Homens, Instituições, Políticas
(séculos XVI–XX)
Introdução Ale
xandr
a Este
ves
Pobres v
estidos de preto: Assistência
, indumentária
e esmola a padres em Brag
a (séculos X
VII-XVIII)
L
uís Gonçal
ves F
err
eir
a
Entre o baraço e o preg
ão: A minoria cig
ana n
as
políticas normativas por
tug
uesas, na Época Mod
ern
a
F
ábio Lopes F
err
eir
a
Gafarias depois da lepra
: Apro
ximação
à história
do
Hospital de S. Lá
zaro de Coimbra na modernidade
Ana M
artins
The institutionalisation o
f medical kno
wledg
e and
its implications for o
fficial health
care pro
fessionals
in P
or
tug
uese America
Laurinda
Abr
eu
Entre forasteiros e pobres da cidade:
As
escolhas
assistenciais dos administradores d
a caridade
em É
vora nos séculos X
VII e X
VIII
Rute P
ar
dal
Dotes de casamento: Ex
emplo
da Santa Cas
a da
Misericórdia de Mang
ualde (séculos X
VIII e XIX
)
P
edr
o
J. B
arbosa da Sil
va
O P
urg
atório a estremecer: Capelas larg
adas e
missas atrasadas nas confrarias das Almas de
Brag
a
(século X
VIII)
M
aria M
arta Lobo de
Ar
aújo
S. Rafael, “
Celestial Médico”: Dev
oção e
caridade no século X
VIII em F
r. João de S. José,
da Ordem Hospitaleira M
aria de F
átima R
eis
Enfermeiros
e
enfermeiras
nos
hospitais
por
tug
ueses
dos séculos X
VIII e XIX: Continuidades e ruturas
M
aria
Antónia Lopes
Ex
clusão Social e “loucura
” feminina em P
or
tug
al
em princípios do século X
X: E
studos de caso
R
osário Belo Fr
ancisco
A epidemia de gripe pneumónica pela imprensa local: O caso de Coimbra Ana M
aria
Diamantino Corr
eia
Francisco de P
aula R
odrig
ues Alv
es: O homem,
o político e o sanitarist
a
Ale
xandr
a Este
ves
Alimentar os desvalidos: Os donativ
os em g
énero
à Associação
Protectora da Infância Des
valida
e dos P
obres do L
umiar (1927
–1964
)
Raquel
Caçote Raposo
7
12
32
44
60
92
102
120
144
154
174
184
198
218
61
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE L A URINDA ABREU*
60
The
institutionalisation
of medical kno
w
ledg
e and
its implications f
or
official
healthcar
e pr
of
essionals
in P
ortuguese
America
* Univ ersidade de É vora Ther e is a vast historiogr aphic liter ature on health, sickness and
tr eatment in colonial Br azil. M an y diff er ent aspects ha ve been
discussed, but ther
e ar
e thr
ee ideas that cr
op up quite consistentl
y.
The first is the major
r
ole that the
Jesuits pla
yed in health car
e –
pr
oducing r
emedies, running apothecaries’
shops and perf
orming sur gery 1. Secondl y, the tr eatments used w er e g ener all y deri ved fr om a mixtur e of kno w ledg
e and beliefs gather
ed fr om the various diff er ent cultur al tr
aditions in the colon
y, w hich w er e holding their
own against Eur
opean attempts at standar
disation
2. The thir
d point
is the shortag
e of qualified doctors and sur
geons in the colon
y, w ho w er e mostl y concentr
ated along the coast and/
or
in the lar
ger
to
wns, although scholars diff
er in the r easons the y put f orw ar d for this: w
hile some point to P
ortugal’
s neglect of Br
azil in this
and other
ar
eas, others, including M
ár cia M oisés Ribeir o, V er a R egina Beltr ão M ar ques and N auk M aria de Jesus 3, belie ve the pr
oblem should be conte
xtualised and question the adequac
y of
the inf
ormation that is curr
entl y a vailable on officiall y r ecognised healthcar e pr of
essionals in the colon
y.
This article seeks to add to this debate
with inf
ormation fr
om
a r
elational database of some 24,
000 nominati ve r ecor ds deri ved fr om documents in the P ortuguese centr al ar chi ves. M ost of these r ecor ds concern licences to pr
actice and appointments of
doctors, s
ur
geons and apothecaries to positions off
er ed b y centr al go vernment or local authorities in P
ortugal and its empir
e betw
een
1430 and 1826. The original intention of pr
oducing a compar ati ve stud y of P ortugal’ s colonies w
as soon abandoned because of the
lar ge number of r ecor ds r elating to P ortuguese America – 2,688 recor ds on 1,325 indi viduals [Fig ure 1] . The anal
ysis has ther
ef or e been r estricted to Br azil betw een 154
9, the date of the first kno
wn recor d, and 1808, w hen the P ortuguese r oy
al court had arri
ved in
Br
azil during the P
eninsular W ar and the Cr own decided to r ef orm healthcar e r egulation . In January 1809 , the Pr otomedicato , the bod y that had r
egulated the healthcar
e pr of essions, w as r eplaced b y the Fisicatur a-M or 4, w
hich also came to centr
alise inf ormation on bloodletters, mid wi ves, tooth-pullers ( dentists ) and man y other kinds of healer .
It should be noted that the data collected do not include
all the healthcar
e w ork ers that w er e acti ve in Br azil in the period in question for tw o r easons: pri vate pr actitioners w er e onl y occasionall y r ecor ded b y g ov ernment ag
encies, and man
y
of those
examined did not tak
e the tr ouble to pa y f or a permanent licence, the f ee f or w hich w ould be r ecor
ded in the chancellery
.5 That w as initiall y the case with Joaquim José P erpétuo, an apothecary in V ila do Príncipe, w ho in 1782 w as pr ompted to con vert the pr ovisional licence a w ar ded to him in 1770 b y his examiner , the commissioner and judg e appointed b y the chief sur geon ( cirur gião-mor ), f or f ear he w ould be disco ver ed b y inspectors sent b y the ne w ly cr eated Pr otomedicato .6
62
63
L A URINDA ABREU In th is e xp lo ra to ry s tu dy , I w il l a tt em p t t o tr ac e th e st or ie s of p hy si ci an s, s u rg eo n s an d a p ot h ec ar ie s w h o w er e bo rn , li ve d o r w or ke d in B ra zi l a t s om e p oi n t i n th ei r ca re er s. I t i s n ot m y in te n ti on to e xa m in e h ow k n ow le d ge c ir cu la te d in th e em p ir e, a to p ic th or ou gh ly e xa m in ed b y ot h er s7 . Th e su bj ec t i s ap p ro ac h ed f ro m th e vi ew p oi n t o f th e m ot h er la n d , n ot o n ly b ec au se P or tu ga l w as th e so u rc e of th e re gu la to ry f ra m ew or k ap p li ed in it s co lo n ie s, b u t i n p ar ti cu la r be ca u se it h as n ot b ee n p os si bl e to en ga ge w it h m u ch o f th e li te ra tu re p ro d u ce d in B ra zi l o r w it h lo ca l so u rc es . I n a d d it io n , m an y d oc u m en ts in th e A rq u iv o H is tó ri co d o C on se lh o U lt ra m ar in o (A H U – H is to ri ca l A rc h iv e of th e O ve rs ea s C ou n ci l) , a v it al r es ou rc e fo r re se ar ch in g kn ow le d ge tr an sf er a cr os s th e A tl an ti c in b ot h d ir ec ti on s, r em ai n to b e st u d ie d in d ep th .From P
or
tug
al to Bra
zil:
Healt
hcare pro
fessionals and
the reg
ulator
y environment
It w as only in the second half of the 17
th century , with the administr ati ve r eor ganisation of Br
azil and the e
xpansion of its
population, that the P
ortuguese Cr own began to in vest to an y significant degr ee i
n furnishing its colon
y – or the P ortuguese settlers mo ving ther e – with healthcar e pr of essionals fr om the motherland. U
p to that point, the inf
ormation w e ha ve on such pr of
essionals is sparse and lacks detail. The first doctors hir
ed by the g ov ernment, Jor ge V aladar es and Jor ge F ernandes, w ent out with the first tw o g ov ernors g ener al of B ahia, T omé de Sousa in 15438 and D om Duarte da Costa in 1553,9 r especti vel y. Among
the duties specified in
V aladar es’ s thr ee-year contr act w er e dail y
visits to the sick
in the city’
s hospital.
