Medical Education in the Sixteenth- and Seventeenth-Century Atlantic World
Medical Knowledge in the Early Modern Iberian Peninsula and the Viceroyalties
Medical education and training took various forms and had a variety of outcomes in early modern Iberia and the viceroyalties. The medical field comprised physicians, surgeons, barbers, apothecaries, midwives, and healers, encompassing a wide variety of educational and training oaths. Previous scholarship on medical education in this context is often forced into binaries. Some debates within the historiography include questions such as: was the training practical or theoretical? Is the surgeon a Romance or Latinate surgeon? However, overall, medical education and practice took place on a spectrum encompassing practical, theoretical, and experiential healing in a context of cultural contact and integration. Frequently medical students and practitioners moved between the Spanish and Portuguese territories. All of the university-educated men discussed in this chapter were born in Portugal but educated in Spain, later working in Portugal or the viceroyalties.
Broadly, physicians needed a university education to practice, and earned the titles of licenciados or bachilleres. In contrast, surgeons (cirujanos), barbers (barberos), or sugeon barbers (cirujanos barberos) trained via apprenticeship with established practitioners in hospitals or via private practice, later obtaining a license to practice upon passage of an oral examination.[1] Surgeons and barbers, commonly referred to as empirics—employing hands on, practical skills in their treatments – often benefitted from the portability of their trade. Imperial armies, navies, and slave traders employed surgeons and barbers for myriad ventures.[2] Apothecaries (boticarios) trained and received certification in much the same way.[3] Healers (curanderas/os) typically benefitted from a generational education, learning Indigenous or African methods of healing from established and well-respected family members or peers. Curanderas operated successfully in the viceroyalties without the support of the protomedicato, the governing body regulating medical practice and practitioners. Curanderas faced persecution from the protomedicato, given their lack of formal education or training, in spite of their popularity with the general populace.[4] In many cases, particularly in rural regions, people only had access to a local curandera for their medical needs. Shortages in medical practitioners led to demands for anyone with medical knowledge, no matter how rudimentary.[5] This context of demand and overlap paved the way for Portuguese-born physicians and surgeons to prosper in the viceregal world.
After the mid-sixteenth century, European universities began to integrate surgical curriculum along with anatomical study and dissection into their medical programs. Thereafter, surgeons trained at universities and versed in Latin terminology were considered Latinate surgeons or latinistas. Surgeons who trained via apprenticeship and worked in Spanish or regional dialects rather than Latin were deemed romance surgeons or romancistas.[6] Governing bodies, like the protomedicato, reinforced a hierarchy of Latinate surgeons enjoying more prestige than their Romance counterparts. Latinate surgeons with access to resources to fund their university education and theoretical training outranked practically trained, apprenticed romance surgeons. This hierarchy played into the binary of either/or, practical v. theoretical, romance v. Latinate, the mind v. the hands, intellectual v. manual labor. To some degree, these dichotomies persisted as Iberian populations made their way across the Atlantic. The demand for qualified practitioners existed in both the ‘Old World’ and the ‘New’, with far fewer medical specialists available in New Spain and Peru. This opened the door for physicians and surgeons from Spain and Portugal to fill a growing demand, even with their perceived dubious origins.
The sheer demand for qualified practitioners in the viceroyalties lessened, to some extent, the binary, but did not eliminate it.[7] Iberian governing practitioners, protomédicos, had a long-established role in regulating the licensing of practitioners to uphold this hierarchy.[8] In New Spain and Peru, the Protomédicato took time to set up; its “definitive” establishment did not occur until 1646 in the Indies.[9] While individual protomédicos existed for licensing and certification for surgeons, barbers, and apothecaries, the institutional regulation took much longer to form. Even after its establishment, the sheer size of the viceregal territories and rapidly expanding populations of New Spain and Peru made effective regulation nearly impossible.[10] Much like the Holy Office, the Royal Protomedicato experienced severe limitations of regulation and enforcement in medical practice. In both Spain and its viceroyalties, the populace did not impose the same binaries on medical education and practice. Selection of a medical practitioner had much more to do with cost, proximity, and reputation than with imposed binaries and hierarchies.
