Maria Gabriela S.M.C.Marinho
In face of the technical-scientific demands daily embodied on its first years, the Faculdade de Medicina e Cirurgia de São Paulo, created in 1912 and implanted from 1913 , didn’t neglect to develop its traditions and to erect symbols, supporting on them the “paulista” strength that should represent and become, first of all, a device of elite’s former and, therefore, amalgamate in the individual who there enters, scientific and political content. The scientific production of this medical school gained explanatory strength not only for corporative and technologic demands from the market but to build, equally, what Eric Hobsbawn called the traditions’ invention . For the posterity would last, therefore, assinalate its birth as marked out by the competence and heroism of its peers, result of a paulista strength from the bandeirantes’ time, able to ensure for the “Casa de Arnaldo” life and reputation as locus of its best souls and minds, instituting a “genuinely paulista medicine” in a real “giants’ land” .
In the context of the superiority and hegemony of São Paulo, even today crystallized within the school and its representatives, the contradictions of the daily basis, the life and the political practice offer other explanatory dimensions for its appearance. Nuances of the ruptures and the permanencies of its institutionalization allow it to rebuild its accident in a story that was first told as linear, progressive and grandiose for its scientific production and corporate training, but it is possible to identify detours, shortcuts, agreements, disputes and contradictions, thus removing the illusionist lenses of the paulistanidade .
In this sense, the Faculdade de Medicina e Cirurgia de São Paulo, official school, began by organizing courses and hire professors on a modernizing perspective of medical science. It assembled the preliminary course of a year and another five years of general, with a total of 28 seats, according to the legal standards and offering in their divisions, two chairs that did not exist in the federal clauses: the eye clinic and otorhinolaryngological clinic. The classes begin on March 15, 1913 and would end on November 10 of each year, being allowed to enter both sexes, with the requirement to join the diploma awarded by state official gyms or approval in entrance examination .
The diligent and prestigious director of the new institution, Arnaldo Vieira de Carvalho, would feature the conception, implementation and improvement of medical education in São Paulo. Under his guidance, the teaching should have the scientific and experimental basis, especially for research and laboratory studies, in contrast to the model that prevailed in other medical schools in the country, with emphasis on theoretical and clinical classes . To achieve this project, São Paulo should have physical and intellectual apparatus that corresponds to such huge requirements - buildings, laboratories, students prepared for high school exams applied, faculty organized for teaching their chairs - in addition to the fight, at the federal level, for the recognition of diplomas. The effort would not solve the doubt among physicians: Was the School being erected within the quality standards and according to the technical and scientific requirements postulated by themselves?
In its early years, the Faculdade de Medicina was facing serious problems and disastrous consequences, reveal the trades submitted to the Secretary of Internal Affairs . Most of these difficulties were manifested in the day-to-day: the precariousness of installations and equipment, impairment of the faculty, unprepared freshmen. In the correspondence exchange , the deviations of the backstage were exposed.
The first temporary headquarters of the Faculdade de Medicina e Cirurgia, located in the Escola do Comércio Álvares Penteado at Largo São Francisco, the downtown area had been ceded by the direct action of Arnaldo with the directors of that institution. The benevolence of managers, who gave way places for classes, did not obscure the problems that were accumulating with the unfolding of classes. Unsatisfactory spaces, lousy installations, reduced size of the rooms. One year later, part of the courses would be transferred to adapted installations of an ancient solar on Brigadeiro Tobias street, to which would be added later two neighboring buildings, which would remain as headquarters until 1930. The poor initial conditions had been revealed by the director of the School in its constant official manifestations to the State government: the current house, although old, is insufficient to house the courses in exercise. It cannot receive the new seats to be premiered in the school year of 1916, insisted Arnaldo Vieira de Carvalho with the Secretary of the Interior .
