The Brazilian Challenge

    The Brazilian Challenge

    By Brazzil Magazine

    When in 1865 in Salvador da Bahia some fourteen doctors started meeting regularly to
    discuss their local cases and original research, they initiated one of the few significant
    episodes of successful science in nineteenth-century Brazil and, indeed, in Latin America.
    The men met every two weeks at each others’ houses and, after a long day’s work, talked
    late into the night about unusual cases they had come across, medical articles that had
    caught their attention, the advances of parasitology and microscopy, and how it could all
    be applied to Brazil. They dreamed of producing original research that would "clarify
    and develop the study of Brazilian medicine."

    This seemingly innocuous intention jolted the Brazilian medical establishment in which
    medical ideas and practice were marked by conformity and replication of Western European
    medicine, particularly French. The group, known retrospectively as the Escola Tropicalista
    Baiana, proposed to develop a distinctive medicine of the tropics that although attuned to
    the newest European advances, adapted those advances to the particular concerns of Brazil,
    especially the Northeast.

    The regional specification was important because from its very inception the school
    challenged Rio de Janeiro’s medical hegemony. One of the group’s early problems was that,
    having no official framework within Salvador from which to operate, they had to carve out
    their own institutional base. They did this by using the main charity hospital as their
    "teaching" base, creating an influential medical journal, and, following the
    lead of three foreign founders with little insertion in the established patronage network,
    they struck out in new and original ways.

    The Evolution of a Medical Community in Salvador

    From its inception, medical education in Brazil was characterized by its adherence to
    French medical models, centralization, and the importance of patronage connections for
    advancement. Medical teaching in Brazil began in 1808 when the Portuguese Crown, fleeing
    Napoleon I, moved from Lisbon to Brazil. The arrival of King João VI in Brazil in 1808,
    accompanied by some fifteen thousand persons, under the protection of a squadron from the
    English fleet, inaugurated a period of fundamental change in Brazilian history. During his
    stay in Brazil, King João VI ushered in a number of momentous economic and social reforms
    as part of his attempt to upgrade the status of Brazil from peripheral colony to center of
    the Brazilian Empire. For example, all Brazilian ports were opened to foreign trade, thus
    undoing almost three centuries of mercantilist policy; prohibitions on manufacturing
    enterprises in Brazil were revoked; a Royal Committee of Commerce, Agriculture, Factories,
    and Navigation was appointed to encourage the expansion of these activities in Brazil; and
    the Bank of Brazil was established in Rio de Janeiro with branches in São Paulo and

    Equally important were the cultural changes introduced largely because the king
    recognized that, given the uncertainty of the outcome of events in Europe, the ruling
    elite would have to be trained on Brazilian soil rather than on Portuguese, as had been
    the custom. Thus printing presses became legal for the first time in Brazil and papers
    such as the Gazeta do Rio de Janeiro (1808) and the Idade d’Ouro do Brasil (1811)
    commenced publication. The first public library was established in 1810 in Rio de Janeiro
    with sixty thousand volumes. Realizing it needed to produce locally trained military and
    naval officers, engineers, and other experts, the government created a Naval Academy in
    1808 and a Royal Military Academy in 1810, and organized courses in economics,
    agriculture, and industry in Salvador and Rio de Janeiro.

    The government quickly recognized, too, the need for schools of medicine to train
    Brazilians as doctors. The high death rate among soldiers in Brazilian hospitals had long
    been a source of denunciation by colonial authorities and some voices had long clamored
    for the creation of local medical schools. Now, these voices were joined by those of king
    and court who wanted to see health care practices in their newly adoptive country conform
    more closely to those in Portugal. In 1808, at the instigation of the surgeon-general,
    José Correia Picanço, João VI set up two chairs in the instruction of surgery and
    anatomy, and later two more in obstetrics and pharmacy in Salvador and in Rio de Janeiro .

