Spread of homeopathy in the early nineteenth century: the comparative approach and the cases of Sweden and Brazil

A difusão da homeopatia no início do século XIX: abordagem comparativa e os casos da Suécia e do Brasil

Abstract

The comparative approach has been advocated to overcome some flaws inherent to case studies. Here, the spread of homeopathy in the early nineteenth century is addressed through a comparison of the cases of Sweden and Brazil, where homeopathy met diametrically opposed fates. The parameters used for the comparison are the standard for studies on the early spread of homeopathy, such as the concept of the “introducer,” and reception by the medical and academic community, the government, and society at large. The results suggest that analysis of contexts, determinants, and the interactions of practitioners and institutions representing different health care approaches, whether dominant or alternative, seems to provide a more accurate picture of different moments in the global history of medicine.

homeopathy; nineteenth century; Sweden; Brazil; comparative approach

Resumo

A abordagem comparativa foi adotada com o intuito de suplantar algumas falhas inerentes aos estudos de caso. Nela, a difusão da homeopatia no início do século XIX é tratada por meio de uma comparação entre casos da Suécia e do Brasil, onde a homeopatia encontrou destinos diametralmente opostos. Os parâmetros usados para a comparação são padrão para estudos sobre o início da expansão da homeopatia, como o conceito de “introdutor”, e a aceitação por parte de governo, comunidades médica e acadêmica, e sociedade como um todo. Os resultados sugerem que a análise de contextos, de determinantes, e das interações de médicos e instituições representando diferentes perspectivas de tratamento médico, fossem elas dominantes ou alternativas, parecem oferecer uma análise mais precisa de diferentes momentos da história global da medicina.

homeopatia; século XIX; Suécia; Brasil; abordagem comparativa

Reports on the spread and fate of homeopathy in various countries around the world began at practically the same time as the initial formulation of this medical approach in the early decades of the nineteenth century. As a result, the literature on this topic is so large it is impossible to survey and compile. Interest in the subject has not receded with the passing of time. Indeed, ever more studies have continued to appear, dealing with the history of homeopathy in national contexts, accompanying the evolving historical trends in writing the history of medicine.¹

The value of this work is indisputable. Yet, as Martin Dinges (2001, p.52-53) pointed out, it is not free from some epistemological and methodological flaws: (1) scattered evidence taken as sufficient proof for a general trend; (2) exaggeration of alleged “crises” in conventional medicine and underestimation of the ability of dominant systems to recover; and (3) underestimation of the broader socio-historical context and assumption of a unilinear, teleological view of historical developments. Against this, Dinges calls attention to the ability of the comparative approach to control for the errors resulting from the wishful thinking proper to the internal history of homeopathy (and other modes of complementary and alternative medicine). In particular, since proper attention is paid to the necessary contexts, it helps overcome problems derived from the number of actors, duration of periods of observation, and size of geographical units.

In this study we compared the early arrival of homeopathy to Sweden and Brazil in the first half of the nineteenth century. The initial reason was to contribute to an ongoing project aiming to analyze the transit of scientific knowledge. The emphasis of this project is on patterns of exchange and interaction of major European centers with their (former) colonies, as well as with European areas without direct participation in colonial dynamics.

As is known, the earliest attempts at understanding the spread and/or transmission of scientific knowledge were based on the application of a vertical model, in which exchanges and interactions were represented in the terms of “centers” and “peripheries” (Sivasundaram, 2010). This view became the target of considerable criticism (Bourdieu, Wacquant, 1999) and was followed by an approach that emphasized local science. Also, due to intrinsic problems (Secord, 2004; Sivasundaram, 2010), a new model was developed according to which knowledge “circulates” in a decentered manner instead of being transferred vertically. Nevertheless, it has been suggested that the “circulation” model bypasses, rather than solves, the problems associated with the relationships between centers of power – or better, “centers of calculation” (Latour, 1985, 1988) – and less influential areas in terms of knowledge production.² One way to test this hypothesis is, for instance, to conduct and compare case studies, here, those of Sweden and Brazil. We should observe that it is not possible to analyze or understand constructs, such as nineteenth-century Swedish and Brazilian medicine, without simultaneous consideration of how the medical communities of these countries related to centers of knowledge production, namely European countries such as Britain, France, and Germany. In comparison, Sweden might be considered a (near) periphery and Brazil a colonial (distant) periphery. Brazil later became a peripheral center, following the move, in 1808, of the Portuguese court to the country, establishing Rio de Janeiro as the capital of the United Kingdom of Portugal, Brazil, and the Algarves, and, as of 1822, the establishment of the Empire of Brazil. However, as we shall argue, their apparent geopolitical disadvantage in the nineteenth century notwithstanding, the arrival and spread of homeopathy to both countries was much more complex than traditionally assumed in narratives of the history of homeopathy.