University Education
University medical curriculum throughout Western Europe in the sixteenth and seventeenth centuries emphasized Hippocratic and Galenic medicine as well as the Avicenna’s Canon of Medicine. Broadly, Hippocratic medicine emphasized the body’s humors. Humoral imbalance led to disease, while balance indicated a healthy body. Galenic medicine expanded upon the Hippocratic Corpus, most notably implementing bloodletting as a means of draining the blood to rebalance the humors.[11] Avicenna’s Canon, a compilation of Greco-Arabic medicine has five parts: the human body, ailments and their treatments, materia medica, pathology, and fevers and accidents. This magnum opus served as the preeminent medical text throughout Europe from the 11th through the 16th centuries.[12]
Humanistic thinkers aimed to replace medieval scholasticism and revive ancient texts. This change led to broader knowledge application and interpretation, and ultimately to the establishment of anatomical and surgical chairs at European universities.[13] These new curricula combined both theoretical and practical learning. Surgical dissection of bodies of the unclaimed poor and the executed served as practical application of anatomy and physiology.[14] The Italian University of Padua led the charge in this field with Andreas Vesalius lecturing in anatomy and performing dissections for students between 1537 and 1542.[15] Padua’s second anatomical theatre, constructed between 1594-1595 still stands today. Salamanca commenced its anatomical studies program in 1551, following the Vesalian Reform movement in Spain. This movement emphasized the “renewal” of anatomical knowledge in Spain after Vesalius’s works were published during his time in Padua.[16] After leaving Padua in 1542, Vesalius served as the Imperial Physician to Holy Roman Emperor Charles V (Charles I of Spain) and later to his son, Philip II.[17] The University of Coimbra in Portugal likewise boasted an anatomy and dissection curriculum by the mid-sixteenth century.[18] A royal order in 1556 established an aula for anatomy and surgery in New Spain.[19] The Real y Pontífica Universidad de México incorporated anatomy and surgery into its medical curriculum by 1621.[20] While Lima’s University de San Marcos had a chair in medicine at this time, the royal approval for a chair in anatomy and dissection did not pass until early in the eighteenth century.[21] In spite of shifting curriculum and training and the combination of practical and theoretical application via dissection, governing bodies still reinforced the binary that ranked university-educated surgeons higher than their apprenticed counterparts.
Many students travelled from Portugal to Spain, Salamanca in particular, to attain their medical education. The fact that, in 1545, Portugal’s King Joao III increased the University of Coimbra’s medical curriculum to eight years of combined theoretical study and practical training might have motivated their desire to earn the degree in Spain. A significant number of aspiring Portuguese physicians left Portugal for Salamanca where the degree could be completed in four years. According to Angel Marcos de Díos, prior to 1570, Portuguese students made up 20% of Salamanca’s matriculated students. By 1580, the number had risen to approximately 28%.[22] Portuguese graduates who returned to Portugal only had to pass a licensing exam by the Chief Physician (Físico-Mor) in order to receive their credentials to practice.[23]
The University of Salamanca required medical students to first acquire a degree in the arts before commencing medical education. Salamanca’s medical curriculum required students to complete four years of course in medicine, attend a minimum of ten different public lectures on medical topics, and pass a final oral examination.[24] Those physicians who studied at universities in the viceroyalties likewise undertook a curriculum of both theoretical and practical study. Students of the Real y Pontífica Universidad de México also had to have a degree in the arts before studying medicine. Those who advanced to the study of medicine completed the necessary coursework, attended at least ten public medical lectures, and engaged in public discourses featuring discussion and analysis of relevant subject matter with fellow students and faculty members before they could petition for graduation and defend their thesis. Some students who obtained experiential training elsewhere sought to ‘test out’ of required coursework and discourses by obtaining waivers. Crown mandates and university bylaws put an end to this practice by the early 1600s, requiring students to complete the entire curriculum.[25]