10
In 1556 B
ahia also had a sur
geon, ‘M estr e P edr o’ , w ho tr eated
and bled the ‘men of the r
oy al na vy (arri ving ) in this city’ ,11 an d another w as ther e in the f ollo wing year: Af onso M endes, a ‘N ew Christian ’ ( a f or ced con vert fr om Judaism or a descendant of one ),
had been the chief sur
geon in P
ortugal but had chosen to lose his
position ther e and flee to Br azil r ather than sta y and be arr ested by the Inquisition. 12 Fr
om then until the end of the 16
th century the database includes onl y fi ve mor e r ef er ences to Br azil: L uís Antunes w as appr ov ed as an apothecary in 1591 to w ork in ‘P ernambuco
and the parts of Br
azil’ , an d f our ‘pr ovisional ph ysicians’ ( médicos a termo
), in this case sur
geons and medical students,
w er e gr anted tempor ary licences to pr actise medicine b y the chief ph ysician (físico-mor ) under highl y r estricti ve conditions, as w as the norm 13 . All of these pr of essionals intended to w ork in Br azil and M adeir a, or in Cape V er de and ‘ other
islands in the parts of Br
azil’
, or
e
ven
perhaps in Guinea and
Ang ola, although i t is not kno wn w hether the y actuall y cr
ossed the ocean.
14
A
t the beginning of the f
ollo wing century , the chancellery recor ds sho w a very slight, gr
adual rise in the number
of pri vate indi viduals w ho set sail f or P ortuguese America on their o wn account. This w as the case of tw o apothecaries ( one in 1621 holding a sur geon
’s licence and the other
in 1633 licensed as a pr ovisional ph ysician ), tw o sur geons (
1625 and 1636, one of them a pr
ovisional
ph
ysician
) and one medical student (
1635, pr esumabl y also intending to w ork as a ship ’s doctor ). The onl y r ef er ence to a Br azilian municipal partido – a post f or a healthcar e pr of essional w ho w as hir ed and w hose salary w as paid b
y a local council – concerned the r
ene w al of a ph ysician ’s contr
act and the hiring of a sur
geon in B ahia in 1618. What w as ne w w as the incr easing e vidence of military sur geons during the Dutch– P ortuguese W ar . The letter
that the captain of the
Gr
ão-P
ar
á garrison sent to the king in
January
1623, r
equesting
a sur
geon and medicines alongside munitions, standar
ds and drums, sho w s ho w w ell integr ated the y w er e, as if the y w er e just another w
eapon in the arsenal of
w arfar e. 15 As w ell as sur geons, the f orts and
garrisons also began to r
ecei ve permanent medical personnel, as happened i n O linda in 1622 and B ahia in 1626, during their armed r esistance to the in vasion b y the Dutch W est India Compan
y. In 1635, at one of the dir
est moments in the conflict,
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE Fig ure 1 Doctors, surg eons and apothecaries in the Por tug uese Empire (1496– 1808) Sour ce: M edical Pr of essions D atabase, 1430– 1826 0 500 1000 KM 12 83 300 750 13 2 5
64
65
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE L A URINDA ABREU D om L uís de R ojas y Borja, arm y commander of the Captainc y of P
ernambuco, appealed to King Filipe III to send ph
ysicians,
sur
geons and medicines so he could set up a field hospital.
16
M
an
y other
sur
geons must also ha
ve contributed to the w ar eff ort betw een the in vasion of S al vador (1624–25) and the P ernambuco Insurr ection ( 1644–54
), but the centr
al ar chi ves contain no tr ace of them. The y do sho w , ho w ev er , that in 1641 M anuel D oli val P ai va, chief sur geon of the na vy
, applied to become sur
geon to the r
oy
al
household in r
ecognition of his services during the
w ar; that in 1651 a ph ysician, Diog o P er eir a, w as made a knight ( Ca valeir o Fidalg o da Casa Real );17
and that Sebastião M
artins w as appointed sur geon to the Rio de Janeir o garrison. 18 The arm y r emained the pr ef err ed choice f or healthcar e pr of
essionals until the end of the 17
th century . Since the y corr esponded to the r ank of lieutenant, 19 military chief -sur geon posts w er e highl y sought after
, with the rich Captainc
y of
P
ernambuco and the r
ecentl y f ounded ( 1680 ) Colônia do Sacr amento ( no w in U rugua
y) at the top of list. In Colônia do
Sacr amento ther e w er e se ven candidates f or a single position in 1688, 20 demonstr ating P ortugal’
s confidence that it could hold
the territory
against S
panish claims. Less attr
acti ve w er e soldier -sur geon posts, tw o varieties of w hich ha
ve been identified although
not
yet quantified: one consisted of soldiers
with some e xperience of sur gery w ho pr actised as if the y w er e qualified pr of essionals; the other included sur geons r ecruited b y f or
ce and turned into soldiers
of cir
cumstance at the mer
cy of the po w erful – ‘ ev en if he has to be coer ced with violence ’, wr ote the g ov ernor g ener al of Br azil, D om João de Lencastr e, on 30 A
ugust 1698 to the captain-major
of
P
ar
aí
ba, or
dering him to include a sur
geon in the r egiment that w as being f ormed to fight indig enous gr oups in Rio Gr ande.21 As the century dr ew
to a close, the people (
thr
ough the local
councils that r epr esented them ) called e ver mor e insistentl y f or healthcar e pr of essionals, w hich ma y account f or
the fact that some
military
sur
geons’
contr
acts stipulated that the
y should attend the
poor in the ar eas w her e the y w er e stationed. M or e often, ho w ev er , it w as mer el y implicitl
y assumed that that
w as part of their duties, not least because man y of them w er e paid by the local councils. In A pril 1728 the sur geons M anuel F err eir
a da Costa and Inácio Capelo de
V allenci vela, w ho w er
e attached to the infantry
r
egiments stationed
in B
ahia, complained of the uncertainty
surr
ounding their
r
oles.
As the
y did not kno
w pr ecisel y w hat their
duties consisted of, the
y w er e r equir ed to tr
eat not onl
y the soldiers in the barr
acks but also
‘outside assistants fr
om said city
and their
households and, in those
of the higher
-r
anking officers, their
serv
ants and sla
ves’; f eeling exploited and ‘highl y incommoded in their persons’ , the y petitioned the king to gr ant them a r
egulation setting out their
duties so that the y could better serv e him. 22 While it w as undoubtedl y difficult for
these men to tak
e car e of a constantl y gr owing population – ther e w er e betw een 200 ,000 and 300
,000 people subject to the
P ortuguese Cr own b y that time 23 – it is also clear that the y w er e mor e willing to do so w hen the y w er e paid separ atel y f or it.
It appears that Rio de
Janeir o had onl y f our doctors in 16 71 – ‘not enough f or so man y people ’, accor
ding to the authorities.