One particular advantage in comparing the arrival of homeopathy to Sweden and Brazil has to do with its current state of institutionalization (or not) in both countries. In Sweden, homeopathy is barely tolerated as a “last resort” and is provided exclusively in response to patient demands and as a complement to conventional medicine, but is looked down on by the medical establishment (Eklöf, 2014). It can be practiced by non-medically qualified practitioners, with the following restrictions: it cannot be used to treat children under eight years of age, serious communicable diseases, conditions like cancer, diabetes, epilepsy, or pathological conditions related to pregnancy and childbirth, according to the Patient Safety Law (Sweden, 2010, ch. 6 §1, ch. 8 §1). By contrast, homeopathy has experienced dramatic success in Brazil. It is currently taught in official university courses (medicine and pharmacy), there are at least three medical residency programs in homeopathy, it is included in the national health system, and is covered by private health insurance (Pustiglione, Goldenstein, Checinski, 2017; Salles, 2008). There is also an official Brazilian homeopathic pharmacopoeia, and homeopathic medicines are regulated by the national health surveillance agency (ANVISA) in addition to being dispensed gratis at public health facilities.

Finally, a comparison of case studies allows the pattern that emerges from traditional accounts of the early dissemination of homeopathy to be tested. Homeopathy began to spread immediately after its initial formulation by Samuel Hahnemann (1755-1843) in Germany at the turn of the eighteenth century. It arrived in Sweden in the 1820s, directly from Germany, and in Brazil in the 1830s, with a mixed provenance (France and Switzerland), as we discuss more thoroughly later on.

The traditional narrative states that homeopathy was introduced in a given country by a physician or lay aficionado – the so-called “introducer” – to quickly awaken the interest of doctors and influential members of society (politicians, intellectuals, journalists, nobility, government, military etc.) (Tarcitano Filho, Waisse, 2016, p.780-782). As a result, associations, journals, and courses were established together with facilities to provide care for patients. In time, claims for the establishment of hospitals and university courses emerged, which were systematically opposed by conventional medicine. These attempts had variable outcomes.

Following this script, we performed our comparison based on the following categories: “introducers,” reception by the medical/academic establishment, reception by the government, reception by influential members of society (and society at large, when applicable), and institutionalization (when applicable). These criteria are similar to the ones employed by Felix von Reiswitz (2012) in his comparative study of the creation of two homeopathic hospitals in the nineteenth century in London and Madrid, respectively. This is the only study with a comparative approach we were able to locate. Interestingly, just as in Reiswitz’s study, in ours the academic training (or not) of practitioners emerged as a significant factor. Whether this aspect is generalizable requires future comparisons of a larger number of case studies.

The textual sources for the comparison were previous publications on the history of homeopathy in Sweden and Brazil, to which the authors have substantially contributed.

The “introducer”

According to extant sources, homeopathy was introduced to Sweden in the 1820s by Göran Wahlenberg (1780-1851), a professor of medicine and botany at Uppsala University, best known for his botanical work – to the point he was appointed to the Linnaean chair. While it is not known how he first heard of homeopathy – he exchanged correspondence with German associates of Hahnemann’s, such as Johann E. Stapf (1788-1860) and Philip W.L. Griesselich (1804-1848) – the fact is that he included it in his university courses, despite the opposition of his faculty colleagues (Eklöf, 2007a, p.171; 2003, p.204).³

Among Wahlenberg’s students were Pehr Jacob Liedbeck (1802-1876) and Carl Ulric Sondén (1802-1876), who were active members of the circle around Pehr Henrik Ling (1776-1839), creator of the famous Swedish gymnastics and physical therapy, in German also called Heilgymnastik (Eklöf, 2007a, p.171; Ottosson, 2016). Ling and his followers were strongly against the use of medications, and considered gymnastics a form of natural medicine. In Liedbeck and Sondén’s view, Hahnemann’s homeopathy and Ling’s gymnastics were two branches of the same tree, and set themselves to promoting homeopathy in Sweden. In parallel, Liedbeck also contributed to the introduction of gymnastics in Germany, through his correspondence with the aforementioned Griesselich (Eklöf, 2007a, p.172). Other members of Ling’s circle also developed an interest in homeopathy, such as Lars Gabriel Branting (1799-1891), Ling’s successor at the Central Institute for Gymnastics, and Carl August Georgii (1808-1882), Liedbeck’s son-in-law. Georgii travelled to Berlin, Paris, and London, where he taught Swedish gymnastics and practiced homeopathy. He also sent updates on the worldwide situation of homeopathy to Liedbeck, who then published them (Eklöf, 2007a, p.172).

Due to the conflict with conventional doctors described in the next section, in time Sondén disassociated from both gymnastics and homeopathy to devote himself to the organization of mental health care in Sweden, for which he is known (Eklöf, 2007a, p.172). This left Liedbeck as the foremost advocate and practitioner of homeopathy in the country, having published several papers on this subject and translating Hahnemann’s seminal book, Organon of medicine, in 1835.

Liedbeck’s efforts were, however, fruitless and isolated. The effective “introduction” of homeopathy in Sweden only took place in the early decades of the twentieth century, especially through the work of the physicians Adolf Grundal (1841-1920), the founder of the first Swedish association of homeopathic doctors, in 1912, Hjalmar Helleday (1844-1922), and Hjalmar Selldén (1849-1922), and the well-known lay homeopath Klara Fransén (1862-1943). In the 1920s, Carl Sundberg (1859-1931), a reputed professor of anatomical pathology at Karolinska Institute and member of the Nobel Committee, turned to homeopathic practice (Eklöf, 2003, p.210-219; Eklöf, 2014, p.93-101). This was the period of highest development of homeopathy in Sweden, which, however, did not survive amongst physicians.⁴

The situation in Brazil as to the “introducer” of homeopathy is likewise unclear, albeit for a very different reason: there is not just one, but three contemporary self-defined contenders to this title.

