Ferreira Antunes Leopoldo, Jose. Medicina, Leis e Moral: Pensamento medico e comportamento no Brasil (1870-1930). Sao Paulo: Editora UNESP, 1998. 304 pp. No price listed (cloth), ISBN 978-85-7139-230-4.
Reviewed by Tamera Marko (University of California, San Diego)
Published on H-LatAm (June, 2000)
Jose Leopoldo Ferreira Antunes's Medicina, Leis, e Moral was inspired by a perplexing question: if the majority of the multitude of proposals made by medical doctors were never integrated into effective policies, laws, and social change, how is it possible to speak of a "medicalization of society" in Brazil? Antunes approached this question by restricting his study to the arena of medical thought, defining "medicalization" as "a new attitude among medical experts regarding objects of study and of intervention." (p. 71)  The result of this approach is an important contribution to the study of the history of medicine and society in Brazil between 1870 and 1930, convincingly showing, as have other scholars, a dramatic change in attitude among the medical community regarding their professional objectives and their "inclination . . . to dedicate themselves not only to the ill and to illnesses, but in every possible way to interfere in human life." (p. 71)  Antunes also makes a second major assertion: that this transformation was also a process of "humanizing medicine" which "consolidated a first paradigm for the development of human sciences in the country." (p. 274) Thus, it was neither anthropology nor sociology which developed the first human sciences in Brazil, but medicine. Specifically, Antunes focuses his analysis on three major themes he found emerging in debates among the medical community: crime, sex, and death (crime, sexo,e morte). This work, in just 300 pages, summarizes sixty years of medical thought that involved a confusing multiplicity of doctors, infamous medical cases, and debates that ranged from concerns with the body (defloration, abortion, pre-marital blood testing, rape, murder, and suicide) and the mind (psychiatric determination of insanity while committing a crime or composing a will) to legal questions indirectly related to health (at what age a child can be held legally accountable for crimes, regulating prostitution). The work is mostly a straight-up history of medicine focusing on the intricacies of the medical debates themselves though Antunes does provide some indication of ways in which these debates intersected with other medical, legal, religious, and social institutions, especially concerning infrastructural provisions for the "insane" and the deceased. While this book does provide a bibliography and brief summaries of some of the classic Brazilian literature about the history of medicine in that country, it does not include footnotes nor much beyond Brazilian historiography that could direct readers interested in pursuing specific issues in more depth to other bibliographic sources. However, Antunes explains a wide range of complex issues, outlines some of the most infamous legal medical cases, and introduces the proposals of many of the most influential medical doctors (such as Agostinho Jose de Souza Lima, Nina Rodrigues, Afranio Peixoto, Oscar Freire, and Flaminio Favero) with such concise clarity that this book is useful as an overview for scholars of the history of medicine in Brazil as well as those new to the fascinating topic.
The study is primarily based on the medical press; reports from congressional and professional meetings; medical conferences; doctors' memoirs; and published lectures. Other sources include medical dissertations, books, textbooks, and pamphlets. Occasionally the work cites reports from the mainstream press, such as Jornal do Comercio, when a specific case was especially sensational. Interestingly, Antunes makes a special point to encourage incorporating into future scholarly analysis medical dissertations previously overlooked by those who have compiled medical bibliographies upon which much scholarship has been based. (pp. 22-23).  He especially encourages analyzing dissertations produced during the first three-quarters of the nineteenth century, discounted by doctor and medical bibliographer Flaminio Favero and others as the "fase estrangeiro" (foreigner phase) because they are thought to be merely recapitulations of foreign ideas rather than work based on ideas specific to Brazil.
Although the book is coherent as whole, the individual chapters also read as self-contained outlines of a particular theme. For example, one could read the fifth chapter about death without having first read the previous chapters about crime and sex. Taken together, the chapters' different themes emphasize the wide scope of medical thought in late nineteenth and early twentieth century Brazil.
The first chapter summarizes Brazilian literature on the history of medicine beginning in the 1880s and leading up to what eventually developed into what is called the social history of medicine. Here, Antunes distinguishes between the history of medical hygiene and the focus of his book, legal medicine. He argues that in the field of medical hygiene, vaccination campaigns, for example, "had a strong impact on social life, motivating, still today, various historical and sociological studies." (p. 32) On the other hand, according to Antunes, legal medicine was largely restricted to "laboratory successes" and "the difficulties of public polemics." In fact, he argues that "It can almost be said that the more technically developed the specialization, the less social impact it actually had." (pp. 32-33)
The second chapter summarizes some of the most infamous medical legal cases between 1870 and 1930 in Brazil to introduce the main themes concerning doctors at that time. These events, well known to students of the history of medicine in Brazil, include: "The Trial of Custadio Serrao" "Processo Custadio Serrao] in 1896, regarding a young man who claimed to be temporarily insane when he murdered his tutor; "The Question of Castro Malta" ["A Questao de Castro Malta"] in 1884, in which the cadaver of a prisoner was lost and several doctors were called in to determine the cause of death (suspected foul play by prison authorities) once the exhumed corpse was thought to be found; "The Case of the Baron of Itapoan" [O Caso Do Barao de Itapoan] in which doctors were asked to determine whether the death was, in fact, a suicide; "The Braga Medical Legal Question" ["Questao Medico-Legal Braga"] in which a doctor attempted to annul his marriage after he claimed to find that his bride was not a virgin on their wedding night; and the "Abel Parente Invention" ["Invention Abel Parente"], regarding an Italian doctor in Brazil, Parente, who had developed a highly publicized form of female sterilization. Finally, the chapter addresses the issue of faith healers (medicos sobrenaturais), particularly the case of Eduardo Silva, a former engineer who was widely sought for his services "to cure in the name of God." In each one of these events, "Antunes writes, "to a greater or lesser degree, they include the same ingredients: passionate debates, disputes between professionals, press coverage, public commotion and a popular affinity for tragic sentiment." (p. 35) These events also especially reveal the intersections between medical, legal, religious, and familial institutions as well as the sensational nature amid which legal medicine came into being in Brazil.