24 In P ernambuco ther e w as one: ther e w as a r eport that a Fr ench doctor with a ‘ good r eputation in science ’ but ‘little e xperience of Br azil’ 25
had been ther
e that
year
, but he had left because he had
not b
een paid. This, complai
ned the g ov ernor of Rio de Janeir o, set a poor e xample to other doctors, as it no w
made the packag
e off er ed to an y doctor w ho wished to g o ther e less attr acti ve. 26 N ot onl
y did the motherland not send them doctors (‘w
e don ’t usuall y g et an y doctors fr om P
ortugal’), but it also depri
ved them of the on es w ho w er e ther e. The N ew -Christian doctor Andr é R odrigues Fr anco fr om I danha-a-N ov a in eastern P ortugal, w ho
had been con
victed b y the Inquisition of Judaism in 1658 and deported, 27 w as subsequentl
y stripped of all the positions he
held in B ahia by a decr ee of 9 M ar ch 16 73, after failing to win the
position of chief sur
geon in 1665. The city
unsuccessfull
y appealed
on behalf of the doctor
, pointing out his
‘wide e xperience and kno w ledg e and charity with w hich he tr
eated rich and poor
, to w hom w e find he ga ve man
y alms, and because he is an indi
vidual w hose ag e made it easier f or w omen in their modesty to tell him of their ailments’; furthermor e,
without him, the population of the city
w
as left in the hands of tw
o local doctors, ‘both
young ( and fr esh ) out of school’ .28 In N ov ember 1694, it w as the r esidents of P ar aí ba w ho w er e
demanding that the local authorities hir
e a doctor
fr
om P
ortugal.29
São P
aulo had been pr
otesting to the Ov
erseas Council about
the lack
of a doctor
and apothecary
since 1638 at least; the local
council s
ugg
ested that as no doctors
w
anted to mo
ve ther
e of their
own accor
d the king should or
der
‘one
w
ho has less impediment
in this court’
to g
o, and the council
w ould pr ovide him with g ood li
ving conditions and a g
ood salary .30 The y r epeated their petition in 1700 31 and again in 17 48 ( in 1753 the
post had still not
been
filled32
), asking the Cr
own to send one of the ‘
doctors
w
ho ar
e
learning at the uni
versity at r oy al e xpense ’.33 S uch a r equest could not b e gr anted, ho w ev er
, because the fate of gr
ant-holding medical students did n ot li e dir ectl y in the Cr own ’s hands. It w as in the conte xt of the Dutch– P ortuguese W ar and the gr
owing numbers of sur
geons in Br
azil that the Cr
own took
the
first steps to r
egulate healthcar
e pr
actice in the colon
y. I
t did so b
y
means of the decr
ee of 28 M ar ch 1634 appointing Fr ancisco V az Cabr al, a doctor tr ained in Coimbr a, as chief ph
ysician and chief
sur
geon of Br
azil. The document specified that the decision had
the ‘
consent of the chief ph
ysician and the chief sur
geon of this King dom ’.34 This mo ve not onl y duplicated the tw
o posts but also
assigned them both to the same person in Br
azil, ther
eb
y de
66
67
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE
L
A
URINDA ABREU
them. Cabr
al, in fact, had put himself f
orw ar d at a time w hen these positions in P ortugal w er e sociall y desir
able and usuall
y a w ar ded as a fa vour to doctors of the r oy al household. H e based his r equest
on the service he had r
ender
ed as chief ph
ysician in India and on
his personal connections to the bishop and g
ov ernor of B ahia, w ho had alr ead y pr
omised him the post of municipal doctor
.
In September
1639 Cabr
al also obtained the ‘post of chief
ph
ysician of the arm
y that is g oing to P ernambuco ’, thus – unusuall y f or P
ortugal – bringing tog
ether
the ci
vilian and military
w
orlds. N
ote that this
w
as not the same as being chief ph
ysician
of the P
ortuguese arm
y as a
w
hole, a post that
w
as the military
equi
valent of the ci
vilian chief ph
ysician of the king
dom. In the
arm
y the titles of chief ph
ysician and chief sur
geon w er e applied not onl y to the officers with o ver all r esponsibility f or health car e in the military spher
e but also to the highest-r
anking ph ysician and sur geon in an y particular location, w hether it w as a hospital, a battalion, a garrison or an y other military entity . Cabr al r
emained in his positions until his death in 1665,
w hen he w as r eplaced b y V entur a da Cruz Arr ais, a doctor w ho had been li ving in B
ahia at least since the pr
evious year . A t that point, Andr é R odrigues Fr anco, the N ew -Christian doctor mentioned pr eviousl y, wr
ote to the king pointing out the unsuitability
of assigning both
positions to the same person and putting himself f
orw ar d to serv e as chief sur geon. In this he w
as counting on the support of
the chief sur
geon of P
ortugal,
w
ho indeed appointed him chief
sur geon of Br azil on 3 D ecember that year
, the appointment being
recor
ded in the chancellery
the f ollo wing M ar ch. 35 The chief ph
ysician of the king
dom, ho w ev er , fa vour ed Cruz Arr
ais, and his
opinion pr ev ailed. Cruz Arr ais pr ov ed to be a contr ov ersial figur e w ho clashed with the B ahia misericór dia , w
hich dismissed him
fr om its hospital in 16 79 36 , the city council, w hich w as r esponsible for the garrison w her e he also w ork
ed, and the g
ov ernor , w ho ev entuall y fir
ed him as both chief ph
ysician and chief sur
geon and appointed M anuel de M atos de V iv eir os in his place. 37 V iv eir os, w ho had alr ead y tak en o ver fr om Cruz Arr ais in the misericór dia
hospital, also became embr
oiled in disputes, both personal,
as in 1687
with his neighbours the Capuchin monks of S
anto
Antônio,38
and pr
of
essional,
with the heads of all the institutions
in w hich he w ork ed. 39 In 1699 , King P edr
o II in Lisbon took
the unusual step of
appointing both a ne w chief sur geon f or the king dom, M anuel de Pina Coutinho, on 23 J une and tw o da ys later a ne w chief ph ysician, Diog o M endes de Leão. 40
The fact that later
the same
year
the Cr
own authorised the chief ph
ysician to nominate commissioners f or Br azil sugg ests that V iv eir os ma y ha ve been
the last doctor
to hold both positions concurr
entl
y in the colon
y,
and that the chief ph
ysician and chief sur
geon of P ortugal w er e themsel
ves taking back
contr ol b y sending r epr esentati ves to Br azil as their subor
dinates, as happened in the P
ortuguese pr
ovinces.
In a
w
ay
, this concluded the r
ef
orm begun in 16
78,
w
hen the king
agr
eed to allo
w
the chief ph
ysician and chief sur
geon to appoint
pr
actitioners to deputise f
or
them outside Lisbon at times
w hen the y claimed the y w er e too busy to carry out the e xaminations
and inspections that their
r egulations r equir ed them to perf orm personall y else w her e in the country . Although the 16 78 decision onl
y concerned the appointment
of deputies b
y the chief ph
ysician, it sugg
ests that the chief sur
geon
had alr
ead
y been gr
anted the same pri
vileg e. 41 Some writers ha ve claimed that Br azi l w as r ecei ving a second w av e of N ew -Christian immigr
ants at that time, due
either to the eff ects of the decr ee of 16 71 pr ev enting doctors r econciled b y the Inquisition fr om pr actising in P ortugal ‘ on pain of death ’, or to the widel y-held
belief that the majority
of P ortuguese healthcar e pr of essionals alr ead y in the colon y w er e N ew Christians. H ow ev er , our sour ces do n
ot confirm this; the case of
Andr é R odrigues Fr anco sho w s that Br azil w
as not such a saf
e ha ven f or N ew Christians as some historians ha ve pr oposed.
What appears certain i
s that, although Br azil w as incr easingl y associated with healthcar e car eers r ecor
ded in Lisbon, until the
end of the 17 th century it w as not the pr ef err ed destination f or such pr of essionals, particularl y doctors. Yet it w
as not just the
vast distance, the difficulties of the
vo
yag
e and the pr
oblems of
adapting to conditions deleterious to ne
w
comers unused to local
diseases that k ept them a w ay fr om South
America. Since the
Cr
own had set up a scholarship scheme in 1568 to tr
ain doctors
and apothecaries at the U
ni versity of Coimbr a, funded b y local councils in P
ortugal, the job mark
et f or healthcar e w ork ers in the motherland had b een gr owing str ongl y. The r elati vel y comple x sy
stem of municipal healthcar
e positions thus cr eated r ev eals an embry onic r edistribution of r esour ces betw
een the councils that
funded
the
tr
ainee doctors and apothecaries and the municipalities
that benefited fr
om their
services. This sy
stem came to absorb a
lar
ge pr
oportion of the scholarship holders, not to mention man
y sur geons as w ell, w ho gained fr om the ne w d ynamics cr eated b y the interpla y of centr al and local g ov ernment inter ests.
