BRAIN
A JOURNAL OF NEUROLOGY
OCCASIONAL PAPER
The ‘Ajuda Paralyses’: history of a neuropsychiatric
debate in mid-19th-century Portugal
Paulo Fontoura
1,2
1 Department of Immunology, Faculty of Medical Sciences, New University of Lisbon, Portugal
2 Translational Medicine Group CNS, Roche Pharmaceuticals, Basel, Switzerland
Correspondence to: Paulo Fontoura,
F. Hoffmann – La Roche,
Pharma Research and Exploratory Development,
Grenzacherstrasse 124, Building 74 Room 3W.412,
4070 Basel BS, Switzerland
E-mail: paulo.fontoura@roche.com; paulo.fontoura@fcm.unl.pt
The second half of the 19th century witnessed an increasing interest in neurology and psychiatry by Portuguese physicians, in
parallel with the overall development of these disciplines in other countries. This process is reflected in the numerous case
report publications as well as in debates taking place at the Lisbon Society of Medical Sciences, the major scientific forum of
that time. The ‘Ajuda Paralyses’ were a mysterious succession of epidemics that occurred during 1860–64 in the Ajuda asylum
for cholera and yellow fever orphans, which were extensively discussed during 1865–66 by Bernardino Antonio Gomes, Antonio
Maria Barbosa, Abel Jorda˜o and Eduardo Motta. Studying this debate helps understand the initial stages of development and the
great interest that ‘nervous diseases’ had for Portuguese clinicians in the mid-19th century and possibly provides one of the first
modern descriptions of nutrition-related polyradiculoneuropathy and the ocular findings associated with avitaminosis A. This
debate took place at a decisive time for the scientific development of neurology and psychiatry, concurrent with the widespread
application of the clinical-anatomical method and neuropathology to the study of diseases of the nervous system, which would
set the foundations for our own modern pathophysiological framework. Therefore, the ‘Ajuda paralyses’ debate also provides a
good basis for a discussion on the evolution of the concepts of hysteria and psychosomatic disease and the description of
peripheral neuropathy from among a wealth of other entities that did not withstand the test of science.
Keywords:
history of neurology; 19th century; Portugal
Abbreviation:
SCML = Sociedade das Cieˆncias Me´dicas de Lisboa
Historical context: the great
sanitary crisis of 1856–57
During the second half of the 19th century, Portugal underwent a
period of sustained growth and political stability after the turmoil
of the Civil War (1828–34) and the fractious beginnings of the
constitutional monarchy in the period known to historians as the
‘Devourism’. From the beginning of the ‘Regeneration’ period
onward (starting in 1851), for the first time a numerous elite of
clinicians and researchers appeared in Portuguese medicine,
including several physicians who had been trained and maintained
contact with some of the mainstream centres of European aca-
demic medicine (especially Paris, where the anatomoclinical
method was transforming medical science). The Lisbon Society
of Medical Sciences (Sociedade das Cieˆncias Me´dicas de Lisboa,
SCML), founded in 1822 and today one of the oldest medical
societies in continuing existence, was the privileged forum for sci-
entific discussion during this period and a transforming force for
social change. By the mid-19th century, the SCML had acquired
doi:10.1093/brain/awq211
Brain 2010: 133; 3141–3152
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Received March 1, 2010. Revised June 2, 2010. Accepted June 10, 2010. Advance Access publication August 18, 2010
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The Author (2010). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
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considerable national prestige and a dynamic membership, and its
list of presidents includes most of the major figures in Portuguese
medicine. The SCML Journal, published from 1836 until the pre-
sent day, became the main scientific medical publication at that
time, where the most relevant original works appeared (Torres
Pereira et al., 2006).
Historically, the chief identifiable milestones for the establish-
ment of neurology and psychiatry as independent medical discip-
lines in Portugal came only with the creation of the Lisbon and
Porto Medical Schools in 1911 and their first professorships in
these disciplines, given to Nobel prize winner Egas Moniz
(1874–1955) and to Magalha˜es Lemos (1855–1931), respectively
(Fontoura, 2008). Previously, however, there were already some
signs of activity in these areas. The first dedicated internment unit
for mental disorders in the country, the Rilhafoles asylum in
Lisbon (now called hospital Miguel Bombarda), had been created
in 1848 to replace the markedly unsound conditions in which
‘alienated’ patients had been treated at St. Joseph’s Hospital up
until then (Senna, 1885; Ferreira de Mira, 1947). A similar insti-
tution was founded in Porto in 1883, the Conde de Ferreira
hospital for alienated patients (Pereira et al., 2005). During the
next six decades, several physicians showed an evident interest in
the diseases of the nervous system. Among the better known is
Antonio Maria Bettencourt Rodrigues (1854–1933), who trained
in Paris with Jean-Martin Charcot (1825–93) and Charles-Joseph
Bouchard (1837–1915), gave the first public series of lectures on
‘neuropathology and psychiatry’ in Lisbon in 1887–89 and
founded the first journal dedicated to this area, the Revista de
Nevrologia e Psychiatria (Review of Neurology and Psychiatry),
which lasted from 1888 to 1890. Other relevant figures include
Antonio Maria de Senna (1845–90), the great reformer of psy-
chiatric legislation; Miguel Bombarda (1851–1910) the would-be
first president of the Portuguese republic, responsible for the
clinic for neurological diseases at St. Joseph hospital (Clinica
externa de doenc¸as nervosas e mentais), director and reformer
of the Rilhafoles asylum from 1892 until his death; and
Virgı´lio Machado (1859–1927), trained at the Salpeˆtrie`re with
Edouard Brissaud (1852–1909) and Fulgence Raymond (1844–
1910), author of the first Portuguese textbook on neurological
semiology (Elementos de Neurossemiologia Clinica, 1919) and
founder of the first neurological diseases ward in St. Joseph’s
hospital in Lisbon at the end of the 19th century (Ferreira de
Mira, 1947; Reis de Oliveira, 2006; Araujo, 2007; Fontoura,
2008).