    The teaching took place in the most precarious of conditions, at the military hospitals
    in the two cities. At the end of four years a candidate could petition the surgeon-general
    for certification and on satisfying the requirements was recommended to receive a degree
    from the University of Coimbra in Portugal. By 1815 the Crown had upgraded the medical
    chairs in Rio de Janeiro and Salvador to medical-surgical colleges with a longer five-year
    curriculum, and more demanding entry requirements. In an attempt to replicate the European
    medical practice, the Crown aimed to create a sharp separation between the
    "empiricism" of barber-surgeons, midwives, and bleeders on the one hand, and the
    educated, theoretical understanding of formally trained doctors on the other.

    In 1827 the Crown, aware that Brazil’s newly independent status would require an
    improved infrastructure for education, recommended further reorganization and expansion of
    the early courses into a school with a curriculum and faculty modeled after the medical
    schools in Paris and Montpellier. The changes were adopted in 1832 in the midst of the
    crisis of Pedro I’s abdication and the initiation of the liberal federalist experiment
    during the Regency (1831-40). Initially, therefore, institutions of higher education had a
    good deal of autonomy in the allocation of their resources, the election of their
    directors, and the recommendations for changes in the content of the curriculum. However,
    once the Regency gave way to the increasingly centralized rule of Emperor Pedro II
    (1840-89), school autonomy was ended. Indeed, the creation of medical education by
    governmental decree determined that medicine would become a more or less centralized
    enterprise, depending on the relative power of the royal bureaucracy and the strength of
    local challenges to that power. On the whole, this control stifled moves for innovation
    and reform.

    Gradually the imperial government came to dominate all aspects of medical school life.
    An educational reform in 1854—the Bom Retiro law, named after the presiding prime
    minister—formally ended the autonomy of the medical schools. The stated purpose of
    the new law was to bring Brazilian medical teaching more into line with the latest
    developments in the leading medical schools in Europe. Thus it called for greater
    practical training, for better laboratory and clinical facilities, for maternity centers,
    for adequate autopsy facilities, and for botanical nurseries to carry out research into
    Brazilian plants with medical properties, all improvements that were virtually unaddressed
    for another thirty years.

    However, the underlying purpose of the law, that is, the attack on the autonomy of
    institutions of higher learning, was rigorously implemented. As a result, the imperial
    government controlled the finances of the schools, nominated the directors, and, although
    professors were selected by competitive examinations, was known to overrule the outcome of
    a competition and appoint its own candidate. Another source of regulation over the schools
    was the annual reports dealing with all aspects of the schools’ business, which were
    written by a different professor each year, read to the faculty congregation, and
    forwarded to the central government. In 1875 the government further tightened its control
    by deciding that adjuncts were no longer to compete for full chairs but to be appointed by
    government decree.

    Throughout most of the nineteenth century, the medical schools continued to draw on the
    French example in shaping the curriculum, choosing examination topics for vacant faculty
    posts, selecting subjects for student dissertations, and deciding what to publish in
    Brazilian medical journals. Indeed, many Brazilian doctors preferred to publish in France
    and in French. Ironically, the most original Brazilian medical work in the first half of
    the nineteenth century came from a French physician, Joseph Sigaud, a resident of Brazil
    from 1825 to 1856, who wrote an epidemiological work focusing for the first time on
    illnesses most common in Brazil. His book, Du climat et des maladies du Brésil; ou
    statistique medicale de cet empire (1844), remained the most innovative medical
    approach in Brazil until the advent of the Tropicalistas in the 1860s.

    As the century progressed, the numbers of graduating doctors increased dramatically and
    advancement in medicine became far more competitive. In the early decades of the new
    nation’s history, the number of physicians graduating per year in Rio de Janeiro and
    Salvador was sufficiently small so that the doctor/patient ratio was favorable to the
    physician. Thus Robert Dundas, a British doctor who resided in Salvador from 1819 to 1842,
    noted that the Brazilian physician "is characterized by a great liberality of
    feeling; is little disposed to jealousy, and altogether devoid of professional
    intrigue." But this sort of comment contrasted starkly to the common complaint
    later in the century that some doctors unethically undercut others with discount rates.
    Moving from graduation into a successful career, a thriving practice, and a prestigious
    position on the medical faculty always depended on patronage, but as the numbers of
    graduates grew, competition for patronage was greater and the sought-after posts
    relatively fewer.