The received view attributes Benoit Jules Mure (1809-1858) with the role of “introducer” of homeopathy in Brazil (Tarcitano Filho, Waisse, 2016, p.783). A lay practitioner presenting himself as a university-trained doctor, Mure actually went to Brazil to found a phalanstery, according to the model established by the French utopian socialist Charles Fourier (1772-1837) (Tarcitano Filho, Waisse, 2016, p.785). Following the failure of this project, Mure moved to the imperial capital, Rio de Janeiro, in 1843, where he engaged intensively in homeopathic activity until 1848, when he returned to Europe. These activities included clinical practice, the publishing of books, and the establishment of care and teaching institutions in association with the Portuguese surgeon João Vicente Martins (1808-1854), who was strongly linked to Christian movements. Together, they sought to spread homeopathy across Brazil and neighboring countries. Both believed that no training in medicine was needed to practice homeopathy. In fact, according to them, acquaintance with conventional medical was detrimental, and thus they spared no efforts in establishing homeopathy as a practice for the common man. For this purpose they had kits of medicines prepared, accompanied by books and booklets explaining their use (Tarcitano Filho, Waisse, 2016, p.785-788).

However, Mure’s personal claim of being the “introducer” of homeopathy in Brazil was challenged by Émile Germon (1799-?). Germon was a French doctor who first arrived in Brazil in the 1820s, earning a great reputation as a medical practitioner in addition to undertaking scientific expeditions under commission of the minister of the empire. He then spent a season in Europe, where he learned and practiced homeopathy, before returning to Brazil. In 1843 – the very same year Mure first arrived in Rio – Germon published a homeopathic textbook. This was one of the only 43 books on medicine published between 1808, when local printing presses were first made legal, and 1843. Germon’s handbook enjoyed much success, with two additional editions in 1848 and 1858 (Tarcitano Filho, Waisse, 2016, p.784-785).

Yet the alleged pioneering work of both Mure and Germon was curiously ignored by Domingos de Azeredo Coutinho de Duque Estrada (1812-1900). A conventional doctor, Duque Estrada had free transit across the institutions of conventional medicine.⁵ However, in time, he learned homeopathy from the Swiss physician Federico Jahn – as mentioned in the next section, the first to defend a doctoral medical dissertation on homeopathy, in 1836 (Tarcitano Filho, Waisse, 2016, p.784). Duque Estrada started his initial tests using homeopathy in 1840 in cases in which conventional medicine had failed. A few years later, between 1842 and 1843, he began to use it as the predominant approach on the occasion of a violent and lethal epidemic of scarlet fever. This, despite some fears of persecution, since he believed to be “the only homeopath in Rio de Janeiro, since Drs. Mure and Lisboa did not yet practice here the new doctrine” (p.784).

Therefore, at least three homeopathic practitioners claimed the title of “introducer.” According to Tarcitano Filho and Waisse (2016, p.793), the three contenders played relevant roles in the institutionalization of homeopathy in Brazil: publishing, popular divulgation, and relationship with conventional medical institutions. As a result, the successful implantation of homeopathy in the country cannot be attributed to any one of them alone.

Our analysis thus indicates that the historiographical recourse to the figure of the “introducer” does not seem heuristically fruitful in the cases of Sweden and Brazil. In the former, the actor who might be attributed this role, Liedbeck, did not succeed in promoting homeopathy amidst medical circles. While homeopathy is not institutionalized in Sweden to this day, in the early twentieth century it awakened considerable interest among some physicians, such as Sundberg, a professor at the Karolinska Institute and member of the Nobel Committee. In Brazil, three candidates overtly contended for the title of “introducer” of homeopathy. However, effective introduction involves the successive or joint collaboration of a considerable number of actors. Interestingly, Reiswitz (2012) found that the driving force behind the early institutionalization of homeopathy in Britain and Spain were not its so-called “introducers,” but actors who “sowed homeopathic seeds on soil already tilled by others” (p.133).

Medical/academic reception

The first notice about the reception of homeopathy by Swedish conventional physicians is a severe criticism read by Pehr Gustaf Cederschjöld (1782-1848), a professor of obstetrics at the Karolinska Institute, in the early 1830s, to the Swedish Medical Society. Reproduced in the widely read newspaper Aftonbladet in 1833, this piece triggered intense public controversy involving Liedbeck, Sondén, and Christoffer Söderberg, the district physician (Eklöf, 2007a, p.172). As was mentioned above, this was the trigger for Sondén to dissociate himself from homeopathy and also gymnastics, leaving Liedbeck as the single homeopath in Sweden.

We should observe that until then, gymnastics had been considered a high-status profession, dominated by independently practicing men of good lineage, often with professional military backgrounds, and conventional doctors saw some value in it (Eklöf, 2007a, p.193). However, the fact it became intertwined with homeopathy became a source of distress for the medical establishment. The problems associated with the arrival of homeopathy might be illustrated by the following episode.

In the mid-1840s, a chair became vacant at the school of medicine of Uppsala University. The candidate with the best qualifications was arguably Liedbeck – then anatomy prosector at the medical school – but he was blackballed by Israel Hwasser (1790-1860), head professor of theoretical and practical medicine (Eklöf, 2007a, p.173; 2003, p.205).