The intention of this article is to outline what was undoubtedly
one
of
the
great
debates
on
neuropsychiatric
issues
in
19th-century Portugal, fully absorbing the SCML in 1865–66,
and to comment on the observations of this first generation of
what could be called Portuguese proto-neurologists. Also, I will
endeavour to provide a critical appraisal of the debate in the
light of contemporary scientific knowledge, illustrating the depth
and sophistication of the discussion as well as proposing a new
interpretation for the puzzling clinical phenomena which were
described.
The historical setting for this debate was the great sanitary crisis
that occurred in Lisbon during 1856–57. In those 2 years, epidem-
ics of cholera and yellow fever ravaged the capital city of Portugal
and together caused up to 10 000 deaths (2.5% of the popu-
lation). Lisbon was a prosperous and vibrant city in the mid-19th
century and one of the major European ports. However, sanitary
conditions in the city were deficient, leading to recurrent public
health problems. Yellow fever was not endemic but was regularly
imported in cargo ships coming from Brazil; in fact, in 1723 Lisbon
suffered the first documented epidemic of this disease in Europe
(Eager, 1902; Augustin, 1909b) in which 6000 people died. In
1856, there was a further outbreak of yellow fever in Lisbon,
affecting 122 victims, together with a cholera epidemic [part of
the third cholera pandemic (1852–60)], which killed 3275 people
(Reino, 1859; Augustin, 1909b). During the following year, the
city was again severely hit by this scourge; between 22 July and
10 December, 13 575 cases of yellow fever were registered, with a
total of 5652 deaths (mainly young adults between 20 and
40 years old), and it is quite possible that the total number of
cases was as high as 18 000 (Reino, 1859; Augustin, 1909b). To
put it into context, this is a higher number than for more notorious
contemporary epidemics in the southern United States in that
period, for example in New Orleans between 1817 and 1899
(Augustin, 1909a; Patterson, 1992). The history of this epidemic
was extensively described in a report by the Royal Council of
Public Health; according to this source, three ships from Brazil
(the Tamar, the Gerona and the Cidade de Belem) were suspected
of bearing the disease to Lisbon. In all three vessels there were
records of diseased patients, and the index case of the epidemic
was a customs worker, presumably in close contact with the ship’s
cargo holds in which the mosquito vectors had been transported
from Brazil (Reino, 1859).
As could be expected, the epidemics of 1856–57 had a severe
impact on the social structure of Lisbon’s population and led to
public expressions of panic and religious fervour (Fig. 1). The
demise of a significant number of young adults created a whole
generation of orphans for whom little social support was available.
In response to this emergency, King Pedro V (1837–61) created, in
1856, a new orphan asylum in an abandoned building in the
Ajuda quarter under the direction of the St. Vincent de Paul
Sisters of Charity and Lazarite priests (Esteves Pereira and
Rodrigues, 1904). The Ajuda asylum functioned up until the end
of the monarchy in 1910, when such religious institutions were
extinguished or reconverted. In its latter days, children were taken
in at age 7 and left at 18 years, and endured a ‘[. . .] paternal and
practical education, which prepares the 100 internees for the harsh
chores required of house maids [although some] have studied
in the Normal School and obtained a teaching diploma [. . .]’
(O Instituto, 1904) (Fig. 1). It is not hard to imagine the dramatic
circumstances that surrounded the creation and initial years of the
Ajuda asylum and the physical and psychological conditions in
which the first orphans were admitted. Dozens of young children
in shock, disoriented, malnourished, who would have witnessed
the gruesome death of one or both parents from such dreadful
diseases, were left without means of subsistence and no clear ex-
pectations about their future. These orphans were taken into this
recently created institution, which still had little to offer besides a
roof, some material comfort and a stern religious education, as we
will see later.
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P. Fontoura
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