    After midcentury, the higher number of doctors graduating from the two medical schools
    in Brazil not only created competition among the doctors within the two cities but also
    exacerbated the differences between the two medical communities. Increasingly, the rewards
    for physicians in Rio de Janeiro were much greater than in Salvador. This was in part
    because of the much larger European and Europeanized population that demanded the services
    of Western medicine. The array of medical institutions in Rio was also greater: the
    medical school had more students and thus there were more professors; a successful medical
    association formed in 1829, which became the Imperial Academy of Medicine in 1836; and the
    academy had its own journal, originally titled the Anais de Medicina do Rio de Janeiro.

    But undoubtedly the most important factor for the advancement of the individual
    physician in Rio de Janeiro, as well as for the status of the medical profession, was that
    Rio, as the capital of the Empire, was the seat of the court and of royal patronage. Thus,
    for example, in theory the medical school in Rio de Janeiro lost as much autonomy as the
    Bahian school under the centralizing tendencies of Dom Pedro II’s government. But, in
    fact, the school in Rio de Janeiro could compensate for this loss of autonomy much more
    successfully than the Bahian school simply because it had close connections with the high
    echelons of power. Rio benefited from the emperor’s personal interest in medical affairs.
    Fascinated by the development of nineteenth-century science, Pedro II often attended
    sessions at the Imperial Academy of Medicine, Rio medical school theses defenses, and
    graduation services. He was thus personally known to a number of doctors.

    The outcome of the Rio medical community’s proximity to the seat of power can be dearly
    seen in the more liberal financing of the Rio de Janeiro school and main medical
    institutions. It was also evident in the unbalanced dispensation of noble titles for the
    two medical communities. Of the forty-nine noble titles Pedro I and II granted doctors,
    only one was given to a Bahian physician. The whole theater of royalty in Rio de Janeiro
    also gave the capital’s medical community a glitter and sophistication that, as the
    century wore on, contrasted more and more with the provincial, backwater nature of the
    Bahian one. Whereas early in the century numerous Bahian physicians had managed to become
    nationally prominent, by midcentury the Bahian medical community played second fiddle to
    that of the capital. The justification was that Rio de Janeiro attracted more brilliant
    minds. Ambitious Bahian physicians who could do so moved to the capital to pursue their
    careers. Those who remained behind began to air their grievances.

    It is understandable, therefore, that those who managed to position themselves well in
    the system had little incentive to rock the boat by fostering change. This may have been
    especially true at the Bahian medical school, where a medical education was often prized
    primarily as a means of entering the ranks of power and less as a scientific endeavor.
    Local grandees, when they could, preferred to send their sons to the law schools of Recife
    and São Paulo, from which the highest proportion of imperial civil servants was drawn.

    As the medical historian Cassiano Gomes asserts: "Medicine, at least in Salvador,
    was the profession of poor people, of the sons of merchants with small amounts of capital,
    or even the sons of workers, of the petty bourgeoisie; herein lies the great social
    function of the school." Numerous examples in Salvador bear this out. Antônio
    Pacífico Pereira and his brother Victorino were of humble Portuguese immigrant stock, as
    were José Francisco da Silva Lima and Manoel Joaquim Saraiva. Pedro Severiano de
    Magalhães began his studies at the orphanage school of São Joaquim. All of these men
    became prominent as doctors, as civil servants, or as politicians.

    The Bahian medical school, like the other institutions of higher learning in Brazil,
    was also a vehicle for the rising social status of the mulatto. The fact that the
    government provided scholarships for poor students to enter the professions, regardless of
    color, was one of the underpinnings of the elite’s complacent belief that in Brazil, in
    contrast to the United States, there was no "Negro problem." Brazilians noted
    with pride, and foreigners recorded in amazement, the many prominent mulatto Brazilian
    intellectuals and professionals in the Empire. This was true of medical graduates and
    faculty in Salvador. The professor Lino Coutinho, for example, was of a poor, mulatto
    background, and Domingos Carlos da Silva, Luis Anselmo de Fonseca, and Raimundo Nina
    Rodrigues, students and later teachers at the medical school, were mulatto.