The impact of Hwasser on contemporary Swedish medicine cannot be emphasized enough. Indeed, one of the reasons homeopathy did not attract many Swedish doctors at that time was that most had been trained under the influence of Hwasser’s views (Eklöf, 2007a, p.191). Hwasser was a strict adherent of Romantic medicine and Naturphilosophie, and on these grounds he fully dismissed the value of experience and clinical effectiveness for the sake of theoretical consistency – for which attitude Liedbeck criticized him. Faithful to his credo, Hwasser was indifferent to contemporary developments in anatomy, physiology, and pathology, ascribing to the Romantic theory of polarities. He believed that the only influence on health was God (or life), the task of the doctor simply being to guide the patient toward spiritual growth. Within this context, it is worth mentioning that the first teaching clinic of practical medicine was opened as late as 1839 by Magnus Huss (1807-1890) at Serafimer Hospital in Stockholm (Eklöf, 2007a, p.198). Hwasser’s views also put him in conflict with the recently founded Karolinska Institute (1810). The reason was he adopted a clear position against a purely medical-surgical institute under the control of the government and against specialization in medicine. Very much the opposite, he believed education ought to be integrated, and thus medicine should be taught in close relationship to other sciences (Liedman, 1971).

The foundation by Liedbeck of the monthly journal Homöopathiska Underrättelser för Svenska Folket, and the publication of the second edition of his paper on the status of homeopathy abroad, both in 1855, were the trigger for a new assault on homeopathy. This time the perpetrator was Gustaf von Düben (1822-1892), professor of anatomical pathology at the Karolinska Institute and a member of the estate of Nobility in the Swedish parliament, or Riksdag (Eklöf, 2007a, p.177). Von Düben summarily qualified homeopathy as quackery. The criterion he applied was not the one of therapeutic outcomes, but the judgment of peers. The reason was that, according to him, outcomes depended on too many factors, and medical statistics were highly problematic (Eklöf, 2007a, p.178-179). In his view, the success of homeopathy could be entirely attributed to the healing power of nature and to hygiene – a belief that illustrates the influence of Hwasser’s teachings. In addition, von Düben believed that the support of homeopathy among the people was purely due to the fact that the public – women in particular – were ignorant and believed that medicines cured. For instance, he wrote: “The sensitive, not to say the sentimental part of the female sex, is an especially suitable ground for the homeopathic enterprise” (Düben, 1855, p.75).⁶

Not only von Düben, but also Fredrik August Cederschjöld (1813-1883), the son of the aforementioned Pehr Gustaf Cederschjöld and also a professor of obstetrics at the Karolinska Institute, strongly believed it was not medicine, but nature that fights disease. Consequently, it was not the doctor or medical measures which primarily healed, but the physician’s task was to supervise the patient’s diet and hygiene. Once again, there is evidence here of the influence of Hwasser’s views on Swedish medicine. And just as the latter, Cederschjöld Jr. also strongly believed that the role of the State was not to decide on which types of treatment were the best in practice, but to support the development of medical science and increase the number of doctors in the country. In other words, the government should have no say on medical practice, which was to be left to duly trained physicians (Eklöf, 2007a, p.181).

In Brazil, the reception of homeopathy by physicians was more ambiguous: there were doctors who were overtly against it, others who immediately adopted and actively promoted it, and a third group who were rather neutral and open to give it a chance. Some of the arguments raised against homeopathy were the classical ones – the absurdity of the idea of therapeutic similitude and extreme dilutions, the use of inert substances, and the lack of scientific grounds (Galhardo, 1928, p.274, 294, 316). However, a deeper reason was the very status of medicine, and of physicians in particular, in the country.

As we discuss more thoroughly in the next section, until 1832 – when the first two medical schools (Bahia and Rio de Janeiro) were given the right to grant degrees in medicine, pharmacy, and midwifery – all university doctors had earned their degrees abroad (Pimenta, 2004, p.72). This event was the trigger for an active movement of defense of academic medicine as the true embodiment of the scientific approach to healing, further epitomized by the creation, in 1835, of the Imperial Academy of Medicine. Yet, acceptance was not automatic, with academically trained doctors having to struggle to have their status recognized. Within such a context, it was only natural that the simultaneous arrival of homeopathy would become a source of conflict. And indeed it was, as evidenced by the debates conducted in professional journals, like Revista Médica Brasileira, and regular newspapers, particularly Jornal do Commercio, founded in 1824 and the most widely read (Galhardo, 1928).

A highly illustrative example of this ambiguous situation is the fact that a mere four years after the medical schools were granted the monopoly for licensing doctors, a Swiss physician, Frederico Jahn, defended a doctoral dissertation on homeopathy at the medical school of Rio de Janeiro (Tarcitano Filho, Waisse, 2016, p.784). This dissertation was quickly followed by several others in the 1840s, either for or against homeopathy, defended by José de Calasans Rodrigues de Andrade (1842), Benoit Mure (1843), Jacintho Soares Rebello (1844), and Carlos Augusto Cezar de Menezes (1849). Therefore, the misgivings of the academically trained physicians notwithstanding, homeopathy succeeded in making some steps into academia in those early times, to the point of being considered a suitable subject for a degree of doctor in medicine.