Licensing
In Portugal, where each of the licensed surgeons and apothecaries discussed here received their certification, the Crown established the positions of Físico-Mor (Chief Physician) and Cirugião-Mor (Chief Surgeon). The Chief Physician examined and issued licenses to practice for physicians educated outside of Portugal and inspected apothecaries to regulate prices of sold medicines.[26] Surgeons who trained in hospitals, confraternities or via apprenticeship, needed to pass an examination by the Chief Surgeon. This official also examined and certified barbers, midwives, bloodletters, and dentists. The overlap in services rendered by surgeons, dentists, barbers, and bloodletters – namely bleeding, tooth extraction, and bone setting – indicates a dynamic, often convoluted field of medicine without definitive boundaries or binaries.[27] Portuguese Jews and New Christians (Christãos Novos) made up some 63.5% of licensed physicians and surgeons in Portugal by the end of the fifteenth century.[28]
The School of Surgery at the Todos os Santos hospital in Lisbon offered both practical and theoretical training for surgeons. Hospital surgeons read aloud to apprentice-surgeons in training, who then applied their knowledge in practice.[29] Laurinda Abreu contends that surgeons trained at Todos os Santos enjoyed a better professional and social reputation than surgeons trained in other hospitals. Hospital surgeons also penned many relevant medical texts, further boosting the hospital’s reputation.[30] While this method of training did not require aspiring surgeons to be literate in Latin, or even at all, for that matter, it does blur the binary of practical v. theoretical training.
Spanish regions also required licensing by respective protomédicos. While the greater populace did require university education or licensing to trust a healer, these licenses entitled the practitioner to charger higher rates for services rendered if they were so inclined.[31] In the viceroyalties, the Protomedicato existed only in capital cities. This severely limited the ability to effectively regulate the examination and licensing of surgeons, barbers, and midwives.[32] This resulted in fewer protomédico-licensed practitioners in New Spain and Peru, increasing the demand for practitioners of any background, even if they might be marginalized in other aspects of life.
[1] Raúl Expósito González, “Barberos y sangradores en Iberoamerica,” Cuatrimestre 29 (2011): 35–36; Margarita Cabrera, “Médicos, cirujanos, y curanderos en Córdoba durante la segunda mitad del siglo xv,” Anuario de Estudios Medievales 26 (1996): 340–41; John Tate Lanning, The Royal Protomedicato: The Regulation of the Medical Profession in the Spanish Empire, ed. John Jay Tepaske (Durham: Duke University Press, 1985), 45; For a broad overview of apprenticeships in early modern Madrid, see: Victoria López Barahona and José Antolín Nieto Sánchez, “Artisan Apprenticeship in Early Modern Madrid,” in Apprenticeship in Early Modern Europe, ed. Maarten Prak and Patrick Wallis (Cambridge: Cambridge University Press, 2020), 44–77.
[2] Teresa Huguet-Termes, “New World Materia Medica in Spanish Renaissance Medicine: From Scholarly Reception to Practical Impact,” Medical History 45, no. 3 (2001): 360; Guenter B. Risse, “Medicine in New Spain,” in Medicine in the New World: New Spain, New France, and New England, ed. Ronald L. Numbers (Knoxville: University of Tennessee Press, 1987), 14.
[3] See: Paula Ronderos, “El arte de boticario durante la primera mitad del siglo xvii en el Nuevo Reino de Granada,” Fronteras de la Historia 12 (2007): 175–96.
[4] See: Noemí Quezada, “The Inquisition’s Repression of Curanderos,” in Cultural Encounters: The Impact of the Inquisition in Spain and the New World, ed. Mary Elizabeth Perry and Anne J. Cruz (Berkeley: University of California Press, 1991); Lanning, The Royal Protomedicato, 135–52.
[5] For a general overview of these categorizations in New Spain, see: Sherry Fields, Pestilence and Headcolds: Encountering Illness in Colonial Mexico (New York: Columbia University Press, 2008), 40–89.