    The values of most young men entering the medical school, therefore, led to the passive
    acceptance of medical education as a general, philosophical training rather than as a
    functional and practical profession. As Gilberto Freyre has noted, the value system of
    culture and knowledge in the Bahian medical school, certainly until the last decade of the
    Empire, subordinated the "scientific study [of medicine] to the study of classical
    literature, oratory, rhetoric, elegance, and purity in speaking and writing, to debate
    over questions more grammatical than physiological, and to dissecting problems closer to
    the pathology of literary style than human anatomy." It was unlikely, therefore, that
    the impetus for change would have come from within the Bahian medical establishment.

    The Tropicalistas, more than any other group of doctors in nineteenth-century Salvador,
    first articulated a critique of Brazilian medical teaching and practice. As foreigners,
    the founding Tropicalistas were excluded from the existing network of patronage so crucial
    to the advancement of medical careers; none of them, for example, ever taught at the
    Bahian medical school. The fact that they were on the periphery of imperial power and
    patronage allowed them more room to develop questioning and sometimes controversial ideas
    than if they had been in the capital city, close to official medicine, where such an
    autonomous group would have faced serious obstacles.

    At the same time, they were aware of the important medical strides being made in Europe
    and were especially interested in German advances. Clearly, for these men, audacity,
    daring, and original investigation would pay far greater dividends in possible fame and
    personal satisfaction than adherence to the local Western tradition of medicine, which,
    they saw, was failing to move into the new era of scientific medicine. They pushed,
    therefore, to make full use of the research arsenal of European medicine such as, for
    example, medical statistics, new clinical methods based on measurement and applied
    physiology, the application of chemistry in analyzing bodily fluids, an increased
    understanding of hematology, animal experimentation, and, most important, microscopy,
    which they pioneered in Salvador and through which they began to question hallowed
    theories about the etiology of Brazilian ailments. Above all, they insisted on looking at
    disorders of primary interest to Brazil.

    The "scientific" form of medical knowledge that the Tropicalistas proposed
    was, at first, intrusive and unsettling. Their outspoken belief that it was time for a
    "shake-up" in local medicine threatened to upset the accommodation of Bahian
    physicians within the Empire, especially as the Tropicalistas drew on new German ideas of
    scientific and social medicine that were initially viewed in Rio de Janeiro as rivals to
    the older French environmental approach to disease. Over time, however, because the Bahian
    medical establishment did increasingly poorly within the system of royal patronage—a
    fact it resented more and more bitterly—the Tropicalistas ended up becoming allies in
    the Bahian doctors’ struggle to secure greater munificence from the central government.
    Between 1866 and 1890, therefore, the medical school in Salvador became transformed, a
    transformation initiated by the Tropicalistas’ criticisms and propelled by the larger
    social changes unfolding during this crucial period in Brazil’s history.

    The Founding Tropicalistas

    The three most important founding members of the Escola Tropicalista Baiana were
    Europeans who made their home in Brazil. Two of them, Otto H. Wucherer and John Ligertwood
    Paterson, became well known in Salvador rather suddenly as a result of two epidemics that
    ravaged the city at midcentury: yellow fever (1849) and cholera (1855). Certain events in
    the two epidemics are worth highlighting for they were important precursors to the
    formation of the Tropicalista movement and in creating the early perception of the
    Tropicalistas—in the opinion of some—as disruptive outsiders.

    Soon after a puzzling epidemic arrived in Salvador, Wucherer and Paterson, the latter
    the physician to the British community in Salvador, diagnosed the disorder as yellow
    fever, in opposition to the opinion of most of the members of the medical school and
    several of those on the Council of Health (Conselho de Salubridade). They stated it was
    contagious, although the manner of contagion was unknown. The practical implications of
    this position, which called for quarantines in a port city and the likely disruption of
    trade, were highly unpopular. So, too, was the assault on the prestige of the Bahian
    medical elite.

    The latter retaliated with offensive articles in the local press against the foreign
    doctors, arguing that the disorder was one of local origin and that the epidemic was
    neither as contagious nor as frightening as had been made out. "The serious cases
    that have occurred," they stated, "were caused by the predisposition of patients
    to the disorder, to the panic that has taken hold of them, and to the use of unreasonable
    cures." However, as the cases multiplied in an alarming manner, it became clear that
    the Europeans were correct in their diagnosis and that yellow fever had indeed struck and
    was spreading in a manner suggesting contagion.