Homeopathic associations, schools, journals, and clinics were soon established throughout the 1840s, and calls were made to include homeopathy in the standard curriculum of medical schools.⁷ The foundation of the Medical-Homeopathic Academy, in 1847, is particularly deserving of mention, as it points to an aspect peculiar to the early development of homeopathy in Brazil. As mentioned in the previous section, two of the main agents in the early spread of homeopathy in Brazil were Mure and Martins, who quickly established a large number of institutions for teaching, practice, publication, research, outreach, and preparation of medicines (Galhardo, 1928). However, neither Mure nor Martins was a physician, which made them a special target of the attacks of the medical establishment. Facing this situation, the homeopaths with a medical degree, although they had initially participated in Mure and Martins’ initiatives, broke away from them and created the Academy, exclusive for academically trained physicians and pharmacists (Tarcitano Filho, Waisse, 2016, p.794). In other words, the homeopathic physicians gave precedence to their professional identity as university graduates over their alliance with the lay homeopaths. This proved to be a successful move. Within the debates held at the conventional medical institutions, amidst opponents and partisans, one reason adduced to give the benefit of the doubt to homeopathy was precisely the fact it was practiced by respected physicians (Galhardo, 1928, p.342-346).

Therefore, in regard to this aspect of the comparative analysis, in Sweden homeopathy met opposition among medical circles as a function of the long tradition of medical teaching and strong influence of the state. Moreover, it was a matter of a particular brand of medicine, more concerned with theoretical consistency than with practical outcomes. Differently, in Brazil conventional medicine fought for the monopoly of healing on the grounds of its alleged scientific status. The immediate response was one of hostility, yet the transitional character of the period allowed homeopathy to take some steps into academia. In addition, the fact that some university doctors adopted and advocated homeopathy gave it some legitimacy in the eyes of a handful of conventional doctors.

Reception by society and the government

A more thorough understanding of the reception of homeopathy by society and the government requires some background knowledge on health care in Sweden and Brazil in the first half of the nineteenth century.

In Brazil, as we discuss in more detail later in this section, homeopathy was partially appropriated by some conventional doctors, who sought to make it official. In this endeavor they resorted to standard resources within the government and the medical establishment. Yet, to the best of our knowledge, no case of striking advocacy by powerful members of society or miraculous cures impacting society occurred.

In Sweden, the State had a long history of firm control over medical education and practice starting with the creation of the Collegium Medicum in 1663, which supervised a small number of doctors with royal privileges (Eklöf, 2007a, p.170). The number of doctors remained very small for centuries. For instance, by 1850 there was one doctor for every 7,522 inhabitants (versus 1/1,176 in England and 1/2,665 in Germany) (Eklöf, 2007a, p.191). As late as 1900, there were just 1,131 doctors in the country (1/4,542 inhabitants), double the figure of just 664 in the middle of the nineteenth century. At that time, the largest proportion of doctors worked in urban areas, one-fourth of them in Stockholm (Eklöf, 2007a, p.191). Along the 1800s, there was one single homeopathic doctor in Sweden: Liedbeck. While in Sweden there were never more than ten homeopathic doctors along the twentieth century, and even fewer in the 1800s, by comparison in the United States 6% of all physicians in the 1870s were homeopaths (Eklöf, 2007a, p.191).

Given the shortage of doctors, it was down to lay practitioners to provide health care. Key among these non-academically trained practitioners were the civil servants of the state church, who had health care responsibilities by governmental mandate. Therefore, concerned with the practical side of medicine – versus the theoretical debates characteristic of university doctors – the clergy were very interested in homeopathy. They saw it as advantageous because it did not require many years of study, it did not depend on pharmacies, the cost of its medicines was low, and it also afforded a cure for the soul (Eklöf, 2007a, p.192). Indeed, the possibility to help a fellow human moderated the views on quackery in Sweden: lay practitioners were not accused of quackery. As concerns homeopathy, the State and conventional doctors tolerated the homeopathic practice of priests and noblemen until the turn of the nineteenth century (Eklöf, 2007b, p.192; Ling, 2004, p.69).

While homeopathy had no academic support in Sweden, it was actively promoted by Count Adolf Eugène von Rosen (1797-1886), an engineer and businessman and the driving force behind the Swedish railway system (Eklöf, 2007a, p.175). Between 1853 and 1860, von Rosen sponsored four proposals to the Riksdag for the government to allocate funds for a homeopathic hospital or outpatient clinic. The reasons he adduced were: the strong position of homeopathy abroad, the large number of homeopathic practitioners among the Swedish clergy, the results of clinical studies, especially the ones on cholera epidemics, and his personal experience as a patient, having been treated by Georgii in London (Eklöf, 2007a, p.175-176). After thorough discussions, the proposals were all turned down.

Differently, in Brazil, until 1828, no doctors had been trained in the country, and a government agency (Fisicatura-mor) granted “letters” that permitted a broad gamut of healers to practice. These included doctors, surgeons, barbers, bleeders, midwives, and popular healers (Pimenta, 2004, p.68). The situation changed in 1832, when, as mentioned above, the schools of medicine of Rio de Janeiro and Bahia were granted the monopoly for licensing healers (p.71).

