História da clínica e a atenção básica o desafio da ampliação

A clínica contemporânea é fruto de um processo histórico que combinou diferentes possibilidades epistemológicas com transformações sociais. A ampliação da clínica, especialmente pelo equilíbrio entre suas principais modalidades, da doença e do sujeito, constitui-se em potente ferramenta para profissionais da Atenção Básica.

Armand Trousseau (1801-1867), su historia y los signos de hipocalcemia / Armand Trousseau (1801-1867), his history and the signs of hypocalcemia

Armand Trousseau (1801-1867) was born in Tours, France on October 14, 1801. He graduated as a physician in the same city under the direction of Pierre Bretonneau and received his doctorate in 1825 in Paris. He was the first physician to practice tracheotomy in diphtheria and perform thoracenteses to remove air or fluid from the pleural space. He recommended tracheal intubation in different scenarios. He described the first cases of laryngeal tuberculosis and the presence of carpopedal spasm in hypocalcemia, a sign that has his name. He also described the association between migratory thrombophlebitis and neoplasia, which is known as Trousseau’s syndrome. Ironically, on January 1, 1867 he diagnosed in himself a deep vein thrombosis of the left upper limb and told one of his disciples “I am lost; I have no doubt about the nature of my disease”. He died of gastric cancer at the age of 66 years on June 23, 1867. He carried out an educational and medical work. He instructed his students about the rather instantaneous thought process in clinical medicine. He always conducted his clinical work with the certainty of a sound scientific background. Contemporary physicians should take advantage of the example and lessons of Armand Trousseau.

Silos da clínica médica e psiquiátrica: a anorexia nervosa como paradigma / Silos of internal medicine and psychiatry: anorexia nervosa as a paradigm

Este ensaio pretende resgatar o conceito de clínica, procurando fazer reflexão, a partir da história da medicina e da psiquiatria, das mudanças tecnológicas do mundo contemporâneo e suas consequências na prática médica atual. A Anorexia Nervosa é usada como exemplo paradigmático, permitindo contrapor à posição corrente e discutir a importância da concepção clássica da clínica na abordagem dessas manifestações. O método usado fundamentou-se em leituras da história da medicina e da psiquiatria, o que permite observar, de forma crítica, a orientação da prática médica atual.

This essay aims to rescue the concept of clinic, trying to reflect, from the history of medicine and psychiatry, about the technological changes in the contemporary world and its consequences in current medical practice. Anorexia Nervosa is used as a paradigmatic example, allowing a counterpoint to the current position and discuss the importance of classical conceptions of clinic in approaching these frames. The method for this theoretical essay was based on readings of the history of medicine and psychiatry, which allows us to critically observe the orientation of current medical practice.