    In 1855 the animosity between the foreigners and some of the leading Bahian doctors was
    reinforced when a similar confrontation developed over the arrival of cholera in the city.
    When called to minister to the ailing captain of a British frigate, an English doctor,
    Edward G. Fairbanks, declared the illness was cholera. The provincial governor urgently
    summoned Wucherer, Paterson, and Fairbanks to discuss the situation.

    As in 1849, most local doctors and authorities opposed the view that cholera had
    struck, blaming the epidemic on the sale of rotten codfish and meat. When the Europeans
    proposed that three special centers be set up to treat cholera patients and limit its
    spread, officials opposed the notion. Once again there were scathing articles in the press
    about the foreign doctors, and for a second time, events proved local physicians wrong.

    The two incidents damaged the prestige of some of the most preeminent local physicians
    while enhancing that of the Europeans. The Council of Health, for example, several of
    whose members had opposed the Europeans, fell into disuse and finally ceased to exist in
    1876. After 1851 the main sanitation body was the Board of Public Hygiene (junta de
    Hygiene Pública), run almost single-handedly by José Goes Siqueira, who became inspector
    of hygiene.

    The foreign doctors gained in prestige among the highest administrative authorities and
    in later years were asked to serve on a number of health commissions. Their help and
    courage during the epidemics also earned them praise from wide sectors of the population.
    There was a good deal of sympathy for Wucherer, for example, who lost his wife in the
    yellow fever epidemic after he opened an infirmary in his home for poor patients. The two
    episodes also led to a crisis of confidence in the then prevalent Bahian medical theories
    that, strongly derivative of outdated French medical ideas, pointed to a vague and
    fatalistic notion of climatic miasma derived from the combination of poor living
    conditions and the humid heat of the tropics, rather than a specific source of contagion.

    Wucherer and Paterson’s insistence that yellow fever was contagious suggested that they
    believed that even if unhygienic conditions and a tropical climate were important factors
    in the outbreak of disease, these were not the whole explanation. They wanted to be much
    more specific in pointing out how the peculiarly Brazilian social factors impinged on
    disease, as well as how the special conditions of a warm climate interacted on a human
    constitution to produce disease.

    Thus they provided a new approach to disease etiology in Salvador at a time when
    traditional explanations were being undermined. It took another decade for the
    foreigners—and a handful of Bahian physicians who recognized the deficiencies of the
    state of local medicine—to get together and organize themselves into a group
    interested in the exploration of new approaches. Undoubtedly the two epidemics and the
    role of Wucherer and Paterson acted as a catalyst for that effort.

    Wucherer, who was born of German parents in Portugal and then moved with them to Brazil
    when he was eight, became the most renowned of the Tropicalistas and was the crucial link
    between advanced European medical ideas and local medical concerns. With his studies of
    Brazilian snakes and their poisons, his finding of the hookworm in Salvador, and his
    discovery of the embryonic filaria, Wucherer, more than any other of the Tropicalistas,
    forged the group’s identity, set its program of research, and made it visible in the
    European press.

    Wucherer brought to Salvador the newest ideas of laboratory medicine and
    parasitology—a knowledge he acquired at the University of Tübingen, from which he
    graduated in 1841—at a time when Germany was beginning to play a leading role in
    laboratory medicine. He was particularly influenced by the brand of German medicine
    espoused by Rudolf Virchow, who, even as he moved away from bedside medicine into the
    laboratory and greater specificity, remained one of Germany’s strongest medical advocates
    of social reform. Indeed, Virchow’s axiom, "medicine is a social science," can
    be seen as central to Wucherer and the Tropicalistas’ approach to the profession.

    Wacherer’s exposure to advanced European medicine increased during his time as a
    medical assistant at St. Bartholomew’s Hospital in London before his return to Brazil in
    1843. In 1847 he took up the position of physician to the German community in Salvador.
    After the epidemics mentioned above, he continued to run his own infirmary, where he
    tended to all classes. Although he never received an official appointment to the main
    charity hospital, the Santa Casa de Misericórdia, he worked there closely with a handful
    of colleagues, particularly Paterson, José Francisco da Silva Lima, and Manoel Maria
    Pires Caldas.

