Moments
Professor Francisco Pulido Valente – The Medical View
President of the Pulido Valente Foundation
Chairman of the Board of the North Lisbon Hospital Centre (CHLN)
Relatives of Professor Pulido Valente and Guests
Ladies and Gentlemen:
I wish to thank Professor João Monjardino, the Direction of the Pulido Valente Foundation and the Chairman of the Board of the CHLN for their kind invitation to participate in this act of homage to Professor Pulido Valente, one of the greatest figures in XX century Portuguese medicine.
Someone once wrote that “the past is a foreign country” and that in order to visit it one needs a skilful and knowledgeable pilot. I confess the difficulty of the mission. I have made use of the memories of family members, of those who were students or patients of Professor Pulido Valente, and of the remarkable testaments through which his disciples and family members have praised the meaning of Pulido Valente’s personality and work in Portuguese medicine.
With such illustrious guests who will deal with other aspects of his personality and work, allow me to keep to Pulido Valente’s medical work which has remained and stood up to time and to the ignominy of the dictatorial political sectarianism that surrounded the continuity of his academic and hospital action.
Pulido Valente was the most prominent figure in Internal Medicine of the Portuguese XX century, and his influence was incomparable for successive generations of doctors; for this reason he is a reference, a pillar of the Faculty of Medicine.
His dimension is multifaceted, and thus this mission is difficult. An unusual man with a unique and striking personality, with great intellectual and civic coherence, he was at the time in Portugal the doctor scientist who had trained in experimental activity in the laboratory, and led the great metamorphosis of clinical medicine here, making it evolve, as Diogo Furtado has pointed out, from an art based on observation, to a true science in its permanent search for experimental understanding of pathological phenomena. For this reason he was an uncontested master, demanding, intolerant of ignorance and incompetence, and aroused that intellectual seduction that Steiner talks about, which is a mixture of admiration and fear.
Juvenal Esteves has synthesised these feelings in a telling phrase “The name of Pulido Valente, when stated at the time of his leadership, always rang out forcefully”.
He was the founder and head of a school for medical action and thought, and as an academic and doctor was a committed spectator and active citizen in the defence of the essential values of freedom and democracy.
He was born on the 25th of December 1884, in Lisbon, but His family origins came from the south, the Alentejo and the area of the Spanish border, with no direct roots in medicine with the exception of an uncle, Dr. Francisco Martins Pulido, who was a distinguished doctor at the Rilhafoles Hospital.
(Slide Bibliography I, Bibliography II)
He did all of his training at the Lisbon Medical-Surgical School, founded by King Dom João VI after his return from Brazil, and finished his course in 1909 with the mark of 19 on 20. He was an active student leader in the academic revolt of 1907 against the dictatorial government of João Franco, and a committed defender of the recently-established Republic. His final thesis was on Hysteria, a controversial subject at the time, and from then on he showed the strong characteristics of his personality, as Diogo Furtado stated: unusual intellectual rigour and demand, scientific knowledge and a critical sense, rejecting a priori identifications with conceptions about the anatomical foundations of Hysteria, then fashionable in the positivist and materialist philosophy that attracted him so much. He showed intellectual independence.
All of His school career was remarkable and distinguished him: he received several academic prizes and “Acessits”, which is proof and acknowledgement of merit.
In 1911, through public competition, he became a doctor on the Consultative Board of the Civil Hospitals of Lisbon and, in January 1912, was appointed first provisional assistant in the subject of Psychiatry, directed by Júlio de Matos, a period which had a decisive influence on the future development of Pulido Valente’s skills and clinical method.
The other decisive influence that stands out in his biographical path was that of Aníbal Bettencourt, who provided him with the experimental dimension and laboratory skill, which were fundamental in establishing Scientific Medicine, of which he would be a pioneer and master. Indeed, from August 1914 to July 1917 Pulido Valente attended the laboratory of the Câmara Pestana Institute, headed by Aníbal Bettencourt, who started Experimental Medicine in Portugal and who, in the wake Câmara Pestana, had transformed the Bacteriological Institute into a pole of attraction for new talents and a centre of radiation for new talents within a modern view of medicine.
