso di necessità nazionale’, Le Forze Sanitarie, organo ufficiale del sindacato fascista dei medici e degli ordini dei medici, IX/4 (1939- XVII E.F.), 56.
 Ministero degli Interni, Regolamento concernente le norme ed i programmi degli esami di concorso e di promozione delle assistenti sanitarie visitatrici provinciali dipendenti dall’Amministrazione della Sanità Pubblica (Roma: La libreria dello Stato, 1943).
 Ente Comunale Assistenza, Tabelle per Piani d’assistenza, Report visite domiciliari consegnate dalle Assistenti Sanitarie Visitatrici e Visitatrici fasciste, anno 1937. Milano. Archivio ASPE.
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 Franco D’Alessandro, ‘Sull’istruzione tecnica del personale d’assistenza maschile negli ospedali italiani’. La Federazione Medica: bollettino della federazione degli ordini dei medici, IV/ 4 (1929 – VII E.F.), 43-64.
 Eugenio Diretti, ‘La Potenza Italiana’, Le Forze Sanitarie, organo ufficiale del sindacato fascista dei medici e degli ordini dei medici, IX/6 (1939- XVII E.F.), 743-78.