The third chapter focuses on the overall theme of crime, specifically concerning childhood (infanticide, the age at which a child can be held legally responsible for their crimes, and children afflicted with venereal disease); insanity and civilian internment; wills; and legal testimonies. The chapter also discusses a multiplicity of issues and complicated debates regarding insanity and legal responsibility in the arena of psychiatric and medical thought as well as infrastructural challenges posed by the question of whether the insane are categorized as "ill" or as "criminal". Intrinsically linked with this issue is an especially interesting discussion of the medical-legal debates regarding ways in which to distinguish whether individual behavior was based on acts of conscience (consciencia) and free will (vontade). Also discussed is the relationship between medicine and the modification of penal responsibility, primarily concerning medical doctors' push for more nuanced legal definitions and specific distinctions in applicability of law based on age, gender, and race, as well as those determined to be alcoholics. Finally, the chapter outlines the debates surrounding the methodology of legal identification, specifically finger-printing and discussions regarding ways to prevent waves of "imitation suicides".
The fourth and fifth chapters seem to read more coherently than the previous one on crime. The chapter about sex is divided into legal-medical debates regarding the following issues: the concept of "libertinagem" (which translates as "licentiousness" or "loose living") and the regulation of prostitution; the regulation of marriage (the economic and health "benefits" of marriage, consanguineous marriages, and pre-nuptial medical exams); defloration, rape, and seduction; abortion; and sterilization. The chapter on death focuses on debates surrounding the verification of death, autopsies, death certificates, burial practices, and the cremation, conservation and "terminal disinfection" of cadavers.
The work concludes with a brief summary of the text and assertions of why, ultimately, many of the medical projects were never successfully implemented. Antunes states that this failure was rooted in the medical communities' lack of unified demands and their lack of power which resulted in the inability of these professionals in the "art of curing" to imbed their advocated methods into the moral arena of Brazilian society. They could not transform law into the desired modifications of customs and behavior." (p. 273) Because of this failure to greatly influence societal mores and behavior, Antunes further asserts that this positions his argument as the "antithesis" to the work of Mariza Correa (1982) and Joao Jose Reis (1991) who argue respectively that the doctors of this era were "guardian angels of society" and "civilizing heroes." (p. 12 and p. 271) . This last point deserves some discussion because the evidence in Antunes's text provides enough evidence to only partially support these claims.
Medicina, Leis, e Moral artfully proves the consistent lack of agreement and contradictions among medical doctors, which clearly must have contributed to some degree to the failure of many medical projects. "Nearly every proposal was met with a counterproposal; nearly every initiative aroused ardent supporters and opponents." (p. 34) One could add that if Antunes had consulted the proposals of other members of the medical community -- such as female nurses, teachers, and assistants who were not published in the prestigious medical journals, but had formulated ideas nonetheless -- this lack of agreement would appear even more complex and nuanced. The text does not, however, contain evidence that only these elite members of the medical community are to blame for their inability to effectively implement medical proposals. The author focuses solely on sources that come from this medical community, an approach well equipped to analyze medical debates, but which does not necessarily reveal whether these ideas were incorporated into the morals and behavior of society and why. These questions would be better revealed in personal memoirs, family letters and magazines, works of fiction, and art. For example, Dain Borges's study of the family in Bahia between 1870 and 1945 argues that "accounts of home life in the nineteenth and twentieth centuries do show thorough infiltration by doctors and medical ideas." [5 ] Antunes's assertion that the failure of the "medicalization of society" is rooted in the medical community itself overlooks a more nuanced approach to understanding societal relations of power and influence. In this case, the question of agency is crucial. Important to consider would be the larger community of those involved in health issues, such as midwives and folk healers (curandeiros) who wielded a strong influence among society at that time. It also is very possible that, as scholars have shown regarding public health campaigns in Brazil, resistance among the population contributed to the effectiveness of the implementation of legal-medical proposals.  Interestingly, Antunes does mention a rebellion of patients in a Rio de Janeiro hospital in 1920 which suggests there were probably other such incidences. (pp. 114-115) Antunes's discussion of the debate among lawmakers, politicians, doctors, psychiatrists, and hospital administrators regarding housing the insane also raises the question of budgetary and infrastructural capabilities influencing the ability to implement medical proposals.  In addition, since medical questions, especially in the case of death, intersected with religious beliefs and customs, the Catholic Church itself, as well as adherence to Catholic faith, surely affected influence of medical ideas among the population.