The 18
thcentur
y
It w as only in the 1730s that the r
ecor
ds anal
ysed begin to sho
w
an
incr
ease, albeit slight, in the number
of healthcar e pr of essionals going to or li ving in Br azil [Fig ure 2 ] . Rio de Janeir o became the
most common destination
after
the tr
ansf
er
of the capital ther
e
fr
om B
ahia in 17
63. B
y the end of the century
, most licences f or sur geons [Fig ure 6] and apothecaries w er e being a w ar ded to indi viduals born or r
esiding in the city
68
69
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE L A URINDA ABREU T ab le 1 c om pa re s th e n um be r of li ce n ce s is su ed in P or tu ga l a n d B ra zi l t o ap ot h ec ar ie s, s ur ge on s (i n cl ud in g so m e li ce n ce s to ‘tr ea t w it h m ed ic in e’ ) a n d p hy si ci an s (a cc re d it at io n s of m ed ic al d eg re es a w ar d ed b y fo re ig n u n iv er si ti es , c on ve rs io n s of s ur gi ca l qu al ifi ca ti on s or u pg ra d in g of m ed ic al s tu d en ts ), ac co rd in g to ch an ce lle ry r ec or d s. Th e to ta ls fo r B ra zi l i n cl ud e al l r ef er en ce s to d iff er en t i n d iv id ua ls fo un d in th e ar ch iv es c on su lt ed . A s al re ad y po in te d o ut , p ro fe ss io n al s in p ri va te p ra ct ic e ar e on ly e xc ep ti on al ly co un te d h er e, s o it is im po ss ib le to s ay h ow m an y of th e pr ac ti ti on er s in cl ud ed u n d er ‘P or tu ga l’ in T ab le 1 a ct ua lly w or ke d in B ra zi l. A li tt le b ac kg ro un d in fo rm at io n w il l h el p in in te rp re ti n g th es e d at a. F ir st , i n th e m id -1 8 th c en tu ry th e C ro w n s tr en gt h en ed it s co n tr ol ov er p ub li c li fe , i n cl ud in g th es e ar ea s of a ct iv it y. S ec on d ly , a n d m or e ci rc um st an ti al ly , t h e po st s of c h ie f p hy si ci an a n d c h ie f s ur ge on w er e le ft v ac an t f or c on si d er ab le p er io d s, th e fo rm er a ft er it w as su sp en d ed in 1 77 0 a n d th e la tt er b et w ee n 1 72 4 an d 1 73 8 fo llo w in g th e d ea th o f t h e offi ce h ol d er a n d a ga in b et w ee n 1 77 2 an d 1 77 9 af te r th e pu bl ic at io n o f t h e st at ut es o f C oi m br a U n iv er si ty . Th es e st at ut es tr an sf er re d c on tr ol o ve r em pi ri cs to th e un iv er si ty , t h us fo rc in g th e ch ie f s ur ge on to c ea se h is a ct iv it ie s. Th e un iv er si ty , h ow ev er , p ro ve d in ca pa bl e of c ar ry in g ou t t h e ta sk th at th e C ro w n h ad a ss ig n ed to it an d li ce n si n g re m ai n ed a t a s ta n d st il l u n ti l Q ue en M ar ia I r ev iv ed th e po si ti on o f c h ie f s ur ge on to p ut a n e n d to th e ‘d is or d er in w h ic h th e ar t o f s ur ge ry h as b ee n th ro ug h ou t t h is m y K in gd om d ue to th e la ck o f e xa m in at io ns a nd r el ea se o f o ff en de rs w ho w er e im pr is on ed o r th e pu n is h m en t o f o th er s w h o pr oc ee d ed fr ee ly w it h g re at p re ju d ic e to th e pu bl ic c au se a n d in co m pa ra bl e d am ag e to th e h ea lt h o f m y su bj ec ts .’4 2 Th e tw o po st s w er e al so s ub su m ed fo r a ti m e in th e P ro to m ed ic at o B oa rd , f ro m 1 78 24 3. T w o important r
egulation and inspection measur
es w er e the S tatute of that which the commissioner s deleg ate of the Chief Ph ysician of the King dom must observe in the S tate of Br azil , of 17 42–44,44 an d the S tatute of the prices at which the A pothecaries of the S tate of Br azil shall sell medicines .45 As mentioned pr eviousl y, the commissioners’ statute clarified f or Br
azil the scope of the po
w ers de vol ved to the chief ph ysician ’s r epr esentati
ves, using the 1521 statute as
its model, but it f
ocused primari
ly
on apothecaries and their
busin
esses,
with brief notes on the inspection of sur
geons and an y other indi viduals w ho pr actised medicine without authorisation. The statute e xplicitl
y confirmed that the po
w er to a w ar d licences to ‘tr eat with medicine ’ w as the chief ph ysician
’s alone; the same
applied (
although the inf
ormation is omitted
) to his most important
function: that of accr
editing medical studies undertak
en at
for
eign uni
versities.
The s
tatute setting the prices of medicines sought to r
egulate
a r
apidl
y gr
owing mark
et and the number
of apothecaries
suppl
ying the colon
y’
s people, hospitals, ships, garrisons, ports,
theatr es of w ar and e xplor atory e xpeditions. Among them w er e man y gr eed y apothecaries w
hose prices put medicines out of
reach of the poor
, as the councils of
V
ila do Carmo and
V
ila Rica
complained both bef
or e and after the ne w statutes, 46 as did the councils of M ariana and S ão João del-R ei 47 an d e ven Gomes Fr eir e de Andr ade, the g ov ernor of Rio de Janeir
o and Minas Ger
ais. 48 Ther e w er e g ood gr ounds f or such widespr ead condemnation, as sho wn b y the letter
that the apothecary
of N ov a Colônia, João P edr o Fr eir e, sent in 1739 r eiter
ating a long-standing desir
e to sell
medicines at doub
le the price set i
n the statute
so that he could
pass on his business losses and other
costs to his customers.
49
The tw
o statutes on the price of medicines and on the chief
ph
ysician
’s commissioners br
ought up to date decisions made
by the Cr own in 1627 and 16 78, r especti vel y, and adapted them to Br azilian cir cumstances.
Although the delegation of
po
w
ers to Br
azil had been in f
or
ce since the end of the pr
evious century , these statutes dr afted specificall y f or the colon y gr eatl y str
engthened the chief ph
ysician ’s authority and aff or ded him ne w mechanisms of contr ol. The 17 42–44 statute pr esented the commissioners f or doctors and visiting e xaminers f or apothecaries as a k
ind of public service that
w
ould appl
y to e
ven the most
competent pr
of
essionals but, although the
y attr acted complaints fr om the indi viduals the y inspected, these tw o offices w er e in fact highl y pr ofitable, especiall y that of visiting e xaminers, w hich w er e
often in the hands of po
w
erful mer
chant apothecaries to the r
oy al household. This sy stem persisted without major chang e until the Pr otomedicato w as f ounded, w hich usher ed in mor e comple x local ins pection bodies; f or e
xample, the first appointments of scri
veners
to the commissioners of the medicine and pharmac
y department in B ahia and P ernambuco w er e r ecor ded in F ebruary 1784. 50 Fig ure 2
Licences to practise healthcare pro
fessions in Bra zil (1 700– 1808) Sour ce: M edical Pr of essions D atabase, 1430– 1826 Ph ysicians Surg eons Apothecaries 17 01– 1710 171 1– 1720 1721– 1730 1731– 1740 1741– 1750 1751– 17 60 1751– 1750 17 71– 17 80 17 81– 17 90 17 91– 1800 1801– 1808 400 350 300 250 200 150 100 50 0 450
7
0
71
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE
L
A
URINDA ABREU
A
glance at the figur
es in T able 1 sho w s that the tr ends in the numbers of licences r elating to Br azil g ener all y tr ack ed those of
the motherland, despite the ob
vious diff
er
ences in scale. This is
particularl y clear in the decade 1770–80 , w hen ther e w as no chief ph ysician to validate the e
xaminations of apothecaries, and also in
17
40–50
, w
hen the number
of sur geons’ licences r ose o wing to the inclusion of e xaminations perf
ormed during the absence of a chief
sur
geon; these numbers again r
ose significantl y in the earl y years of the Pr otomedicato .