    They performed operations and autopsies together and consulted one another on their
    cases. Wucherer supported the idea of weekly meetings of those physicians in Salvador
    interested in keeping up-to-date on new developments in medicine, and he was one of the
    founders of the prestigious Gazeta Médica da Bahia, to which he contributed a
    handful of seminal articles. His best-known work was in the field of parasitology. In 1865
    he isolated hookworm parasites for the first time in Brazil; he was the first person ever
    to isolate the embryonic filaria, the parasite that leads to hematuria and elephantiasis.
    He was also a pioneer in the study of Brazilian herpetology, with two of his papers on
    snakes read at the London Proceedings of the Zoological Society in 1861 and 1863.

    The approach to medicine that Wucherer brought to Salvador was reinforced by the
    Scotsman Paterson, who graduated from the University of Aberdeen in 1841. At the time,
    Scottish medical schools were deeply interested in the idea that it was the government’s
    task to safeguard the health of the public, and that questions related to housing,
    sanitation, sewerage, the water supply, and the adulteration of food were all within the
    purview of government. Moreover, they believed that such a government could act
    practically and legislate wisely only if it considered the advice of the physician. After
    graduating, Paterson was accepted into the Royal College of Surgeons in London. He went on
    a medical tour of the best-known hospitals in France, Switzerland, Italy, and Vienna
    until, encouraged by his older brother, Alexander, who had set up practice earlier in the
    British community in Salvador, he traveled to Brazil.

    By then in his early twenties, John Paterson planned to settle in Paraíba do Norte but
    succeeded unexpectedly to his brother’s practice after the latter succumbed to a
    paralyzing stroke in 1843. Except for a few years from 1869 to 1872, and 1879 to 1881,
    during which he returned to Britain, Paterson remained in Salvador until his death, at
    which time his practice had become the largest in Salvador. Like Wucherer, Paterson was
    dedicated to the treatment of the poor. In a biographical article on Paterson written in
    1887, Silva Lima told how, from the beginning of his work in Salvador, Paterson had
    reached out to more than just the British community. He worked from early sunrise in a
    small infirmary attached to his house and at the Santa Casa Hospital, serving not only
    British sailors but needy Bahians, some of whom he never charged for his services.

    At noon he would start paying sick calls on horseback, often until after nightfall.
    When the infirmary ran low on the contributions on which it survived, he subsidized it for
    a time from his own pocket before reluctantly closing it down. Although other foreign
    doctors also attended Brazilian patients, none had the large numbers of poor patients that
    Paterson did. Thus, in his adopted town, wrote Silva Lima, he came to be fondly known as pai
    do povo (father of the people).

    Paterson was important for Bahian medicine in two ways. First, he marshaled the
    interests of the early Tropicalistas by proposing that they hold informal meetings in
    order to exchange ideas, talk about their own cases, and keep abreast of developments in
    medicine and surgery. The suggestion led in 1866 to fortnightly meetings of about fourteen
    Bahian doctors and, eventually, to the birth of the Escola Tropicalista. The meetings, at
    which there were earnest discussions on the work in parasitology of Angelo Dubini, Theodor
    Bilharz, and Wilhelm Griesinger, among others, emboldened Wucherer to write about his own
    findings. Here, too, the third member of the initial Tropicalistas, José Francisco da
    Silva Lima, first raised his interest in beriberi. There were talks about advances in
    surgery, an area that particularly attracted Paterson. From these interchanges also came
    the idea of starting a medical journal; the Gazeta Médica da Bahia was not the
    first medical journal founded in Salvador but it became the most successful, privately
    financed Brazilian medical journal in the nineteenth century.

    Second, as a result of his sojourns in Europe, especially in Scotland where he learned
    about antisepsis, Paterson was instrumental in introducing Lister’s method into Bahian
    medicine. During these visits, sometimes extended due to family reasons, Paterson spent
    time at the most advanced hospitals in Britain and attended the lectures of some of the
    most famous physicians of the time. In 1869 he worked with Joseph Lister in Edinburgh.
    This was a turning point in Paterson’s professional life, for he was rapidly won over to
    Lister’s method of antisepsis.