A Study on Horace N. Allen's Medicine and Recognition of Korean Body / 의사학

Je Jung Won was the first modern-style Government hospital built by the Korean King Ko-Jong in April 1885, and it was the medical missionary Horace Newton Allen(1858~1932) who made one of the greatest contributions to the establishment of the hospital. Allen was an American missionary. He graduated from Ohio Wesleyan University with a degree in theology in 1881, and completed one-yearcourse at Miami Medical College. In Korea and America he worked as a physician, a missionary, an American diplomatic minister to Korea and a Korean minister's secretary to America. While acting as a mediator between Korea and America, he knew and recorded the domestic and foreign situation of Korea during Gaehwagi(the civilized and enlightened age). Thus to study him is to understand Korea's Gaehwagi as well as to research American medical missionaries. During his stay in Korea(1884~1905), Allen steadily wrote diaries and letters about Korean politics, diplomacy, society, culture, and medicine. Thus his public/private record through diaries and letters(the quantity of these materials amounts to several thousands) supplements the Korean early modern era's historical record. However, until now these materials have received little scholarly attention from researchers except for a few historians of missionary work between Korea and America, or of Korean modern medicine. I intended to use these materials to suggest a new perspective on the study of Korean Gaehwagi. Allen, along with John W. Heron, who came to Seoul on June 21st 1885, treated about 10,460 Korean patients in the first year of the opening of JeJungWon. They made "the first annual report of the Korean Government Hospital". This report explained how Allen and Heron regarded and treated Korean patients. Allen's diaries, letters and other writings offer a realistic view of how the western people actually recognized the Korean people at that time. As a western doctor, Allen had an ambivalent attitude toward Korean medical concepts and systems. On the one hand, he thought that medical idea, some food and drug of Korean is valuable. He said that the native Korea faculty had some good ideas with regards to treatment. And he held Korean rice, ginseng, and so on in high regard. However, he did not rate Korean acupuncture and Korean traditional ointment at all. In addition, he sometimes cured Korean patients dangerously and with imprudence. The amputation of patients' body, no matter how little, must ask the permission of the patients themselves. Especially, the sense of Korean filial duty couldn't accept amputation of body at those times. The artificial change of body meant to hurt parents' body, because at those times Korean people thought that my body was my parent's possession. But Allen did it without enough explanation or persuasion. Moreover he didn't feel guilty for the behavior at all. Besides, he seemed to be proud of it in the above mention. Such careless or unethical behavior cannot be excused. On the other hand, he had made mistakes in treatment according to his record. He pulled out some healthy teeth of patients who had a bad toothache. But he didn't explain nor apologize the mistake. Besides, he refused treatment of patients until the hospital would be opened in order to push Korean government to prepare hospital quickly. Why or how did he do that? The first answer available to the question, he might be so confident of his medical knowledge and skill that he didn't feel the need to ask the patients' thought and will. However, as stated above, his medical study was just one year. And he worried about his inexperience of surgery. Thus the first assumption seems to be false. He wasn't confident of his medical knowledge. The fact that nevertheless Allen treated Korean patients at his will, is still blamable. The second assumption is that he regarded western modern medicine as the only correct and proper approach. He didn't have many experiences, but his west modern medicine made him proud of its achievement. After middle 19th century of modern times, Micheal Foucault said at The Birth of Clinics, western modern medicine believed itself scientific on the ground that west modern medicine could have pathology and surgery. Allen might also trust the scientific ability of western modern medicine. So he might think that he didn't need to explain 'modern and scientific' medicine of West to people in 'premodern and non-scientific' medicine of Korea. The third answer is his 'Orientalism'. He thought that Koreans were dirty, lazy, and barbarous and, therefore, he made a clear distinction between Caucasian and Korean. He set his affection on 'Cho-Seon' and made efforts to cure Korean patients and establish the first western Government hospital in Korea. However he, as a westerner, could not free himself from 'Orientalism' and 'Imperialism'. Thus, he might ride so roughshod Korean patients. In fact the 'Orientalism' was not only Allen's thought. Many western visitors thought Korean as an 'Orient'. The West regarded themselves as civilized and the East as uncivilized or barbarous, therefore the West thought that the East should be modernized with the help of the West. This thought rationalized their imperialism and colonialism toward the East. In addition, he seemed to have some ambition in politics and diplomatics. He wanted to be a high-ranking official, so his goal of his life was political or economical power rather than medical missionary.

Luis Hidalgo y Carpio, editor de Gaceta Médica de México (1818-1879) / Luis Hidalgo y Carpio, editor of Gaceta Médica de México (1818-1879)

Luis Hidalgo y Carpio (1818-1879) fue un insigne médico mexicano especializado en aspectos forenses, que hizo interesantes aportaciones a la medicina de su tiempo; sin embargo, para el perfil que interesa destacar, el de editor, las fuentes no son abundantes, pues precisamente en 1867, cuando Hidalgo y Carpio ocupó la presidencia de la Sociedad Médica de México, conocida posteriormente como Academia Nacional de Medicina, se interrumpió la publicación de Gaceta Médica de México, medio informativo de la Sociedad Médica. El papel de nuestro personaje como editor fue de gran trascendencia debido a que la comunidad médica requería un medio de comunicación donde externara sus logros científicos y se retroalimentara con las lecturas de la publicación en cuestión, que tuvo un gran alcance no solo por el carácter periódico que la caracterizó sino también por el organismo que representaba.

Luis Hidalgo y Carpio (1818-1879) was a notable physician who made important contributions to the field of medicine during his time. Nevertheless, reference sources on the aspect from Hidalgo y Carpio that we would like to emphasize (i.e. as an editor of a medical journal) are scarce since precisely when Hidalgo y Carpio was named President of the Medical Society (later the Academia Nacional de Medicina), in 1987, the publication of the Gaceta Médica de México was temporarily interrupted. Hidalgo y Carpio played a key role as an editor at a time when the medical community of Mexico required a means whereby the scientific achievements could be published and discussed among peers and colleagues. Under Hidalgo y Carpio, the Gaceta Médica de México soon reached a wide audience, not only as a periodical publication but also for the prestige of the Academy that represented.