However, the excluded healers (bleeders, barbers etc.) were not the target of significant persecution. Indeed, they were officially accepted in places without a sufficient number of academic doctors or surgeons: “individuals endowed with some intelligence and willing to be useful to their fellow men” were allowed to work as doctors (Pimenta, 2003, p.40). However, these healers did not limit themselves to such remote areas. Contrariwise, they continued their practice according to the preferences of patients, even advertising in the main newspapers of Rio de Janeiro, the imperial capital (Pimenta, 2004, p.76).

Indeed, the regulation of medical practice was not a government priority and surveillance was inconsistent. As Tânia S. Pimenta (2003, p.34-35) observes, this is evidenced in the laws and decrees passed throughout the period of interest, while their enforcement was sporadic, usually upon the request of one of the official medical institutions. Of no lesser relevance, still according to this author, was the lack of uniform views among conventional doctors themselves, who not infrequently adopted opposing positions (p.36). Yet, the medical establishment, under the newly founded institutions, such as the already mentioned Imperial Academy of Medicine, the Medical Society of Rio de Janeiro (1830), and National Board of Hygiene (1850), did not miss any opportunity to assert its preferential status.

We have just mentioned the National Board of Hygiene. It was established in 1850 for the explicit of purpose of dealing with public health matters, epidemics in particular. Indeed, the immediate trigger for its creation was a yellow fever epidemic in 1849-50 (Pimenta, 2003, p.39). Epidemics are particularly suitable for observing first-hand the ambiguous situation of homeopathy and the fractious relationship between conventional doctors, keen to gain a monopoly over healing, and homeopathic doctors.

For most of the nineteenth century, the vast majority of the university-trained doctors only practiced in Bahia and Rio de Janeiro. In July 1855, at the height of the cholera epidemics that ran throughout the decade, the Police Secretariat of the Court made a list of all the doctors in Rio de Janeiro, organized per area of residence and type of medicine (Pimenta, 2003, p.215-216). The list named 242 doctors in total, twenty of whom were homeopaths (just over 8%). As Pimenta (2003, p.216) observes, this list highlights the government’s recognition of the relevance of homeopathy among the population.

Then, a health survey performed in 1851 across the whole of the province of Rio de Janeiro found that in the 16 districts surveyed, only three had conventional medicine as the only clinical method available. In one only homeopathy was offered, while in the remainder twelve forms of conventional and homeopathic medicine were the methods preferred (Porto, 1989, p.88). By 1860, 85 of the 95 registered homeopathic physicians in South America were working in Brazil, from Pernambuco in the north to Rio Grande do Sul in the south. There were six homeopathic pharmacies in the country, four professional associations (including a homeopathic school), thirty outpatients clinics, and a hospital ward, inaugurated at the time of the 1855-1856 cholera epidemics (Catellan, 1860, p.401-410).

One additional illustrative example is the opening of the first public homeopathic outpatient clinic in Rio de Janeiro in 1843. From 1843 to 1856, it provided care for 81,824 patients, corresponding to a mean of 5,844 patients per year (Porto, 1989, p.91). For the purposes of comparison, the first homeopathic outpatient clinic in history was run in Leipzig, Germany, the birthplace of homeopathy, from 1833 to 1839. The total number of patients for the full period was about 2,500, or about 360 patients per year (Waisse, 2017, p.255).

The examples described above show that homeopathy found fertile soil upon its arrival in Brazil. Yet, it did not stop there: the homeopaths took one step further and publicly criticized the ineffectiveness of conventional medicine. In this endeavor, they cited quantitative evidence for the effectiveness of homeopathy in epidemics. They also demanded the inclusion of homeopaths in municipal medical committees and the opening of cholera wards at local hospitals, which indeed took place (Pimenta, 2003, p.216-218). Moreover, within the context of the epidemic, some conventional doctors came to admit homeopaths in the cholera clinics they ran (p.218). Homeopaths were members of the official medical institutions, including the National Board of Hygiene (p.218). And the rate of conversion from conventional to homeopathic medicine dramatically increased during the epidemics of yellow fever and cholera (p.218).

It could be inferred from this that at the time of its arrival in Brazil, the conflict was not so strong among doctors, conventional or homeopathic, as between university-trained doctors, both conventional and homeopathic, and lay homeopathic practitioners. On the side of the conventional medical establishment, the most irritating element was the existence of a homeopathic institute, founded by Mure and Martins, which taught homeopathy to individuals without any previous formal education whatsoever. The inability of the government to control this situation is shown by the final decision of the State Council: it confessed it was unable to prohibit the teaching of homeopathy and the granting of certificates, but said that such certificates could not be registered at public health agencies and did not give their holders the right to practice medicine (Pimenta, 2003, p.222). In turn, the homeopathic doctors openly combatted the training and practice of lay homeopaths, as mentioned above, through the creation of the Medical Homeopathic Association exclusively for university-trained physicians and pharmacists.