    In 1871 the Bahian physician Antônio Pacífico Pereira visited Paterson in Edinburgh.
    Paterson took his friend to have a lesson in antiseptic measures from the master himself.
    In 1879, once again on leave in Scotland, Paterson received a visit from Antônio’s
    brother, Victorino Pereira. He too was introduced to Lister and made familiar with his
    antisepsis. Paterson and the two Pereira brothers were sufficiently impressed with what
    they had learned from Lister to introduce the method into their Bahian medical practice.
    In subsequent reports on surgery in the Gazeta Médica da Bahia, whether by
    Paterson or his colleagues, the antiseptic preventions taken are usually noted.

    The third in the triad of founding members of the Escola Tropicalista, José Francisco
    da Silva Lima, provided the perseverance and continuity that led to the group’s success.
    Born in Portugal, Silva Lima moved at the age of fourteen with his parents to Salvador,
    where his father was a merchant and his uncle a pharmacist. He graduated from the medical
    school in Salvador in 1851. Between 1853 and 1881 he made five trips to Europe in
    part to advance his medical knowledge. One of the founders and longtime editor of the Gazeta
    Médica, he contributed some two hundred articles to the journal. His range of
    interests and activities within medicine was enormous. Like Wucherer and Paterson, he was
    a clinician who made his original contributions to the school from cases in his sizable
    practice. He was the first Bahian doctor to report on what he considered the beginning of
    an alarming epidemic of beriberi in the city.

    He was the first to describe ainhum, a disorder that caused the growth of a tumor on
    the small toe of a person’s foot and that, according to Silva Lima, struck only Africans.
    He worked closely with Wucherer and others on hookworm, filariasis, and schistosomiasis.
    But it would be misleading to classify Silva Lima as interested only in what we now term
    tropical disorders. A scan of his writings in the Gazeta Médica reveals him as a
    doctor concerned with a whole range of clinical problems including heart disorders,
    diabetes, tumors, stigmata, surgery, hygiene, and legal medicine. He was very interested,
    too, in the latest developments in gynecology and obstetrics and sought to expand these
    specialties in Salvador.

    Regarding medicine in Salvador, Silva Lima had two objectives. He wanted to
    professionalize medicine in Salvador, and he wanted to see the Bahian medical community
    contribute to the patrimony of international medicine and be given its due credit for it.
    By "professionalize" I refer to Lima’s attempts to set boundaries around the
    medical profession in Salvador, excluding the "irregular" healers and including
    physicians and pharmacists trained in Western medicine and pharmacopoeia. To do this he
    worked to forge a spirit of solidarity among physicians, and also between physicians and
    pharmacists, so that they should agree on ethical standards of practice and behavior. He
    also endeavored to draw more physicians into medical scientific research.

    Physicians united in this way, he believed, would be in a stronger position to force
    the authorities to recognize their importance as experts in the nation’s decision-making
    processes. To this end, Silva Lima was tireless in his efforts. Although he never held a
    paid official position, he helped create and chaired numerous professional bodies, such as
    the Doctors’ and Pharmacists’ Mutual Aid Society (Sociedade Médico Pharmacêutica de
    Beneficência Mútua), formed in 1868; the Bahian Medical Society (Sociedade Médica da
    Bahia), formed in 1888; and the Medical and Surgical Society of Bahia (Sociedade de
    Medicina e Cirurgia da Bahia), formed in 1894. He pushed for a national medical congress
    to be held in Salvador (it finally was held there in 1890) and sat on commissions to
    promote vaccination, to contain yellow fever epidemics, to improve the sanitary conditions
    of the city and of the port, and to look into the spread of beriberi in the province.