Estratégias terapêuticas no tratamento da dor crônica: uma genealogia da clínica da dor / Therapeutic strategies in the treatment of chronic pain: a genealogy of the pain clinic

O objetivo desse trabalho é analisar a singularidade das estratégias terapêuticas introduzidas pelo modelo das Clínicas da Dor, através de um estudo genealógico desse projetoterapêutico e sua contextualização no âmbito da racionalidade científica moderna. Mais especificamente, pretende-se analisar as transformações na racionalidade médica que permitiram, sucessivamente, a apreensão da dor pelo discurso médico, a concepção da dorcomo uma doença e a construção e a consolidação do modelo terapêutico das Clínicas da Dor. Para tal, inicialmente, analisamos o modelo terapêutico desenvolvido pelo médico anestesista John Bonica, idealizador do modelo das Clínicas da Dor, destacando as ferramentas conceituais que possibilitaram a compreensão da dor crônica como doença e como fenômenobiopsicossocial. Num segundo momento, realizamos uma descrição e análise dos principais eventos que permitiram a consolidação da medicina da dor como uma prática específica e multidisciplinar, dando destaque à inserção deste modelo no contexto do Sistema Único de Saúde Brasileiro. Finalmente, a partir de uma experiência clínico-institucional buscamos refletir sobre os limites e possibilidades da aplicação prática deste modelo, lançando luz sobre os impasses da clínica e tensões oriundas da problematização do dualismo mente e corpo e das práticas terapêuticas interdisciplinares.

The Life of Dr. RO Kishun, a Reflection of Modern Korean Medical History of the Borders / 의사학

RO Kishun was born on February 2, 1893 in Ongjin County, Hwanghae Province of Joseon Korea. He graduated from the Medical Training Center, a campus associated with the Joseon Government-General Hospital, in 1915, and from Kyushu Imperial University School of Medicine in 1917. He continued his medical study at the university in 1929, majoring in biochemistry, and earned a doctorate in medicine in 1932. Dr. RO, one of the earliest pioneers in Korean biochemistry, was active in his research, publishing four studies in the Japanese Journal of Biochemistry between 1931 and 1932. After returning from Japan in 1932, Dr. RO opened a medical practice in Mokpo and Busan, port cities situated on the southern tip of Korea. Later in 1936, he moved north to Manchuria (northeast China) to practice medicine at the International Hospital in Mukden (present-day Shenyang). He also served as president of Tumen Public Hospital between 1942 and 1946. When Japan signed unconditional surrender bringing World War II to an end, Dr. RO relocated to Yanbian and began providing medical training to ethnic Koreans. In October 1946, he was appointed dean of the First Branch School of China Medical University in Longjing, and in October 1948 the first dean of Yanbian Medical School, the predecessor of Yanbian University College of Medicine. Dr. RO dedicated his life to medical practice, teaching and training students, and mentoring younger faculty. A brilliant clinician, he also inspired and helped his colleagues with his outstanding ability to diagnose and treat patients. He was one of the founding members of Yanbian University College of Medicine. RO Kishun died on June 7, 1957 at age 64. Ethnic Koreans hailed him as Sinui (literally, the physician of God), and a bronze statue of himself was erected in front of the medical college in 1988. Dr. RO's life brings modern historians' attention to the issue of determining geographical territories and nationality, in that his life unfolded at the borderlands or frontiers of Joseon Korea, China, and Japan, where the history of the three nations met and intermingled with one another. He was a biochemist and researcher, practicing physician and medical professor of the era under Japanese Rule and the one following it. In modern Korean medicine, his life is viewed as a history of the borders, or a transnational legacy going beyond individual history of Korea, China, and Japan.

Sobre um parágrafo de Michel Foucault: resposta a muitas questões? / About a paragraph of Michel Foucault: answer to many questions?

Em "Resposta a uma questão", artigo-réplica a perguntas encaminhadas a Michel Foucault pela revista Esprit, um parágrafo concernente às relações entre a constituição da medicina clínica e a Revolução Francesa nos parece, ainda hoje, paradigmático do modo de pensar foucaultiano. O presente ensaio dele parte, no intuito de distinguir a perspectiva foucaultiana daquelas ligadas à História das Mentalidades e à Sociologia do Conhecimento. Em seguida, usa-o como ferramenta analítica de uma recente polêmica, relativa a uma investigação que se propõe a mapear o cérebro de "adolescentes infratores". Avalia-se que o parágrafo mencionado faculta entender de modo singular o repúdio de uma parcela da intelectualidade e da militância ao projeto de pesquisa em pauta. Com isso, a "Resposta a uma questão" se amplia a uma resposta a muitas questões, especialmente ao que se pode entender por defesa dos Direitos Humanos no campo dos saberes e regimes de verdade.