[6] Risse, “Medicine in New Spain,” 13–14; Lanning, The Royal Protomedicato, 45.
[7] Huguet-Termes, “New World Materia Medica in Spanish Renaissance Medicine,” 360.
[8] Risse, “Medicine in New Spain,” 15–16.
[9] Lanning, The Royal Protomedicato, 62.
[10] González, “Barberos y sangradores en Iberoamerica,” 38–40.
[11] Robin Price, “Spanish Medicine in the Golden Age,” Journal of the Royal Society of Medicine 72 (1979): 13; Ian H. Kerridge and Michael Lowe, “Bloodletting: The Story of a Therapeutic Technique,” Medical Journal of Australia 163, no. 11–12 (1995): 631; See also: K. Codell Carter, The Decline of Therapeutic Bloodletting and the Collapse of Traditional Medicine (New Brunswick: Transaction Publishers, 2012).
[12] O. Cameron Gruner, M.D., A Treatise on The Canon of Medicine of Avicenna, Incorporating a Translation of the First Book (London: Luzac & Co., 1930); Nancy G. Siraisi, Avicenna in Renaissance Italy: The Canon and Medical Teaching in Italian Universities after 1500 (Princeton: Princeton University Press, 1987); Sajjad Sadeghi et al., “Galen’s Place in Avicenna’s The Canon of Medicine: Respect, Confirmation and Criticism,” Journal of Integrative Medicine 18 (21-25): 2020; Francisco Guerra, “Medical Education in Iberoamerica,” in The History of Medical Education: An International Symposium Held February 5–9, 1968, ed. C. D. O’Malley (Berkeley: University of California Press, 1970), 419–62; Joseph Shatzmiller, Jews, Medicine, and Medieval Society (Berkeley: University of California Press, 1994), 48–50.
[13] Kristy Wilson Bowers, Renaissance Surgeons: Learning and Expertise in the Age of Print (London: Routledge, 2023), 16–17.
[14] Blaise Cronin, Cathedrals of Learning: Great and Ancient Universities of Western Europe (Cambridge, MA: Chandos Publishing, 2016), 110.
[15] Cynthia Klestinec, “A History of Anatomy Theaters in Sixteenth-Century Padua,” Journal of the History of Medicine and Allied Sciences 59, no. 3 (2004): 380–82; Cronin, Cathedrals of Learning, 216; Andrea Porzionato et al., “The Anatomical School of Padua,” The Anatomical Record 295, no. 6 (2012): 903–5.
[16] José M. López Piñero, “The Vesalian Movement in Sixteenth-Century Spain,” Journal of the History of Biology 12, no. 1 (1979): 45–81; Álvar Martínez-Vidal and José Pardo-Tomás, “Anatomical Theatres and the Teaching of Anatomy in Early Modern Spain,” Medical History 49 (2005): 256.
[17] Bjørn Okholm Skaarup, Anatomy and Anatomists in Early Modern Spain (Farnham: Ashgate, 2015), 13.
[18] Guerra, “Medical Education in Iberoamerica,” 28–30; Charles R. Boxer, “Some Remarks on the Social and Professional Status of Physicians and Surgeons in the Iberian World, 16th-18th Centuries,” Revista de Historia 50, no. 100 (1974): 201; Francis A. Dutra, “The Practice of Medicine in Early Modern Portugal: The Role and Social Status of the Fisco-Mor and the Surgião-Mor,” in Libraries, History, Diplomacy, and the Performing Arts: Essays in Honor of Carleton Sprague Smith, ed. Israel J. Katz (New York: Pendragon Press, 1991), 138; Laurinda Abreu, “Training Health Professionals at the Hospital de Todos Os Santos (Lisbon) 1500-1800,” in Hospital Life:Theory and Practice from the Medieval to the Modern (New York: Peter Lang, 2013), 128.
[19] Guerra, “Medical Education in Iberoamerica,” 429.