Finally, although the author does not makes these issues explicit, his analysis of such a broad range of six decades of medical debates in Bahia, Sao Paulo, and Rio de Janeiro raise intriguing questions for further research. This broad overview suggests that these new medical proposals continued across the board to reflect and reinforce hierarchical relations of power and influence based on class, race, gender, and age. It also suggests that new approaches to medicine simultaneously had the potential to liberate and protect women in the sense that doctors encouraged female literacy, promoted knowledge about causes of defloration other than sexual intimacy which would protect a woman's honor, and urged that legal punishments should be less severe for women than for men.
Antunes's analysis also highlights the key role that both the medical and mainstream press itself played in influencing the course and influence of medical debates. This press influence seems in some ways to be markedly different than today in which journalists, not necessarily the doctors themselves, regularly write articles. Antunes aptly points out that the late nineteenth and early twentieth centuries "was a period during which the newspapers opened their pages to specialists." (p. 33) This was the general case, not only for sensational cases such as a misplaced cadaver or someone buried alive. Doctors also argued that the press was one of the best ways to properly indoctrinate Brazil's children with hygienic habits and values. Finally, Antunes's discussion of several cities reveals that there were regional differences in approaches to medical ideas, infrastructure, and implementation. (p. 65 and p. 115)
Overall, Medicina, Leis e Moral provides an interesting and lucid discussion of the complex web of medical thought in late nineteenth and early twentieth century Brazil.
. This and subsequent translations from Portuguese to English are by the reviewer.
. Works that make similar assertions regarding the type and dramatic shift of issues concerning medical thought in Brazil at this time include: Gilberto Freyre. Sobrados & mocambos. Rio de Janeiro: J. Olympio, 1968, 2v; Robert Macado, Angela Loureiro, Rogerio Luz, and Katia Muricy. Danacao da norma: medicina social e constituicao da psiquiatria no Brasil. Rio de Janeiro: Graal, 1978; Jurandir Freire Costa Historia da Psiquiatria no Brasil. Rio de Janeiro: Documentario, 1976 and Ordem medica e norma familiar. 2. ed. Rio de Janeiro: Graal, 1983; and Dain Borges. "Medicine and Families", pp. 85-111 in Dain Borges, The Family in Bahia, Brazil, 1870-1945 Stanford: Stanford University Press 1992. See also Lycurgo de Castro Santos Filho. Histoia geral da medicina brasileira. Vol. 1. Sao Paulo, 1977 and Historia da medicina no Brasil (Do seculo XVI ao seculo XIX). 2 vols. Sao Paulo: 1977.
. Specifically, Antunes criticizes the following bibliographies for overlooking medical theses: Flaminio Favero. "Evolucao cientifica da medicina legal no Brasil." Arq. Soc. Med. Legal e Criminologia de Sao Paulo, p. 139-56, 1922; Favero. Medicina legal. 12 ed. Belo Horizonte: Villa Rica, 1991; Ernesto Nascimento Silva. "Medicina legal. In: Academia Nacional De Medicina. Em comemoracao do centenario do ensino medico. Rio de Janeiro: Tip. Jornal do Comercio, 1908. p. 613-9; and Afranio Peixoto. Medicina legal_. 3. ed. Rio de Janeiro: Francisco Alves, 1918.
. Cited from Mariza Correa, "As ilusoes da liberdade: a escola Nina Rodrigues / a Antropologia no Brasil". Sao Paulo, 1982. Tese (Doutorado em Antropologia) - Faculdade de Filsofia, Letras e Ciencias Humanas, Universide de Sao Paulo and Joao Jose Reis. A morte e uma festa: ritos funebres e revolta popular no Brasil do seculo XIX. Sao Paulo: Cia. das Letras, 1991.
. Quoted from "Medicine and Families", pp. 85-111 in Dain Borges, The Family in Bahia, Brazil, 1870-1945. Stanford: Stanford University Press 1992, p, 93.
. See for example, Sidney Chalhoub. Cidade Febril: Corticos E Epidemias Na Corte Imperial. Sao Paulo: Compania das Letras, 1996; Nancy Leys Stepan. Beginnings of Brazilian Science: Oswaldo Cruz, Medical Research and Policy, 1890-1920. New York: Science History Publications, 1981 and Nancy Leys Stepan. "The Hour of Eugenics": Race, Gender, and Nation in Latin America. Ithaca: Cornell University Press, 1991.
. Gilberto Hochman in A Era do Saneamento: as bases da politica de Saude Publica no Brasil. Sao Paulo: Editora Hucitec -Anpocs, 1998, argues for example that many public health policies emerged in Brazil out of elites' concern with social consience (meaning that illness prompted a conscience of social interdependence) and material interests. Thus, the implementation of medical programs were motivated greatly for political and economic reasons and encouraged by politicans as well as medical doctors.
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