In a text paying homage to Aníbal Bettencourt, Pulido Valente states the importance of experimenting in medical education and the impact of that period in his own training. He mentions Bettencourt’s role in the opening up of new scientific horizons, besides the traditional French influence and states: "there is no competent doctor without a strong laboratorial preparation because in diagnosis laboratory and clinical elements are constantly at play... they call upon each other, they clarify each other and they correct each other".
It was at the Bacteriological Institute that Pulido Valente’s restless and unsatisfied spirit found itself, as a volunteer researcher, beginning a remarkably productive period from the scientific point of view. Here a set of research activities were carried out on a common disease – Syphilis – a decision that was coherent with his pragmatic and utilitarian view of research, which should be concentrated on seeking an effective solution for relevant clinical problems.
Syphilis was the experimental model that allowed him new horizons into pathological research, into the mechanisms of disease and of the patient’s biological reaction, always with the final aim of treating the social scourge that was, at the time General Paralysis.
Three important monographs are from that period, and are about the experimental model of the disease introduced into a rabbit, about early infection and the mechanisms of its progression to the encephalon and about the etiopathogeny of General Paralysis, and which were the subject of a lesson for his competition to become a full professor. Some of his observations represented a scientific advance at the time, namely the demonstration of the presence of the infecting agent in the cortex of 70% of the patients observed, a new fact in the scientific literature of the time, as well as the mechanism for early contamination of the cephalic-rachidian liquid after contact with the infecting agent.
This period of innovating clinical research was very important and productive, and was the expression of the influence of German medicine, the paradigm of which would be the inspiration for his future action as a clinical head doctor and teacher.
Simultaneously, from 1915 he begins collaboration as a free assistant at the 1st Surgical Clinic under the direction of Francisco Gentil, where he becomes familiar with pathological research through the study of operational pieces and collaborates on medical accompanying of surgical patients.
This was a very fruitful collaboration. Diogo Furtado and Jaime Celestino da Costa agree in their interpretation that Francisco Gentil saw in Pulido Valente the qualities that would make him the mentor for new generations and indispensable medical skill. For Pulido Valente the anatomical-pathological experience gained in a major surgical service was important, marking the final stage of his training in a path towards the top position in the university hierarchy and gave rise to the importance of medical-surgical collaboration, of its advantages for teaching and for treating patients, as he clearly stated later: “practice has shown that teaching is seriously harmed by the lack of connection between medical and surgical teams” having proposed practical solutions in order to reinforce that medical-surgical cooperation.
This desideratum in the life of public hospitals would be achieved in the final years of activity, when Reynaldo dos Santos took over the Chair of Clinical Surgery at Santa Marta Hospital in 1941. Jaime Celestino da Costa refers to that short period, contemporaneous with Wolwhill, as a perfect educational triangle: medicine with Pulido, surgery with Reynaldo and Pathological Anatomy with Wolwhill.
All of this period, which was one of consolidation of the teaching and scientific production, would be interrupted by his being called up for service on the World War I Expeditionary Force.
In France he is firstly placed in the Merville Blood Hospital, then in Hendaye and finally at the Base Nº 2 Hospital, always occupying head positions in these services.
The experience of war medicine would produce within him a critical attitude in relation to the structure of medical teaching in Portugal, as we will see, a facet of his that is usually given less attention in his biography, but which Miguel Carneiro de Moura analysed in a conference he gave in 1993 at a Pulido Valente Prize award session.
On his return to Portugal in 1919 he resumed his university career, and in September of that year he applies and is accepted as Assistant in 1st Clinical Medicine, being awarded 20 on 20 and finishing in first place, and in December he was put in charge of the chair in the Course of Medical Pathology.
In February 1921 he successfully applied to the position of Full Professor of Pathology and Medical Therapeutics.
The organisation of medical teaching, the selecting and preparation of assistants and the development of clinical services, fighting for the incorporation of laboratory diagnostic sectors that are indispensable to research on patients become his priority and will definitively mark out his future action. He will do this in detriment to the innovating scientific research that he had carried out during his period of work at the Câmara Pestana Institute.