The most discr
epant tr
end
w
as in the numbers of sur
geons
ar
ound the turn of the century
(especiall y after 1799 ), r eflecting the pr omotion of the Pr otomedicato to the status of a r oy al
tribunal, as discussed belo
w . This tribunal w as mor e acti ve in Br azil than in P ortugal, w her e it faced opposition fr om other authorities with po w
ers in the field of medicine. One r
eason f or this opposition, w hich w as also echoed in Br
azil, can be seen in
the numbers of licences to ‘tr
eat with medicine ’, a categ ory of healthcar e pr of essionals in w hich ther e w as less of a diff er ence betw een P
ortugal and the colon
y.
Although the number
of licences issued and the number
of acti ve pr of essionals ar e not mutuall y dependent quantities, the data deri ved fr
om the documents consulted sho
w
closel
y
corr
elated tr
ends, as mentioned abo
ve. Thr
oughout the first half
of the 18 th century , ther e w er e very f ew
doctors and sur
geons in Br azil, e xcept, compar ati vel y speaking, in B
ahia and Rio de
Janeir o – in 1753 the arm y based in Rio de Janeir o had at least fi ve sur geons and tw o ph ysicians. 51 Else w her e ther e ar e r ecor ds of sur geons (
including postings, first appointments and r
ene w als ) onl y f or S antos ( 1702 ), N ov a Colônia ( four in 1718 ), R ecif e ( 1724 ), São L uís ( 1727 , plus a pr oposal to send a ph ysician ther e), P ar á and Itamar acá garrison ( 1733), tr oops fr
om the Minas Ger
ais garrison
(1733), Cuiabá (
1735, on the death of the incumbent
), Belém (
1738
),
the garrison
on S
anta Catarina island (
1739–40 ), an d P ar aí ba ( 1739 , ph
ysician and sur
geon ).52 Ther e w as also a r equest f or a ph ysician for the Captainc y of P ernambuco ( 1703) and f or sur geons f or the fort of T amandar é ( 1732
) and the garrisons of M
orr
o de S
ão P
aulo
(w
hich had 170 men in 17
40 ) and Rio Gr ande de S ão P edr o ( 1739 ).53 The mi
ddle of the century
sa w a significant chang e, lar gel y due to the cr eation of ne w
municipalities and, in particular
, the
expeditionary
f
or
ces sent to demar
cate the country’
s bor ders. After the Tr eaty of M adrid ( 1750 ) and subsequent tr eaties, sur geons with their
field medicine chests accompanied the tr
oops
at all times, assisting engineers an
d mathematicians or
, in their
absence, carrying out meas
ur
ements and making maps themsel
ves
in addition to tr
eating the men – ‘I ha
ve them mak
e some
measur
ements and maps of those countries and (perf
orm ) the other ex er cises of their pr of ession ’.54 These e xpeditionary f or ces, tog ether with ne w infantry
regiments such as those of P
ar
á and the F
ort of M
acapá,
55
expanded the number
of openings f or chief sur geons and a f ew chief ph ysicians w ho alr ead y had some pr of essional e xperience. That w
as the case of the ph
ysician P ascoal Pir es de Castr o, w hose car eer had begun as a volunteer at the F ort of M azagão in north-w est
Africa; that helped him gain a position at
T odos os S antos H ospital in Lisbon in 1752, fr om w her e he mo ved to the fr ontier as chief ph ysician f or the ne w ly r enamed S tate of Gr ão-P ar á and M ar anhão, to w hich he w as appointed on 1 J une 1753. 56 Other chief ph ysicians w er e to be f ound in Goiás, P ernambuco, M ariana prison, S ão L uís Military H ospital, P ar á, S ão P aulo, S anta Catarina island, B ahia and V
ila Rica, among other
places. M
or
e
than the arm
y itself, it
w
as military
hospitals that doctors f
ound most attr acti ve, especiall y the R oy al H ospital in Rio de Janeir o, w her e the criterion f or
hiring often seems to ha
ve been clientelism
rather
than the candidate
’s o wn merits. José Soar es de O li veir a
complained of this at the
very
end of the century: although he had
w
on first place in the competiti
ve e xamination f or a post ther e, he w as passed o ver in fa vour of João António D amasceno, a pr otég é of the vicer oy of Br azil. 57 Another pr ospecti ve chief ph ysician at that hospital w as José Pinto de Azer edo, w ho alr ead
y had the post
of chief ph
ysician of
Ang
ola to his name.
58 After 1750 , the Ar qui vo Histórico Ultr amarino contains hundr eds of r equests f or
the appointment of sur
geons and
for
letters patent f
or
the positions of chief sur
geon and chief
ph ysician. As with pr of essional e xaminations, appointments to these positions – gener all y pr oposed b y vicer oy s, g ov ernors or captains-g ener
al of the captaincies – onl
y became eff ecti ve once the y w er e r egister
ed in the chancelleries. The documents sho
w
Table 1 Healthcare practice in Bra
zil and P or tug al (1 700– 1808) Sour ce: M edical Pr of essions D atabase, 1430– 1826 Apothecaries Surg eons Ph ysicians Bra zil P or tug al Bra zil P or tug al Bra zil P or tug al Dates Licences Total refs Licences Licences Total refs Licences Licences Total refs Licences 1701 –1 0 4 9 133 6 23 439 1 24 11 1711 –20 8 16 183 16 40 518 29 3 1721 –30 5 6 320 5 61 264 11 7 1731 –40 9 20 386 4 90 496 39 12 17 41 –50 11 41 408 56 136 961 41 18 1751 –60 15 22 423 41 134 906 1 33 21 17 61 –70 26 36 553 67 115 947 17 16 1771 –80 9 103 143 731 25 1 1781 –90 67 94 57 4 135 252 802 4 29 27 1791 –1800 42 57 335 88 261 765 2 41 9 1801 –08 41 81 372 101 401 404 2 80 5 T otal 228 391 3687 622 1656 7233 10 369 130
72
73
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE L A URINDA ABREU to aff or d their salaries. When in 1734 the w ar der of the prison in V
ila Rica accused the local council of being the onl
y one that
did not hir
e sur geons or ph ysicians f or the ‘ good r egimen of the public g ood and r emed y of the poor’ , he pr obabl y kne w that that w
as not true. His aim
w as to f or ce the council to pr ovide medical car e f or his prisoners, w hich it finall y did later that year 66 . Other municipal healthcar
e posts in the first half of the 18
th century ha ve been identified in P ar á captainc y ( 1727 ), V ila Rica ( 1730 ), S ão L uís (1734 ), O linda ( 1704 ), P ar aí ba ( 17 46 ), Belém ( 1735), Arr
aial das Minas
de P ar acatu ( 17 46 ), V ila do Carmo ( 1736 )67 and V ila da Cachoeir a in B ahia ( 1735). Other localities, such as V ila de S ão Fr ancisco de Ser gipe do Conde ( 1712 ), Goian a ( 1736 ), S antos ( 1736 ),68 Ar acati (1755) and V ila N ov a da Rainha ( 1756 ) (Fr anco, 2011: 222 ), w er e making eff
orts to set up such posts (
Santa Catarina island, 17
49 ) or r estor e them ( O linda, 17 45) and w er e attempting to con vince the g ov
ernment in Lisbon that the
y had the means to pa
y f
or
them;
the g
ov
ernors of the colon
y often interv ened on their behalf, as happened in S antos, P ar aí ba, M ato Gr osso, S ão L uís, Piauí, P ar anaguá and I gar açu. N onetheless, e
ven if all the posts that the local councils
w
anted to set up had been authorised,
w
hich
w
as not the case,
and all e
xisting positions had been r
egularl y r ene w ed – the abo ve-mentioned case of O linda pr ov
es the opposite to be true – the
ov
er
all number
of ph
ysicians and sur
geons hir ed b y the councils w ould still ha ve been very small f or
the size and population of
Br azil. Although ther e w as still a demand f or medical doctors – ph ysicians’ posts w er e r equested f or S ão João del-R ei, Laguna and D esterr o in the 17 60s; 69 B ahia in 1772; 70 M ariana in 1797 (hir ed in 1799 );71 Belém ( tw o posts );72 V ila Rica in 1799; 73 and S abar á in the f ollo wing decade 74 – after the 17
60s the councils sho
w ed a pr ef er ence f or sur geons. Contr acts f or sur geons ( first appointments and r ene w als ) ha ve been f ound f or V ila Bela, V ila de S ão José das Minas, P ar anaguá and S ão L uís. 75 The to wns of S ão João del-R ei and V ila Rica ha ve a w ell-documented history in this r espect. When the f ormer wished to hir e a ph ysician in 17 64, the ou vidor (magistr ate ) hastened to assur e the C ro
wn that the municipality
had sufficient income
to pa y his salary .76 Six y ears later , ho w ev er , the doctor had to petition the Cr
own to help him r
eco
ver
all his back
pa
y. In
June
177
4 the council itself applied to abolish the post of ph
ysician
on the gr
ounds of financial constr
aints.