The records of the Santa Casa demonstrated the precariousness of a routine drudgery. According to Arnaldo, the 480 beds would fulfill the minimum requirements, but in the day-to-day, the number of inpatients and consulted exceed the number of vacancies. In 1914, after several unanswered letters about the situation of Santa Casa, Arnaldo, in a tone of confrontation, ordered to photograph the conditions of service and sent to authorities photographs that should confirm reports:
For you see there is no exaggeration in my statements, I refer with photographs of the Santa Casa nursing wards taken precisely at the time of medical service. There you will see the point we have reached to almost bordering on crime, consenting such agglomeration of sick people. "
Amounted to this situation, the closure, in 1917, of the activities of Universidade Livre de São Paulo (see entry), that held a private school of medicine since the beginning of its functioning in 1911. The closure and the consequent transfer of students to the official school worsened the overcrowding in the courses, beyond the already exigua capacity . To equate the two issues - the precariousness of Santa Casa and the increasing number of students – a drastic measure was taken: reduction of the student body. According to the evaluation of Arnaldo, "the only remedy to the case would be to build the buildings necessary for our School, thing too hard at the time that passes. Thus, as a remedy for time, to avoid accumulation, it becomes necessary to limit the Government the number of students we receive annually. This number must be fifty for the Single Year of the Preliminary Course.
The city suffered from "swelling urban" with enormous population living in slums and in the near and far outskirts, devastated by disease, lack of sanitation and apparatus of any social protection. The Santa Casa exposed in its blemish, disinterest and lack of assistance in an urban environment increasingly complex and riddled with growing demands. Thus, poor facilities and service would accompany for a long time the clinical education at the Faculdade de Medicina. The first sign of change in the bleak picture come with the agreements signed between the Rockefeller Foundation and the Faculdade de Medicina from 1918 and in the 1920s, but whose final implementation would have to wait until 1944, when in fact the facilities that would be inaugurated to should be a teaching hospital model, the Hospital das Clínicas.
The construction of the Hospital das Clínicas, "the largest in South America"
When, under strong internal opposition, Pedro Dias da Silva, personal physician of the then Governor Carlos Campos, graduated at the School of Medicine of Bahia assumed the directorship at the Faculdade de Medicina de São Paulo in 1924, he received a costly burden: to ensure the internal reforms that would change radically the statutes of the school and would enable, finally, the agreements with the Rockefeller Foundation that had been dragging since the death of Arnaldo Vieira de Carvalho in June 1920.
The resources that would transform the structure of the Paulista College demanded that its regulation introduce the numerus clausus (limitation of admission of students), full-time professors in pre-clinical disciplines and the construction of the teaching hospital in consideration of the State government. Having overcome the resistance of the group of professors who were betting on the failure of the new director, Pedro Dias managed to articulate the changing of the regulations through voting by the state congress of Act No. 2016 of December 26, 1924 and No. 2128 of December 31, 1925, who approved the decree. 3874, of July 11, 1925 .
Approved the legislation, the Congress authorized the opening of credit of 2,000 contos to the beginning of the hospital’s construction and should make up 6,000 contos according to the State President, Carlos Campos. The School of Medicine established a commission to study the best alternatives for the design of the school and the hospital and set to compose it the professors Benedicto Montenegro , Ernesto Rezende Puech and Ernesto de Souza Campos. The commission traveled in 1926 to the United States, Canada and Europe, visiting about two hundred medical institutes, scientific research laboratories and hospital units that have been thoroughly studied in terms of services and activities provided in vivariums, power houses, laundries, ventilating, cooling, maintenance, among others.
Later, in several studies about large hospitals performed by Rezende Puech, the importance of a hospital unit of this nature should, in so-called acute cases, restore quickly the patient to social life, verifying that the chronic cases would prolong too much the stay of sick people in hospital units. Therefore, it proposed that the so-called Central or General Hospital was reserved for acute cases. Chronic cases or in acute of convalescence prolonged, the patient should be removed to special hospitals.