    Together, these three men spearheaded changes in Bahian medicine that led to their
    national and international recognition. Their vision led to the formation of a small
    research community in Salvador informed by some of the newest European ideas in medicine
    that provided an important precedent of original research and experimentation in Brazil
    yet never altogether shed the idea of the importance of environment in understanding

    The Making of a School of Tropicalistas

    Although existing sources do not give an exact figure for how many men formed the
    Escola Tropicalista, a rough estimate is possible. In 1887 Silva Lima provided a list with
    the names of fourteen men whom he recalled started meeting regularly at Paterson’s house.
    The approximate correctness of this figure is confirmed by an examination of the doctors
    who published regularly in the Gazeta Médica, and who were on its editorial board
    up until the fall of the Empire in 1889. Further data can be gleaned through a careful
    examination of the Tropicalistas’ clinical papers published in the Gazeta Médica, which
    reveal the names of doctors who assisted, observed, and commented on their work as well as
    the lists of members of the professional associations formed by the Tropicalistas.

    A prosopographical analysis of all these sources together suggests a "core"
    group of Tropicalistas that, though never numbering more than about twelve members at any
    one time, was surrounded by a larger circle of identifiable supporters of about twenty to
    twenty-five men. Among the Tropicalistas were five foreigners: the three founders I have
    already mentioned, and two supporters, Dr. Thomas Wright Hall, who worked with the British
    community, and Dr. Alexander Paterson, John Paterson’s nephew. The rest of the
    Tropicalistas, core or supporters, were Brazilian-born and trained, although a number of
    them made visits to European centers of medicine after their graduation.

    Since there was an average of thirty doctors on the faculty of the medical school and
    possibly as many as eighty-six to one hundred and fifty regular practitioners in the city,
    the Tropicalistas constituted a sizable minority of the total medical community. Moreover,
    because they were such an active minority in teaching (albeit extraofficially), in the
    creation of the city’s medical institutions and commissions for the improvement of
    hygiene, in the main charity hospital, and in the establishment of the only successful
    medical journal in Salvador, they exercised an influence upon the whole medical community
    that belied their numbers.

    Because in their first decade nearly all the core Tropicalistas operated outside the
    existing Bahian medical establishment, and rapidly became a forum for its critique, they
    needed an institutional framework if they were to be a successful, innovating force in
    Bahian medicine. Of the fourteen men Silva Lima recalled at the early meetings held first
    in Paterson’s house, only two were on the medical school faculty at the time. Over the
    next two decades the Tropicalistas had considerable success in winning over adherents from
    the medical school, and many of their earliest supporters moved into teaching posts in the
    medical school. Thus, by the late 1880s, their teachings had become mainstream. But in the
    1860s the two institutions that became pivotal to the success of the group, the Santa Casa
    de Misericórdia Hospital and the Gazeta Médica da Bahia, were outside the
    medical school.

    The Santa Casa de Misericórdia Hospital was a charity hospital administered by nuns
    that provided many social services under the aegis of the historic "Brotherhood of
    Our Lady," a part of the Portuguese colonial legacy. The hospital attended to the
    poor who were reputed to have a "horror of the hospital," so that they sought
    out its services only when they were already extremely ill. It also attended to sailors,
    prostitutes, those afflicted by venereal disease, and women with birthing problems. Other
    charity services provided by the Santa Casa included the provision of burials for the
    poor, dowries for poor female orphans, a "roda," which was a foundling wheel
    made from a little revolving door to the side of the main door, or elsewhere, where
    unwanted babies were left, a retirement house for "wayward" women, and another
    for orphaned girls.

    At the time of Emperor Pedro II, the province of Bahia had six charity hospitals run by
    the Santa Casa. The largest was the Santa Casa de Misericórdia in the city of Salvador,
    which from 1833 was housed in the old Jesuit quarters in the Terreiro de Jesus next to the
    medical school. It operated largely with donations and legacies made to the order by
    wealthy members of the community, and through the years it had amassed considerable
    wealth. In the course of the century its expenses mounted as a result of a rising
    population and growing expectations in social services. Moreover, the economic decline of
    the province that exacted its toll on the generosity of donors and the mismanagement of
    its finances led to hard times for the order.

    Excerpted from the first chapter of Race, Place, and Medicine _ The
    Idea of the Tropics in Nineteenth-Century Brazilian Medicine by Julyan G. Peard, Duke
    University Press, 1999, 316 pp. Peard is Associate Professor of Latin American History at
    San Francisco State University.

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