77
V
ila Rica had alr
ead
y
done the same in 1770
, k eeping onl y tw o sur geons, 78 thus putting an end to a series of r ecipr
ocal accusations about unpaid salary
and poor perf ormance.79 In 1787 the counci l of V ila do S abar á ask ed to r eplace its ph ysician with a sur
geon and an apothecary
,80 although subsequentl y it tried to g et another doctor’ s post appr ov ed. Cases such as that of V
ila da Campanha da Princesa,
w
hich in 1802
that se
ver
al
years could elapse betw
een a name being pr
oposed
in Br
azil and confirmed in Lisbon. That might of course be
due mer
el
y to the inefficienc
y of the Ov
erseas Council and the
difficulties of long-distance communications, as
w as the case with so man y other petitions r elating to services r ender ed to the Cr own 59 , but ther e ar
e also signs that the g
ov
ernment emplo
yed
dela
ying tactics so as to postpone ha
ving to pa y the corr esponding salaries. That w as the e xperience of Joaquim José Fr eir e da Sil va, the first doctor appointed f or
the garrison and tr
oops of S ão P aulo captainc y. H aving r
equested his letters patent in 1770
, he
w
as
still being ask
ed in 177
4 to suppl
y the name of his pr
edecessor .60 For man y appointees, ho w ev er
, it appears that the fact of ha
ving
applied to the Cr
own f
or
their
letters patent acted as a kind of
pr
e-confirmation of their
position.
This is not the place to e
xplor
e connections betw
een these
issues and the sequence of military
, economic and administr
ati ve ev ents, but tw o separ ate tr ends in vol
ving chief sur
geons deserv e mention. The first is a w av e of appointments up until 1780 , closel y link ed to g old pr ospecting in the ne w captainc y of M ato Gr osso and the e xpeditions r ef err ed to abo ve, f or
Cuiabá, Pitangui and
the captainc y of Espírito S anto, Goiás, P ar á, R ecif e, Rio Gr ande do N orte, Oeir
as do Piauí, Minas and
V
ila Rica. The second
occurr
ed after
1800 and in
vol
ved assistants to chief sur
geons appl ying f or their superiors’ posts, her
alding the imminent end
of the latter’ s pr of essional car eers. Another note w orth y f eatur e of the time w as the number of pr of essionals appl ying to r etir
e ‘with chief sur
geon ’s honours’ . This w as a w ay of asking f or
some sort of financial compensation f
or
a
pr
omotion that had ne
ver been f orthcoming, as ma y be gather ed fr om the letters written b y António H enriques de Almeida 61 and M anuel P er eir a P acheco. 62
The distribution of these men g
ener all y matched the r outes f ollo w ed b y the P ortuguese in occup ying the colon y: primaril y do wn the A tlantic seaboar d 63 fr om the north-w est to the south, f ollo
wing the ‘main spatial d
ynamics of the e volution of the sy stem of g ov ernment’ 64 [Fig ures 3 and 4 ]. A ccor ding to D auril Alden 65, the 19 th century began with 62% of the P
ortuguese population concentr
ated in the captaincies of
P
ernambuco, B
ahia and Rio de
Janeir o, and 19 .7% in Minas Ger ais. That is also w her
e most of the sur
geons, doctors and apothecaries
mentioned in the centr
al ar chi ves w er e to be f ound.
Municipal posts for doctors and
surg
eons – few jobs and few prospects
In P
ortugal and its empir
e it
w
as up to the local councils to hir
e healthcar e pr of essionals, w
hich implied that the
74
75
0 500 1000 KM Bra zil ( Treat y o f Madrid, 1 750) Main Riv er R outes Main Ov erland R outes Ph ysicians Apothecaries Surg eons Others THE INSTITUTIONAL ISATION OF MEDICAL KNOWL
EDGE L A URINDA ABREU hir ed a doctor , a sur
geon and an apothecary
81 – the standar d trio of healthcar e pr of essionals hir ed b y municipalities in P ortugal – seem to ha ve been r ar e in Br azil. Our
documentation in fact sho
w s that f ew apothecaries w er e hir ed f or municipal partidos , although
it cannot be ruled out that that
w
as due to personal choice, since
pri vate pr actice w as mor e pr ofitable. 82 Santos council pr
ovides one of the best-documented e
xamples
of the difficulties that local authorities faced in establishing and maintaining medical posts.
A
t the beginning of the 18
th century it w as serv ed b y a single military chief sur geon, w ho tr eated soldiers, the r eligious community and the g ener al public, but b y 1721 he w as no long er w orking ther e. 83 Ther e w
as still no medical car
e in Santos or its surr oundings in 1732, e xcept f or the car e pr ovided in the hospital b y ‘poorl y pr epar ed sur geons’
, as the council claimed.