Back in Brazil, after the long journey by international medical centers, the study for the construction of Hospital das Clínicas, teaching hospital model, was especially in charge of Rezende Puech to be executed with care and boldness, in the technical office of works of the School . Through the study, it was calculated for each clinic of the college - medical or surgical - an internal service with 70 beds (forty to men and thirty for women) and an outpatient clinic to assist daily 50 patients. In total, it was expected capacity to one thousand beds.
The rise of Getúlio Vargas to the power reoriented the political situation of the country and to São Paulo in particular. The centralization and the withdrawal of autonomy of the medical and scientific institutions of the state, gathered around some federal government institutions, have been radicalized with the creation of the Ministry of Education and Public Health in 1931, which would articulate unified policies with the goal of building government apparatus capable of acting in the Brazilian territory, coordinating actions at federal, state and municipal levels .
For São Paulo, the year of 1932 represented the ostensible and fierce vocalization of the opposition to medical policy from Vargas. The government response also fierce was made on several fronts: the dismantling of the current health-medical project with making the building of the School by federal forces and the attempt to transform the Institute of Hygiene, in 1931, in a military base. The process of dismantling would culminate with the College layoffs and "musical chairs" in its management. In the same context, a new medical school eventually split the scene with the oldest college, with the creation of the School of Medicine (see entry), in 1933, in the wake of divisions, clashes and political passions of local groups.
On September 21, 1937, the intervenor José Joaquim Cardoso de Mello Neto (position held from January 1937 to April 1938) received the Technical Council of the Faculdade de Medicina to communicate that he would include in the budget of 1938 an amount of 3.000 contos destined to the beginning of the constructions. When Adhemar de Barros, also a physician, took the interventoria in 1938, promptly went to Professor Rao Puech, who exonerated himself from the position held at the State Hospital Care. In granting the exoneration inserted the invitation to take on the construction of the hospital, anticipating changes in the original design of Puech.
Thereby, his performance began to be erected in order to give him the place of "creator and builder" of the Hospital das Clínicas. A booklet entitled Hospital das Clínicas: a large and humanitarian achievement of Mr. Adhemar de Barros, narrating the deficiency of hospital services in São Paulo and his efforts to build a new hospital, pontificated:
(...) His work of social assistance in the sanitary-hospital sector is the most notable figure not only for his plan, as for what is already incorporated into the heritage of the great achievements of São Paulo. Such exploration well gives an idea of the generous conception that the chief of paulista executive has the mission to in São Paulo, entrusted the eminent creator of the Estado Novo, Mr. Getúlio Vargas.
Odair Pedroso Pacheco had been appointed by Fernando Costa, federal intervenor in 1943 to, in committee, hold the position of superintendent of that hospital. At the same time, would be named Enéas de Carvalho Aguiar in the position of Administrative Assistant, Israel Alves dos Santos and Antenor Soares Gandra as assistants-physicians from the Superintendent of the Hospital das Clínicas. Made available to the Hospital das Clínicas of the School of Medicine of São Paulo, Antenor Soares Gandra was physician- auxiliary in the Department of Leprosy Prophylaxis in the Secretary of Education and Public Health .
By decree of November 9, 1943, the post of Superintendent of the Hospital das Clinicas of School of Medicine was deemed vacant with the resignation of Odair Pacheco Pedroso, then filled by Enéas Carvalho de Aguiar. The April 19, the anniversary of Getúlio Vargas and date referring to the Brazilian Army, in 1944, under the interventoria of Fernando Costa, was reserved for the inauguration of the Hospital das Clinicas .
An interesting fact in the process of institutionalization of the Hospital das Clínicas referred to the challenge of ,in a large hospital, combine medical specialties to teaching, while decentralize part of its hospital structure. Intention was to implement specialized professional demands, which, in turn, demanded that consolidate medical training through courses taught by professors of the Faculdade de Medicina . In this direction, on April 11, 1944, Eneas de Carvalho Aguiar ordered to publish in the Diário de São Paulo the winners of contests for Interior Physicians and Adjuncts of the Hospital: included as internal Antonio Cardoso Franco, Silvio Vergueiro Forjaz, Ari do Carmo Russo and Saturnino Antonio Cintra Franco. For adjuncts were hired Paulo Gonzaga Arruda and Ennio Cosimo Damião Barbato.