The paradigm that influences him is that of the University Clinic of German Medicine, which brings together laboratory research as an indispensable instrument for a medicine with a scientific basis and excellent and innovating medical practice. For this reason he insisted during the discussion of the plans for the new school hospital that the clinics should have separate laboratories.
In fact, at that time, at the beginning of the nineteen twenties, it is Pulido Valente who takes on and leads the renewal of medical teaching, bringing the spirit of renewal that had marked out the basic sciences to clinical practice. He does not conform to the norm and his determination is remarkable.
In the report he made for direction of the faculty about his activities as Chair of Medical Pathology he points out new paths indispensable to this strategy of renewal.
He indicates the structural deficiencies, the lack of means, the extremely poor conditions of the wards and the absence of a working laboratory.
He clarifies his teaching strategy, stating that the subjects dealt with were whenever possible shown on patients, macroscopic works and histological preparations.
This view likened him to Sir William Osler, who is not mentioned in Pulido Valente’s work, perhaps because of the dominant Germanic influence, and who had stated that “one should only teach with the patient, he is the compendium”.
He defends the fundamental unity of the course when he states he does not miss a single occasion to stress the importance of the subjects in the First Degree Cycle and the need for the students to remember these subjects. All the teaching should be guided towards clinical medicine, because that is what the mission of a medical school should be.
He sums up his pedagogical philosophy in an exemplary manner “do anatomy, histology, immunity and bacteriology at the patient’s bedside, with simplicity and practical sense.
The teacher, he added, is no more than a guide; the true and profitable learning can only be done by the student in contact with the patient”.
Despite the endemic backwardness of Portuguese culture, one may say that it accompanied the dynamic of renewal that, starting from Johns Hopkins in Baltimore, began the revolution in teaching of Scientific Medicine that marked the first decades of the XX century.
"Only the knowledge that students acquire through laboratory experience is real and authentic"
W. Welch, 1878
“ ... and the student is not just limited to observing, listening or memorising: he does! His activities in the laboratory and in the clinic are the main factors for his instruction and discipline” A. Flexner, 1912
In this report Pulido Valente is deeply critical of the teaching methodology followed after the Reform of 1911.
This Reform of 1911, the precursors and some protagonists of which were portrayed by Columbano, whose canvases now decorate the Council Room and the Office of the Faculty Direction marked an irreversible evolution in Portuguese medicine through a meritocratic policy for the renewal of the teaching staff, the creation of autonomous institutes for the Basic sciences directed by noteworthy personalities with scientific training acquired in Europe.
Concerned about the renewal of clinical teaching and with the need for means towards this end, Pulido Valente analysed the impact of the reform in what he called the final product – the practical doctor who comes out of the medical school wondering whether the training for the recently graduated doctor is better than that of the graduate ten or twenty years ago at the old Lisbon Medical-Surgical School.
This was not a view that longed for the past nor a destructive criticism of the effort to renovate and create science that these figures stimulated at the head of the then created institutes and which were effectively the base for scientific medicine in Portugal.
What Pulido Valente in fact denounced was the deficient translation, using today’s terms, between that scientific education and the acting reality – the practical doctor.
The experience acquired during the war gave him awareness of the true dimension of this problem, which he did not consider exclusively a Portuguese deficiency and about which he wrote “for States, the war has provided the unique opportunity for a thorough and conclusive experience on the incompetence of the practical doctor when leaving university courses”.
He spoke about the "hypertrophy of the basic subjects in detriment to clinical teaching, as if clinical qualification resulted from the algebraic sum of the knowledge granted in the first period of the course”.
And he drew up one of the most lucid descriptions I know of the true essence of medical education “that he considered to be a work of education and culture, as it requires the developing of special psychological qualities, the fixing of mental attitudes and the progressive enriching of the sensorial memory with images of reality to the acquisition of a subtle technique”, in order to state that one was facing a “complex learning of an art in which enter elements of the subconscious and intuition, that are not confused with the conceptual knowledge of their rational bases”.
For these reasons, I have for years been insisting during reception for freshmen that medicine is a higher education that requires culture, and I remind my students of Introduction to Clinical Medicine that the so-called Clinical Art is no more than “organization of the mind, structured knowledge, method and minuteness in observation and promptness in memory”.