Since the onl
y income a
vailable to the council – the ‘
d rinks subsidies’ – h ad b ee n ta ke n b y th e ro ya l e xc h eq u er to p ay f o r D o n a C at ar in a d e B ra ga n ça ’s d ow ry , t h e co u n ci l b eg ge d th e C ro w n to h el p it p ay f o r o n e d o ct o r; 84 f o ll ow in g Sã o P au lo ’s le ad , i t s u gg es te d th at it c o u ld b e se n t o n e o f th e d o ct o rs w h o w er e st u d yi n g at C o im br a ‘w it h th e o bl ig at io n to g o w h er ev er th ey w er e n ee d ed ’.8 5 In 1 73 3 th e co u n ci l w as a u th o ri se d to e st ab li sh a p o si ti o n f o r a p hy si ci an o n co n d it io n th at it w as f o r th e in fa n tr y re gi m en t – in o th er w o rd s th e doctor w ould be shar ed b
y the soldiers and the ci
vilian population
– but it
w
as onl
y in 1739 that the council manag
ed to find someone to fill the post.86 J osé Bonifácio de Andr ade, a Coimbr a gr aduate w
ho had been born in Br
azil, demanded double the salary
set b y the Cr own and thr eatened to lea ve w hen King João V or der ed the
council to annul the agr
eement it had made
with him. 87 H e not onl y w
on this battle, but also boosted his income
with the salary
of garrison doctor and visitor of ships.88 Fig ure 4 Distribution o f healthcare pro fessionals in Bra zil, 1751– 1808 Sour ce: M edical Pr of essions D atabase, 1 430–1826 Fig ure 3 Distribution o f healthcare pro fessionals in Bra zil, 1549– 1750 Sour ce: M edical Pr of essions D atabase, 1 430–1826 0 500 1000 KM Bra zil ( Treat y o f Madrid, 1 750) Main Riv er R outes Main Ov erland R outes Ph ysicians Apothecaries Surg eons Others 85 207 57 10 85 207 57 10
7
6
7
7
THE INSTITUTIONAL ISATION OF MEDICAL KNOWL
EDGE L A URINDA ABREU M u n ic ip al h ea lt h car e posts in Br azil seem to ha ve been highl y inconstant, unlik e the people ’s concerns, w hich continued to bombar d the Ov erseas Council. A dmittedl y, se ver al to wns w er e
still able to use the services of certain hospitals, sometimes e
ven
br
eaching r
egulations to do so, as in the case of the R
oy al Military H ospital in Goiás 89 . Th is a ss is ta n ce s h ou ld n ot b e ov er es ti m at ed , h ow ev er , b ec au se m os t m il it ar y h os pi ta ls w er e sm al l a n d o ft en te m po ra ry fa ci li ti es ; t h e on e in G oi ás h ad o n ly n in e be d s in th e la te 17 40 s, fo r ex am pl e. L ar ge r h os pi ta ls h ad 2 0 –3 0 b ed s, a s in R io d e Ja n ei ro in 1 75 2 an d P er n am bu co in 1 72 4, r es pe ct iv el y. I n th e R io d e Ja n ei ro h os pi ta l i n th e m id -1 8 th c en tu ry a n d in th e V il a R ic a h os pi ta l, fo un d ed in 1 77 1, th e d oc to r an d s ur ge on o n ly p ut in a n a pp ea ra n ce in th e d ir es t c ir cu m st an ce s. H ow m uc h th e h os pi ta ls in P ar á (u n d er c on st ru ct io n in 1 75 4) , C ac h oe ir a (1 75 7) a n d P ar aí ba (1 76 5) co n tr ib ut ed to h ea lt h c ar e in th e co lo ny is n ot k n ow n b ut , a s R en at o F ra n co 90 h as p oi n te d o ut , t h ey w er e n ot ju st fe w a n d fa r be tw ee n b ut th ey w er e al so p oo r, n ot u n li ke h os pi ta ls in P or tu ga l i ts el f. Br azil’ s adoption of the P ortuguese sy
stem of hiring healthcar
e
pr
of
essionals r
aised the hopes of ph
ysicians and sur
geons,
but the
y
w
er
e soon dashed. The idea of a stable centr
al or
local
go
vernment position seldom materialised. These difficulties seem
to ha
ve aff
ected ph
ysicians mor
e than sur
geons, and not just in
terms of their car eer pr ospects. Just ho w little value w as placed on ph ysicians is r ev ealed in corr espondence fr om 17 48–4 9 betw een the commissioner and the pr ovedor of the r oy al e xchequer in Rio de Janeir o on the r ele
vance of building a military
hospital in the city
. A m on g th e co st -c ut ti n g m ea su re s pr op os ed w as th e su gg es ti on th at ph ys ic ia n s sh ou ld o n ly b e h ir ed fo r oc ca si on al w or k, s in ce ‘t h er e w il l be n o la ck o f d oc to rs w h o w il l a gr ee in e xc h an ge fo r m ea gr e pa y’ .91 The fier ce competition f or
these positions is a clear
sign that very f ew jobs w er e a
vailable, and this is back
ed up b
y the fact that
man y people w ork ed f or fr ee w hile the y w aited f or the incumbent in th e co ve te d p os it io n to le av e or d ie . W h il e th is o ft en h ap p en ed in P or tu ga l a s w el l, a fe at ur e th at a p p ea rs to b e sp ec ifi c to B ra zi l w as fo r p ro fe ss io n al s to a cc ep t a m un ic ip al h ea lt h ca re p os t o n c on d it io n th at th ey ‘d id n ot r eq ue st p ay m en t w it h ou t H is M aj es ty ’s a p p ro va l’. Th e se rg ea n t-m aj or M an ue l F er ra z d e A br eu a gr ee d to th is w h en h e to ok th e p os t o f su rg eo n o f V il a d o C ar m o on 2 9 D ec em be r 17 36 . W h en h e as ke d fo r h is s al ar y ar re ar s to b e p ai d , h e w as r em in d ed in M ay 1 74 1 of th e te rm s of h is c on tr ac t: w it h ou t r oy al a p p ro va l t h er e co ul d b e n o p ay m en t, an d th e ap p ro va l w as d el ay ed .92 S uc h is su es n ee d to b e bo rn e in m in d w h en a n al ys in g so m e of th e ba tt le s w ag ed by p hy si ci an s ag ai n st s ur ge on s, b lo od le tt er s an d o th er p ot en ti al ri va ls , a s h ap p en ed in R io d e Ja n ei ro in 1 75 3. 93 Th at is n ot to s ay th at p hy si ci an s th ou gh t scientific and pr of essional matters w er e
unimportant, but the
y
w
er
e not the onl
y issues that ar oused their ir e against their competitors. A g ood e
xample is the fight the
y put
up in Rio de
Janeir
o in 1789 against a German colleague,
Joseph
Struks, because he had begun to pr
actise medicine almost as soon
as he had arri
ved in the city
with a vie w to settling ther e. 94 Y et just four y ears pr eviousl y the city
council had been complaining of the
lack
of doctors. Although sur
geons w er e being hir ed f or council partido s in e ver gr eater
numbers and the
y w er e also being gr anted mor e po w ers, the y had their difficulties as w ell. That w
as not just because the
y too
faced competition – as sho
wn b
y the appeal made in 1787 b
y the go vernor of S al vador , R odrig o M
enezes, on behalf of lando
wners and sugar mill pr oprietors to allo w unlicensed indi viduals to pr actise as if the y w er e licensed 95 – b
ut also because some of
them e ven had to pa y to w ork, co vering their patients’ e xpenses and w aiting to be r eimbursed b y their emplo yers, as appar entl y happened in the Military H
ospital of Minas and the municipal
sur geon ’s post in V ila Rica in 17 60 and 1777 .96 The combin ation of b eing o verw ork ed and underpaid, or
often not paid at all, is r
epeatedl
y mentioned and seems to ha
ve pr ompted man y healthcar e pr of essionals to mo ve on in sear ch of better w orking conditions. S alaries in arr ears ar e one of the
most common topics documented in the ar
chi ves. In certain cir cumstances the Cr own might be r esponsible f or pa ying part of the salary , particularl
y in the case of military
pr of essionals w ho additionall y car ed f or local ci
vilians, but usuall
y, as mentioned
abo
ve, salaries
w
er
e paid out of municipal r
ev enues or , w her e these w er e insufficient or non-e xistent, fr om fintas , e xtr aor dinary tax
es imposed on the poor
est sections of the population,
w ho w er e pr ecisel y the ones w
ho could not aff
or d pri vate doctors. While the e xact terms on w
hich these contributions
w er e dis tributed ar e not kno wn, ther e w as a mo ve in the late 18 th century to seek alternati
ve solutions, such as the ‘liter
ary
subsid
y’
– a tax
on
wine, spirits and
vinegar intr oduced b y the M ar quis of P ombal to fund the r ef
orm of public education, although in 1803 mer
chants
in S
antos complained that it placed an ‘unfair’
bur den on tr aders. 97 A diff er ent solution w as f ound f or P ar aí ba.
When the city
council
pr
otested about the
fintas
, the Cr
own sent a letter
on 2 J
une 1799
or
dering the doctor’
s salary to be cut fr om 200 ,000 to 150 ,000 réis, with 1 00 ,000 r éis coming fr om the council’
s assets and the
other 50 ,000 fr om the r oy al e xchequer . E
ven though his salary
had been cut, the
doctor’
s duties
still included caring f
or the city’ s infantry garrison. 98 R egar dless of ho w their salaries w er e made up, ph ysicians, some apothecaries 99 and sur
geons all suff
er
ed fr
om non-pa
yment.