Our comparison thus shows that in response to the shortage of physicians in both Sweden and Brazil, lay practitioners were allowed to provide health care. In Sweden, the clergy had health care obligations by governmental mandate, and thus, different from physicians, were more interested in the practical side of medicine. In time they were attracted to homeopathy for what they saw as its practical advantages. However, although the State and the medical establishment tolerated the homeopathic practice of priests and noblemen, proposals for its formal institutionalization were systematically rejected, even though they had the support of influential members of society. In Brazil, academically trained doctors were struggling to have their monopoly of healing recognized, and did not yet have enough political power to ban other modalities of healing. In this regard, the government seems to have turned a blind eye, possibly because of a concern with the burden of disease, epidemics in particular, which it had no means to tackle. This lack of health care facilities, the rapid establishment of homeopathic services, a succession of severe epidemics, and the proactive reaction of homeopaths contributed to pave the way for the spread of homeopathy across Brazil. Within this context, the academically trained homeopaths chose to identify with the medical establishment and forsook their connections with lay practitioners and institutions.

Final considerations

Studies on the early spread of homeopathy traditionally tend to emphasize the figure of the “introducer,” sometimes designated an “emissary,” “missionary,” or even an “apostle.” In consequence, the emphasis of scholars has been on the proper identification of “introducers,” the evidence capable of establishing who might be considered the “true” introducer of homeopathy to a given country, and how “introduction” effectively occurred (Tarcitano Filho, Waisse, 2016, p.780-785).

However, as discussed here, the attribution of the title of “introducer” is debatable in the cases of both Sweden and Brazil. If a discipline or field of study might be considered to be institutionalized through the identifiable fulfillment of four prerequisites – the teaching, research, spread, and application of knowledge – and the existence of a community of practitioners that self-identifies as such (Caron, 1988; Alfonso-Goldfarb, Ferraz, 2002, p.4), it is very difficult to argue that homeopathy was institutionalized at all in Sweden in the nineteenth century. As was shown, Wahlenberg merely taught some homeopathy in his medical lectures, seemingly exerting definitive and significant influence on Liedbeck only. The latter, in turn, was practically the only homeopathic practitioner in Sweden in the nineteenth century, and he did not give rise to any school (i.e. he did not teach), he did not conduct or promote research but for a single, small study at his own clinic, and he was not a member of any self-identified community of “Swedish homeopathic physicians;” his efforts did not bear lasting fruit. Therefore, one might adduce that the effective introduction and spread of homeopathy in Sweden was the result of the work of a few homeopathic physicians in the early decades of the twentieth century and the well-known lay homeopath Klara Fransén. Lay homeopathy survived in the country, despite coming up against several stumbling blocks (Eklöf, 2007b, 2014).

In Brazil, homeopathy arrived through various, often mutually conflicting paths, and its success cannot be attributed to the isolated work of any one actor alone, much less without thorough consideration of the socio-historical and scientific context. Homeopathy did not have to contend with a long-established, soundly institutionalized tradition of conventional medicine. Indeed, conventional doctors were themselves fighting to legitimize their practice and acquire a monopoly over healing. In addition, under the local conditions, the dramatic epidemics in particular, the government was more interested in effective means to combat disease than in supporting any particular approach to medicine at the expense of others – including non-medical healing professions. Naturally, these conclusions only apply to the first half of the nineteenth century. Other factors and determinants still deserving of more thorough study entered the picture from the 1860s onward (Weber, 2016, 2006; Waisse, Tarcitano Filho, 2011; Sigolo, 1999; Bertolli Filho, 1990; Warren Jr., 1986).

Therefore, the cases of Sweden and Brazil – and probably also Britain and Spain, according to Reiswitz (2012) – suggest that the traditional recourse to the character of the introducer is heuristically fruitless. At best, it might be seen as a sterile exercise in establishing imaginary priorities and paternities of the kind strongly criticized in the modern historiography of science and medicine (Canguilhem, 1994, p.9-23).

The comparative analysis performed here shows that in both countries in question the number of university-trained doctors was small at the time of arrival of homeopathy, a condition theoretically favorable to its rooting and institutionalization. However, in Sweden homeopathy met opposition, as a function of its long tradition in the teaching of medicine, strong government control, and the pre-existence of a national brand of lay healers. Differently, in Brazil conventional medicine was fighting for a monopoly of healing, while the government was not much concerned with the qualifications of the various modes of healers.

As such, as a function of epistemological factors and throughout the period of debates about homeopathy, from the 1820s to 1860s, Swedish doctors gave theoretical consistency precedence over clinical effectiveness. Medical statistics were mistrusted and there was an overwhelming belief in the healing powers of nature, in agreement with the tradition of Romantic medicine and Naturphilosophie. In Brazil, at the time of the arrival of homeopathy, there was no tradition of local learned medicine, and homeopaths aggressively came to the fore brandishing statistical proof of the success of homeopathy in epidemics – curiously, the very same statistics that Swedish doctors, mainly concerned with medical theory, dismissed.

In agreement with such trends, no clinical teaching was provided to medical students in Sweden until 1839. By that time, the homeopathic care and teaching clinic in Leipzig had already opened and closed, and a mere four years later (1843) the first Brazilian homeopathic outpatient clinic opened its doors. Infectious and contagious diseases, epidemic or endemic, always posed a heavy burden in Brazil, and it is likely that the quantitative evidence provided for the effectiveness of homeopathy was a decisive factor in the early history of this medical approach in the country.