What would Pulido Valente think about the cultural disarmament of the new generations, about the selection of students for the course in medicine based on the capacity to memorise and obtain high marks in specific areas, increasingly narrowing the horizons of culture and the formation of the mind?
And of the recently approved 40-hour week, an invitation to the total functionalising of the profession, to the impoverishing of medical education and the loss of values essential to medical professionalism, namely availability and the spirit of service, he who organized the famous clinical-pathological with Wolwhill on Saturdays, without any doubt an impossibility nowadays?
How often, outside of working hours, have I lived clinical experiences that have marked me and enriched my sensorial memory with unrepeatable images that have turned out to be so useful!
What can one do?
I will now come back to the document referred to, and which is profoundly enlightening as to Pulido Valente’s thoughts and on his action as a leader of the renewing of teaching clinical medicine in Portugal.
He then added “whoever reads what is being written today in Europe and in America will see that one is again return to the healthy good sense of considering first degree subjects not as autonomous sciences and speculating in biology, but as mere subjects in the medical-surgical course, existing for the needs of Professional education and progress”
Some critics of his action have interpreted these concepts, as well as his demand for scientific culture as an essential requirement for serious and truly innovating scientific research, as a limitation imposed on that dimension that is fundamental in academic medicine, and the appanage of our threefold mission: to teach, care and research.
In fact evolution has gone the opposite way. The institutes of fundamental science are today essential to a modern and dynamic medical school, and should be centres for scientific creation, capable of responding to the clinical issues and making instruments available for questioning nature, beyond the “knives, forks and spoons” of which my Master João Cid dos Santos used to speak.
The person who produces knowledge and is not restricted to repeating others’ knowledge will surely be a better teacher, and the scientific training of doctors is an indispensable requirement for XXI century medicine.
His action in renewing medicine and the creation of a School of Medical Thought and Clinical Action would require people, and Pulido Valente surrounded himself with a remarkable group of disciples, whom he meticulously prepared, sending some to centres of excellence in Germany in order to improve their knowledge in the new areas of development in internal medicine.
Jaime Celestino da Costa wisely states: Pulido brought scientific Germany to us! And it is worth reading the correspondence exchanged and published in the “In Memoriam”, which shows the care with which Pulido Valente accompanied his collaborators’ vicissitudes and guided their action from afar.
He was acknowledged by all of them as an unquestioned Master.
He had authority, character, demand, competence and vision, and these are in fact the attributes of a master.
This is the tree with its branches through which his influence radiated out: the people are well-known, and over a decade and a half, until the brutal and unjust withdrawal imposed by the political sectarianism of the dictatorship in 1947, he irreversibly stimulated clinical and academic medicine and in Lisbon.
His removal and that of his main collaborators may have stopped him completing more publications, like his contemporaries Jimenez Diaz and Gregório Marañon in Spain.
Some separata of his lessons remained, of which I have mentioned some, and one which intrigued me as a specialist in vascular disease.
This refers to an analysis of a theory that was fashionable at the time on the physiology of circulation; it is hermetic, deeply mathematical – Bento de Jesus Caraça’s guidance was decisive for this – and it clearly reveals Pulido Valente’s capacity to deepen a subject until its most complex dimension.
I confess my inability to read it, which is certainly not a recommendation in my favour!
Diogo Furtado, in the essay published as a homage on Pulido Valente’s 70th year, stated his “extraordinary intellectual organisation, exceptional memory, capacity for systematisation and timely innovation, and added “I never met anyone who could give such an impression of accumulation of knowledge and of its prompt use”.
Jaime Celestino da Costa admirably synthesised this with sharp clarity, “Pulido didn’t just know more, he knew better”, and this was the basis of the indisputable intellectual seduction that captivated the best and formed a School.
His collaboration with Wohlwill, a Jewish German pathologist who had fled Nazism, had an extraordinary striking influence on Pulido Valente’s action: he finally embodied the essence of the anatomical-clinical method he had cultivated since the beginning of his training, and had been the base for the remarkable development of German medicine in the first two decades of the XX century.