[20] Gerardo Martínez Hernández, “La práctica y la enseñanza de la anatomía en la Real Universidad de México, siglos xvi y xvii,” Studia Historica. Historia Moderna 42, no. 1 (2020): 289; Gerardo Martínez Hernández, “La anatomía en la Real Universidad de México en los siglos xvi y xvii: un acercamiento a su práctica y docencia,” in El libro académico en época colonial y moderna, ed. Yolanda Blasco Gil and Armando Pavón Romero (Bonilla Artigas Editores, 2022), 52. See also: José Pardo-Tomás, “Opening Bodies in a New World: Anatomical Practices in Sixteenth-Century New Spain,” in Anatome: Sezione, Scomposizione, Raffigurazione Del Corpo Fra Medioevo e Età Moderna, ed. Giuseppe Olmi and Claudia Pancino (Bologna: Bononia University Press, 2012), 185–202; Leticia Pérez Puente, “Las cátedras de la Universidad de México: entre estudiantes y doctores,” in De maestros y discípulos: México, siglos XVI-XIX (México, D. F.: Universidad Nacional Autónoma de México, 1998), 15–60.
[21] Agueda María Rodríguez Cruz , O. P., Historia de las universidades hispanoamericanas (Bogotá: Imprenta Patriótica del Instituto Caro y Cuervo, 1973), 219, 223; Julio Luis Cárdenas Valenzuela, “Historia de la anatomía en Chile: los inicios,” International Journal of Morphology 35, no. 3 (2017): 962; See also: Pedro M. Guibovich Pérez, “Society and Education: The University of San Marcos in the 16th Century,” in A Companion to Early Modern Lima, ed. Emily A. Engel (Leiden: Brill, 2019), 216–34.
[22] Ángel Marcos de Díos, Gabriel A. Coelho Magalhães, and Pedro Serra, “La Universidad de Salamanca y la medicina portuguesa: médicos, Judíos, y Cristianos Nuevos,” in Las universidades hispánicas de la monarquía de Los Asturias al centralismo liberal, vol. 2 (Salamanca: Ediciones Universidad de Salamanca, 1998), 338.
[23] Laurinda Abreu, “Tensions Between the Físico-Mor and the University of Coimbra: The Accreditation of Medical Practitioners in Ancien-Regime Portugal,” Social History of Medicine 31, no. 2 (2017): 236; Noemí Cubas Martín, “Salamanca y Coimbra: Universidades Peninsulares del Renacimiento, análisis de la población universitaria a través de los grados académicos” (PhD diss., Universidad de Salamanca, 2013), 359.
[24] Cubas Martín, “Salamanca y Coimbra,” 267; See also: Abreu, “Tensions Between the Físico-Mor and the University of Coimbra”
[25] Gerardo Martínez Hernández, “La trayectoria académica del bachiller en medicina de la Real Universidad de México. Siglo xvii,” Intus-Legere Historia 2, no. 1 (2008): 81–86.
[26] Abreu, “Tensions Between the Físico-Mor and the University of Coimbra,” 234. See also: Boxer, “Some Remarks on the Social and Professional Status of Physicians and Surgeons in the Iberian World, 16th-18th Centuries”; Dutra, “The Practice of Medicine in Early Modern Portugal: The Role and Social Status of the Fisco-Mor and the Surgião-Mor.”
[27] Laurinda Abreu, “Health Care and Poor Relief in Portugal: An Historical Perspective,” in Health Care and Government Policy, ed. Laurinda Abreu (Evora: Publicações do Cidehus, 2019), 06.
[28] Boxer, “Some Remarks on the Social and Professional Status of Physicians and Surgeons in the Iberian World, 16th-18th Centuries,” 198–99.
[29] Abreu, “Training Health Professionals at the Hospital de Todos Os Santos (Lisbon) 1500-1800,” 119–27.
[30] Abreu, "Training Health Professionals at the Hospitals de Todos Os Santos," 129.
[31] Michele L. Clouse, Medicine, Government, and Public Health in Philip II’s Spain: Shared Interests, Competing Authorities (New York: Routledge, 2016), 03–04.
[32] Lanning, The Royal Protomedicato, 45–47.