In "Response to a question", a Michel Foucault's paper in which he answers questions sent by the journal Esprit, a paragraph concerning the relationship between the formation of clinical medicine and the French Revolution seems to be, even today, paradigmatic of the Foucaultian way of thinking. This essay is based on that paragraph, in order to distinguish Foucault's perspective from the History of Mentalities and the Sociology of Knowledge. The essay uses the same paragraph as a tool to analyze a recent controversy, linked to an investigation that intends to map the brains of "juvenile delinquents". We think that the aforementioned paragraph allows us to understand in a unique way the rejection that a parcel of the intellectuality and the militancy directed to that research project. In this sense, "Response to a question" is extended to answers to many questions, especially to the way one can understand the defense of Human Rights in the field of knowledge and regimes of truth.

A serendipidade na medicina e na anestesiologia / Serendipity in medicine and anesthesiology

JUSTIFICATIVA E OBJETIVOS: Neste trabalho foram examinados mais de uma centena dos mais felizes acoplamentos de uma mente brilhante com a sorte benfazeja (serendipidade), através da releitura das mais relevantes histórias sobre invenções e descobertas relacionadas à ciência (n = 46), à Medicina (n = 46) e à Anestesiologia (n = 16). CONTEUDO: Conceito de serendipidade; exemplos célebres de serendipidade em Ciência e Tecnologia; serendipidade na pesquisa e prática médicas; serendipidade na Anestesiologia; serendipidade e criatividade na pesquisa. Através da história do desenvolvimento médico, a natureza provou que o caminho mais efetivo e mais barato na obtenção de drogas, instrumentos e serviços pode ser a sorte fortuita porque muitas descobertas são serendípticas. Este artigo educacional encoraja o anestesiologista a apreciar os eventos relacionados com invenções e descobertas científicas, mostrando-lhe que a serendipidade é possível, desde que seja aguardada. Cada descoberta ou invenção inclui história, biografia e explicação científica ou anedótica. Além das descobertas tradicionais como pão, vinho, gravidade, fotografia, velcro, air-bag, etc., há outras relacionadas à Medicina (microscópio, Raio X, vacina, penicilina, insulina, laser, esfregaço de Papanicolaou, etc.), e à Anestesiologia, como: isomeria, luvas, N2O, éter, barbitúrico, benzodiazepínicos, tampão sangüíneo, entre outros. Criatividade e serendipidade podem servir de linha mestra para pesquisa clínica e básica de invenções pioneiras para avanços médicos e anestesiológicos. Realmente, devem-se controlar tópicos relacionados com biologia, anatomia, física, química, fisiologia, farmacologia, astronomia, arqueologia e... muita sorte. CONCLUSÕES: Embora acidentes na pesquisa e na sala de operação sejam lamentáveis, há aqueles que acontecem e, às vezes, podem levar a avanços espetaculares, como tratamentos heróicos e até Prêmios Nobel. Manter a mente aberta é um traço comum àqueles que ensejam contar com a sorte grande, como afirmava o físico americano Henry (1842): "As sementes da descoberta flutuam constantemente à nossa volta, mas apenas lançam raízes nas mentes bem preparadas para recebê-las".

La interculturalidad en la práctica médica del doctor Albert Schweitzer / Interculturality in the Medical Practice of Dr. Albert Schweitzer

El joven alemán Albert Schweitzer (1875-1965) después de realizar promisorios estudios musicales en París (1899) y haber obtenido los doctorados en Filosofía y Teología en Berlín, decide a los 29 años iniciar la carrera de medicina en la Universidad de Estrasburgo. A pesar de su cómoda y asegurada vida profesional en las grandes ciudades europeas a partir de 1913, en forma por demás sorpresiva, decide ejercer la práctica médica en un remoto pueblo del Africa ecuatorial. Construye un hospital en Lambarené y durante poco más de 50 años dedica lo mejor de símismo al servicio de los pacientes de raza negra. En esta presentación hacemos una aproximación a los aspectos interculturales en la obra médica del doctor Albert Schweitzer, tomando como ejes analíticos algunos indicadores socioculturales en hospitales que atienden enfermos con características culturales diferentes al personal que organiza, administra y ejerce funciones curativas.

Albert Schweitzer (1875-1965) was a young and promising German who at age 29 decided to undertake the profession of Medical Doctor at the University of Strassburg after finishing a career in musical studies in Paris (1899) and obtaining in Berlin a doctoral degree in Philosophy and Theology. Surprisingly, Albert Schweitzer, despite his comfortable life in Europe, decided in 1913 to practice his medical career in a remote and small Equatorial African country. He devoted nearly 50 years of his life caring for the Black population at Lamaberene, where he built a hospital. In this paper, we attempt to develop some theoretical aspects related with interculturality in the medical practice of Dr. Albert Schweitzer. We begin by considering certain sociocultural variables in hospitals that give care to patients with cultural characteristics that are substantially different from those of the health care personnel who organize, administer, and execute medical functions.