From then on, newspapers would be prodigals in reporting the installation of several clinics, recording how quickly the Hospital would gain capillarity in the assistance and care, through their expertise and laboratories. Thus ensued, in February 1945, several facilities like the Neurological Clinic under the command of Adherbal Tolosa, in March, the Urology Clinic, directed by Luciano Gualberto, in May, the Medical Clinic of Almeida Prado, then exercised in Santa Casa de Misericórdia, soon adding more than ten clinics operating in the Hospital with annual budget of 30 million cruzeiros .
Developments in the laboratorial field could also be followed in April 1946 with the inauguration of the Blood Bank and Plasma Baxter. With this method, the blood collection and the plasma separation started to be used entirely under air, using bottles provided with enough vacuum to aspirate blood directly from the vein of the donor .
Among the areas which required the construction of new installations, independent of the Central Building, the Hospital of the Psychiatric Clinic (see entry) has become an emblematic case. The project for the construction of a decentralized unit was approved in 1944 and would be directed by psychiatrist Antonio Carlos Pacheco e Silva, former director of the Hospital do Juquery. The projected building would have capacity for 150 beds, with ambulatory space for the triage of patients; clinics specialized in cases of schizophrenia, neurolepilepsia, psiconevroses, among others. Also was designed living room and rest for patients submitted to electroshock therapy and demonstration rooms for the students to familiarize themselves with the new techniques undertaken, as malariotherapy, and the convulsive therapy by cardiazol and by electroshock, hibernation and psycho-surgery, besides the Library, museum and an amphitheater for 150 people.
Throughout the 1940s and 1950s, it would intensify the corporate transformations linked to the training of specialists, conferring on the clinical thinking an increasingly broader facing the medical matters and public health.
In this sense, it was instituted in São Paulo actions that would change the medical-sanitary structure existing, then considered important pillar of the oligarchic ruling , while it sought an ideology suitable for the new professional conformation. As noted Merhy supported the conceptual categories of technology in health work , opening up space for an organization of health services for specific problems, vertically administered, using all the instruments of the campaigns and the sanitary education of curative medicine.
By entering the 1950s, the Hospital das Clínicas deepen the knowledge produced by the specialties and the creation or consolidation of related institutes and centers that would compose the hospital complex. At the same time, São Paulo entered a new stage in history when the industrialization, the apparatuses and the modernization discourse invade the hospital routine, requiring the medical corporation and health professionals different levels of commitment and engagement in the fortunes of the institution.
The numbers presented by the Medical Records of Hospital das Clínicas in 1950 signaled the growing demand and showed the rapid pace of population growth, along with the lack of hospital infrastructure. Five years after opened, the Hospital has documented the passage of 50.960 patients enrolled, as follows: First Aid Service: 4.090; Orthopedic and Trauma Clinic : 3.822; Obstetrics: 1.963; Clinical Surgery: 1.014; Gynecology Clinic: 714; Urology : 452; Dermatological and “Sifiligráfica” Clinic 243, Neurologic Clinics: 242; Otorhinolaryngology: 207; Endoscopy Service: 88; Ophthalmology Service: 376; Service of Burned: 312; Pediatrics Clinic: 232; Service of Diseases of Nutrition and Dietetics : 84, Service of Radiotherapy: 33; Clinic of Infectious and Tropical Diseases: 16 ".
When the American Medical Association in 1951 catapulted the Faculdade de Medicina da Universidade de São Paulo among the top 15 medical schools in the world, there was no doubt of the power raised from the laboratories, wards and all the technology learned and exercised within the Hospital das Clínicas. The work of the teachers, students, researchers and technicians, but mostly the experience of their patients would be fundamental for an identity between the city, its population and those who come from outside begin to establish a place. Place able to pass on the work and profession of the physician, of its clinical discourse about the body that gets sick and, crucially, the "best way to lead the life."