Local councils, hospitals, the arm
y and ships – in r
elation to
shi
ps’
sur
geons, posts that the sur
geons of B ahia, supported b y the city’ s commissioner ph
ysician, tried to mak
e compulsory in 1750100 – often r an up arr ears, sometimes o ver se ver al years. Ther e w er
e constant complaints about non-pa
yment during the period
in question, incr easing significantl y after 17 60 . Br each of contr act
78
79
THE INSTITUTIONAL
ISA
TION OF MEDICAL KNOWL
EDGE L A URINDA ABREU by the emplo yer occurr ed as much in lar ge cities lik e B ahia or Rio de Janeir o as in smaller to wns and aff ected both ci vilian and military healthcar
e personnel. The latter
w
er
e also paid diff
er entl y depending on w her e the y pr actised: sur geons in Colônia do Sacr
amento earned less than those in the ‘T
er ços do Br asil’ (1722 ); infantry sur geons in R ecif
e less than those in B
ahia ( 1724 ); P ar á pr
actitioners less than those in M
ar
anhão (
1733); and the ones in
P
ar
aí
ba less than those in O
linda and R ecif e ( in 17 40 and 1798 ).101 The first pr otests that ha ve come to light w er e in fact fr om military sur
geons, and the
y also had the long
est periods in arr
ears.
In 1726, f
or
e
xample, Cosme Gomes P
er eir a complained that he had ne ver r ecei ved an y salary in the 30 years he had w ork ed as a sur geon in F ortaleza do Cear á. 102 A
t the close of the century
,
regimental chief sur
geons and their
assistants w er e also to lose their ‘br ead pa y’ ( vencimento do pão ), a salary
bonus that the
y had appar entl y been r ecei ving undul y; b y r oy al or der of 13 J anuary 1799 it once mor e became pa yable onl y ‘ during a campaign or mar ch of the r egiment’ .103 W h il e it w as c om m on p ra ct ic e in a n ci en r égi m e P or tu ga l f or p eo pl e to p et it io n th e C ro w n to b ec om e a m em be r of a m il it ar y or d er o r an ac ti n g pu bl ic o ffi ci al , a n d a lt h ou gh it is n ot a lw ay s po ss ib le to li n k su ch r eq ue st s d ir ec tl y w it h th e d eb ts o f h ea lt h ca re p ro fe ss io n al s, th e fa ct is th at s om e d oc um en ts e xp li ci tl y m ak e th is a ss oc ia ti on a n d m or e su ch e n tr ea ti es w er e in d ee d m ad e by d oc to rs a n d s ur ge on s in B ra zi l t h an in o th er p ar ts o f t h e em pi re o r ev en P or tu ga l i ts el f. M or e th an a s co re o f r ef er en ce s to h ab it s of th e m il it ar y or d er s of C h ri st , aw ar d ed e sp ec ia lly to p hy si ci an s, a n d S an ti ag o, m os tl y to s ur ge on s, h av e be en fo un d , b eg in n in g w it h th e ch ie f s ur ge on s of C ol ôn ia d e Sa cr am en to a t t h e tu rn o f t h e 18 th c en tu ry . In addition to land gr
ants, made to military
chief sur geons especiall y fr om the latter half of the 18 th century on w ar ds, r oy al fa
vours of making an applicant an acting public official or
e
ven an
actual office holder
– almost al w ay s as a scri vener – became mor e
common in the earl
y 19 th century , either alone or in combination w it h m em be rs h ip o f a m il it ar y or d er . S om e of t h e ex am p le s fo u n d w er e sc ri ve n er s at ta ch ed t o th e co u rt t h at a d m in is te re d m is si n g p er so n s’ p ro p er ty in t h e d is tr ic t of V il a d o P rí n ci p e, t h e bo ar d o f m ag is tra te s an d e cc le si as ti ca l c ou n ci l o f th e bi sh op ri c of M in as G era is , t h e co u rt o f li ti ga ti on a n d p ro ba te o f th e bi sh op ri c of R io d e Ja n ei ro , t h e ch am be r of o rp h an s of th e to w n o f Sa n to A m ar o,
and the court of appeal of Rio de
Janeir o.
Final con
siderations on
an expanding field o
f study
The pr ecise number of officiall y r ecognised ph ysicians, sur geonsand apothecaries that
w ork ed in Br azil bef or e 1808 is unlik el y e ver to be kno wn. Ther e ar e se ver al r easons f or
this, most notabl
y the vicissitudes as sociated with the r egistr ation of licences to pr actice
and appointments to centr
al or
local g
ov
ernment posts. The fact
that uni
versity
degr
ees did not need to be r
ecor
ded in a chancellery
means that medical gr
aduates ar e e ven mor e poorl y r epr esented in the documents. In addition, it is almost impossible to tr ace all those w ho w ent to Br azil and pr actised ther e pri vatel y in the to wns or on sugar plantations; on ly local histories w ould be able to r ev eal w ho these virtuall y anon ymous people w er e. The absence of r ef er ences to the w ell-kno wn sur geons L uís Gomes F err eir a and José António M endes104 gi
ves an idea of the gaps in the sour
ces consulted her
e. W h at th e d oc um en ts d o re ve al u n eq ui vo ca lly is th e pr ed om in an ce of s ur ge on s, w h ic h in it se lf is n ot h in g n ew e it h er in B ra zi l o r an yw h er e in E ur op e in th e ea rl y-m od er n p er io d . Th e d iff er en ce li es pa rt ly in th ei r h ug el y d is pr op or ti on at e n um be rs , b ut th er e is a n ot h er fa ct or . A ft er 1 78 2, d ur in g th e ti m e of th e P ro to m ed ic at o, s ur ge on s sp re ad to a re as w h er e th ey h ad n ot b ee n fo un d b ef or e, e sp ec ia lly al on g th e n or th a n d n or th -e as t c oa st s. [F ig u re s 5 a n d 6 ] Th e ac tu al n um be r of m ed ic al g ra d ua te s p ro d uc ed b y C oi m br a U n iv er si ty b ef or e 18 0 0 is n ot y et k n ow n fo r ce rt ai n , b ut th e av ai la bl e d at a su gg es t t h at it w as le ss th an te n p er y ea r fo r lo n g p er io d s in th e 16 th–1 8 th c en tu ri es . O n go in g re se ar ch h as s o fa r fo un d th at b et w ee n 14 95 a n d 1 80 1 th e ch ie f p hy si ci an r ec og n is ed 6 59 p hy si ci an s tr ai n ed in fo re ig n u n iv er si ti es , e sp ec ia lly S al am an ca . Th e n um be r of s ur ge on s is k n ow n w it h m or e ce rt ai n ty : 1 2, 17 7 w er e aw ar d ed qu al ifi ca ti on s by th e ch ie f su rg eo n o r, in e xc ep ti on al c ir cu m st an ce s, th e ch ie f p hy si ci an b et w ee n 1 49 5 an d 1 82 6. S ur ge on s w er e p re fe rr ed by th e p eo p le , g iv en th at th ey w er e so ci al ly c lo se r to th ei r p at ie n ts , ch ar ge d lo w er fe es a n d o ft en p ro vi d ed th e sa m e ki n d o f se rv ic e as p hy si ci an s. A s th e su rg eo n J os é d a Si lv a Fe rn an d es a ss er te d in L is bo n in 1 72 9, ‘i t i s a fa ct th at p eo p le a re in th e h ab it o f ca ll in g fo r a su rg eo n r at h er th an fo r a d oc to r.’ 10 5 D ecades later in P aris, the ph ysician António Ribeir o S anches made
the same kind of r
emark,
w
hich Pina M
anique, the
intendant-gener
al of police,
w
as to r
epeat at the end of the century
w
hen
he decided to in
vest in tr
aining and specialisations f
or
sur
geons.
It should not be f
or
gotten that at the time ther
e w as a gr owing demand f or ph ysicians in P ortugal f or both official partidos and pri vate pr
actice, including positions left
vacant after the various pur ges of N ew Christians. I t is unlik el y, ho w ev er , that people in P ortugal w er e a w ar
e of the difficulties that doctors had to cope
with in Br azil. E ven those ( fe w ) nati ve-born Br