To be sure, health care was a serious public policy issue in both countries, leading to a tolerant attitude vis-à-vis non-academically trained providers. In Sweden, lay homeopathic practitioners belonged to two of the four estates represented in parliament, i.e. they were respected members of the community. Nevertheless, their situation was not comparable to the open royal support received in Britain, for instance (Reiswitz, 2012). In the case of Brazil, the current state of the art points to an unexpected picture: more than a conflict between conventional and homeopathic doctors, homeopathy triggered a division between academically trained and non-academic practitioners, with the homeopathic doctors siding with their conventional colleagues in the quest for a monopoly over healing.

Reiswitz (2012) identifies a different picture in Britain and Spain. In the former, conventional medicine was strongly institutionalized. As a result, the strategy of legitimation chosen by Frederick Quin (1799-1878), the founder of the London Homoeopathic Hospital (1849), was to emulate the institutional structure of conventional medicine and establish homeopathy as a practice of the exclusive domain of academically trained doctors. The fact that Quin was a highly reputed physician and had wide transit among the English elites hindered the medical establishment from barring him from practice – yet he was blackballed for admission to the Royal College of Physicians. In Spain, at the time of the arrival and early institutionalization of homeopathy, the medical profession was in a state of thorough disarray, and thus it was not rejected outright by doctors. Indeed, as Reiswitz observes, José Nuñez Pernía (1805-1879), the founder of the Homeopathic Institute and San José Hospital, in Madrid (1878), met with a reasonably well-informed, initially neutral medical opinion. Also, Nuñez had easy access to the elites, and was the personal physician of the Spanish queen; in fact, the hospital was created by royal decree. Due to the chaotic state of the medical profession, differently from Quin, Nuñez did not find institutional structures to emulate, so he had to develop original ones. This he did in a highly rigorous manner that put homeopathy one step ahead of the institutions of conventional medicine.

Therefore, Reiswitz’s and our results point to three different patterns of interaction between conventional and homeopathic medicine: full rejection and failure of the institutionalization of homeopathy (Sweden); hostile reception, but success of the advocates of homeopathy – Britain and Brazil, the former with and the latter without the support of influential members of society; and neutral reception (Spain). In the case of Brazil it is worth remembering once again that conventional medicine was struggling to legitimize itself as “scientific medicine” and acquire a monopoly over healing.

To conclude, our results strongly suggest – corroborating Dinges’s (2001) observations – that the analysis of contexts, determinants, and the interactions of practitioners and institutions representing different health care approaches, dominant or alternative, seems to provide a more accurate picture of different moments in the global history of medicine. We might thus expect that future studies conducted with the comparative method will improve our understanding of the transnational spread of homeopathy at different times and under different circumstances.

ACKNOWLEDGEMENT

This paper is a result of a collaborative project jointly conducted by Uppsala University (Department of History of Science and Ideas), the Karolinska Institute (Unit for Medical History and Heritage), and the Graduate Program in History of Science/Center Simão Mathias of History of Science (Cesima), Pontifícia Universidade Católica de São Paulo, funded by the governmental agencies STINT (Sweden) and CAPES (Brazil).

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NOTES

• 1
  For updated historiographical reviews of the history of homeopathy in the early nineteenth century in Sweden and Brazil, see Eklöf (2003, 2007b, 2014), Weber (2006, 2016), Tarcitano and Waisse (2016), and Waisse and Tarcitano (2011).
• 2
  For a thorough and updated review of historiographical models to represent the transit of knowledge, see Alfonso-Goldfarb et al. (2015).
• 3
  The earliest mention to homeopathy in Sweden was in an article written by the Royal Doctor Sven Hedin, in 1797, “Essay on a new principle to ascertain the curative powers of drugs,” published the year before by Hahnemann, where he first announced the principle of similia (Eklöf, 2003, p.204).
• 4
  The period from the 1910s to the 1930s was the most prosperous for Swedish homeopathy, including the creation of associations of medical and lay practitioners, journals and public debates. In particular, successful lobbying in parliament resulted in amendments to the legislation on pharmaceuticals – favorable to homeopathy – and the abolition of the monopoly over healing by academically trained physicians in 1916 (Act regarding authorization to practice the art of doctoring [Lag om behörighet att utöva läkarkonsten], from 1916), which paved the way for legal lay practitioners of so-called alternative medicine. For more on this, see Eklöf (2001).
• 5
  Duque Estrada studied medicine at the Escola de Medicina e Cirurgia do Rio de Janeiro, concluding the course in 1833, when he was appointed adjunct secretary of the Escola Médica do Rio de Janeiro. From 1835 to 1844 he served as head librarian at this school, and in 1840 was elected a representative to the congress of the Rio de Janeiro province. In 1847 he earned a degree in medicine in Belgium (Galhardo, 1928, p.277).
• 6
  In the original: “Den känsliga, för att ej säga den sentimentala, afdelningen af qvinnokönet, är ett särdeles lämpligt fält för homeopatins verksamhet.”
• 7
  Yet homeopathy was first taught at university level only in 1912 (Salles, 2008, p.286). As in the United States (Winston, 1999), this homeopathic medical school later became a conventional school, which exists to this day. In honor of its origin, the Medical School of the Universidade Federal do Estado do Rio de Janeiro (UNIRIO) has to this day a department of homeopathy, and was the first higher education institution in the world to establish a medical residency program in this field (Salles, 2008, p.286).

Publication Dates

• Publication in this collection
  28 Nov 2019
• Date of issue
  Oct-Dec 2019

History

• Received
  20 Mar 2018
• Accepted
  2 July 2018