We know too little of the practice of medicine in late colonial and early national Latin America. The author, concentrating on Peru, the centre of Spain's administration of South America until the Bourbons in the eighteenth century established two new viceroyalties, Nueva Granada and Rio de la Plata, helps fill that gap. Although Adam Warren's title suggests that the study ends with independence in the early 1820s, the final two chapters move into the mid-1840s. It is here that Warren explores the wasted legacy of earlier attempts to reform the teaching and practice of medicine. Although not mentioned, his thorough research and well-written narrative focuses on what historians increasingly refer to as Latin America's ‘middle period’.
From the first chapter Lima, the viceroyalty's capital, is the focus. Here the first medical school was founded, and it was here that most physicians practised. Provincial cities and the countryside shared little in developments taking place in the centre of authority. Warren points out that medical practice, from native practice through to midwives, pharmacists, barber-surgeons and university doctors, was for almost two centuries based on traditional concepts. Most had little relation to a ‘modern’ understanding of disease. Colonial practice was based on Spanish methods. Warren may underestimate the significance and quality of medical schools and knowledge in Spain in the mid-Hapsburg period. Many treatises on illness, medicine and surgery were written, and trends leading to more ‘modern’ concepts of the Bourbons were in motion. Spanish knowledge, after all, was based on both classical foundations and the rich legacy of Jewish and Muslim physicians. Further, the Spaniards from the era of exploration were on a constant search for native medicines which might provide new cures that could be as valuable as gold.
Warren speaks with authority in the following chapters. He next deals with the attempts of Bourbon reformers to professionalise healers. A key figure was Dr Hipólito Unanue, active in the last third of the eighteenth and the first decades of the nineteenth century. He and other creole and peninsular intellectuals were major contributors to the Mercurio Peruano, a venue for publishing a vast array of studies on subjects ranging from mining and agriculture to weather conditions, earthquakes and population, as well as medicine, and all things relating to the ‘New Learning’ that characterised the Peruvian Enlightenment. Here, as elsewhere, Warren compares the Andean case with developments in other places in Spanish America. His coverage of the role of the Protomedicato in controlling the delivery of healing is succinct. Especially informative is Warren's close analysis of the heated disputes between Unanue and José Pastor Larrinaga on the proper training of physicians. Larrinaga stressed that surgeons had to learn by practice, and experience gained in dissections was much more effective than studying manuals. Conflict between the two was related to caste and class, and although Unanue considered himself the reformer, Larrinaga and those of like mind considered themselves the ‘modern’. The breach between surgeons and doctors ultimately led to the creation in 1800 of the Sociedad Patriótica del Monte Pío de los Cirujanos (Patriotic Society of the Mount of Piety of the Surgeons of Peru). This provided assistance for surgeons and their families in time of need, and provided the group with status and a place to discuss and advocate their concerns about the profession. One consequence was the establishment of the School of Medicine and Surgery of San Fernando, a surgical school separate from the medical college of the University of San Marcos.
Warren next focuses on the peninsular vaccination campaign in Peru. Here, as before, he explores the debates and jealousies between creole health care providers and outsiders. José Salvany, a member of the Francisco Xavier de Balmis expedition to bring vaccination to Spain's colonies, reached the Peruvian coast in 1806 and immediately faced resistance from locals. In addition to what peninsulares expected to face, a suspicious clergy, poorly educated health care providers and a superstitious native population, here they met the unexpected. Viable smallpox vaccine, carried by Pedro Belomo aboard a merchant ship from Buenos Aires via Chile, had arrived a year before. The campaign Belomo initiated in 1805 was largely complete, or so argued Lima's doctors. Hence there was no need for ‘outside’ assistance. Salvany was furious and attacked local physicians, accusing them of backwardness. Creoles resisted the paternalism exemplified by the arrogant attitudes of the peninsulares. Before his work in the Andes ended, Salvany was abandoned by muleteers, driven from towns and called an Antichrist, in experiences reminiscent of a picaresque novel.
Both this chapter and the subsequent ones can profitably be read as self-contained essays. The two following chapters bring us into the mid-nineteenth century. The first covers leprosy, the second the contentious issue of forcing the people to abandon traditional burial within the churches and monasteries. Here, as elsewhere, Warren emphasises the conflict between old practices and those reputedly more modern. Although a 1789 Spanish order stipulated that there should be no more burials in churches, it was not until 1808 that Lima's cemetery was opened. The noxious stench and the impact on drinking water vividly described by contemporaries are well analysed by the author. Arguments between the two proponents were heated and prolonged. Compromise was impossible; enemies, given the too-consuming cultural concept of honour, could not back down. In the case of burials there was the related concept of social status. It took many years before some elite members realised the status symbol embodied in an elaborate family mausoleum.
There are minor issues and points of fact that specialists may note. Perhaps the most problematic is the subtitle, Population Growth and the Bourbon Reforms. The argument is that Bourbons, recognising the relationship between a healthy, growing and productive population, could arrest Peru's decline by control of disease and improving health in general. That issue was already recognised in the late sixteenth century by creole and peninsular observers. The real problems lie in endemic and epidemic disease, malnutrition, terrible sanitation and overwork. And in spite of an upward tendency of the population that took place, I would argue, sometime in the eighteenth century, the above factors could do as much damage to recovery as those two centuries before. In general, epidemic mortality until the later 1900s was as high as in earlier centuries, no matter what officials did.
Sadly, reform attempts initiated in the eighteenth century did not result in the successes proponents expected. With independence in 1821 came political chaos, economic disasters and the decline and virtual demise of Lima's college of medicine. Some of the top reformers became political leaders of the new republic, and neglected their prior goals for better health care. In short, by the mid-nineteenth century the state of healing in Peru was not significantly different from what it had been a century before. Warren provides us with a well-written and valuable study of public health and medical practice that will be read and discussed widely.