Wohlwill’s action was decisive for the progress of medicine in Lisbon and of the Faculty of Medicine; he created a School and an important group of followers, among whom were Jorge Horta and Arsénio Nunes, and I had the privilege of having been a student of the two.
This was pathology stopping the whims of clinical medicine: a model imported to the famous anatomical-clinical meetings on Saturdays, in which the making of the diagnoses was confronted with the cruel and harsh reality of pathology and the cases discussed were published in the magazine Lisboa Médica.
Their repercussion on the medical life of the city has reached our times, and, unfortunately for us, were unrepeatable.
Wohlwill and Pulido Valente’s relationship was based on mutual admiration, between two figures with solid scientific and medical knowledge, and was summed up like this: “Pulido had finally med an interlocutor of his own calibre”.
His action was decisive for Wohlwill to stay in Portugal for some time and create a school of pathological Anatomy in the Faculty of Medicine, as can be seen in this letter by Francisco Gentil.
Pulido Valente was indeed the interlocutor for Wohlwill’s being transferred from the IPO to the Medical School, where he remained until he left for the United States in 1946.
Pulido Valente was critical of some scientific research, which he considered amateurish, unprofessional, removed from concrete reality and sometimes dangerous, and that was a reality that may have diminished the academic dimension in his extraordinary renovating action for thought and medical culture in Portugal.
He would have been indifferent to angiographic research, which was started by Egas Moniz and later continued by Reynaldo dos Santos and João Cid dos Santos and others, and which was an unusual scientific research, inappropriate in a backward country distant from the scientific world its time.
And in fact, ladies and gentleman, it was the Portuguese School of Angiography, with its innovating action, that was the most important Portuguese contribution to medicine, and is still today referred to and well known, that was the basis for the original work by Cid dos Santos on the unblocking of arteries indispensable to the development of vascular surgery, for which he is recognized as the founder throughout the world.
Angiography was the Great contribution made by Egas Moniz and his followers, more than prefrontal Leucotomy, of which Pulido was a critic avant la lettre and which only know, thanks to the new developments in imaging the brain and locating some points of dysfunction, may regain importance and usefulness.
In an unbiased analysis, I agree with the observations published by João Monjardino in the book “In Memoriam” by Pulido Valente about the lesser importance that research had on his action.
The expression “on my service scientific discoveries are forbidden” was well known, but more than the hostility towards the spiritual disquiet indispensable to research, it was an appeal to rigour, to exhaustive study of current knowledge, the only way of avoiding “successive ongoing rediscoveries” which ignorance and a somewhat provincial approach sometimes tend to overvalue, and is the expression of intellectual and scientific underdevelopment that unfortunately still persists among us.
Perhaps what Pulido Valente meant was the need for a scientific attitude that would generate the small conquests of research and created ecology favourable to discovery and innovation.
He perhaps undervalued the impact of the individual and solitary creative mind.
I am quoting Jaime Celestino da Costa when he relates an episode that took place during the famous application competition by Cascão de Anciães, a disciple of Pulido’s who was also removed from the faculty in 1947, during which after speaking about the “joy of the mind that was research”, Pulido Valente sternly responded: “Research is a social function!”.
Excessive zeal for some intellectual orthodoxy that tended to undervalue the individual’s creative dynamic faced with imposed aims and rules? Excessive condemning of what might be taken as an expression of intellectual dilettantism?
I will leave the history and interpretation of the facts to historians, as I accept I am incapable of doing so!
Pulido Valente’s medical and educational influence lasted through time and has marked successive generations.
His concept of a clinical medicine with a scientific base has lasted, as well as the rigour and methodology of the clinical exam, the careful semiology and the empathy he established with his patients, and his solid psychiatric training has influenced doctors and patients.
Allow me to recall an aunt of mind who has died, who was a patient of Pulido Valente’s, and who insisted on describing her consultation with him to me, always repeating “learn from that, son!”. He was deeply admired, almost idolised by his patients!
Pulido Valente’s continued influence through his disciples who marked out the medical practice of Lisbon, in its widest sense, has reached us and continues to be the most secure weapon against the medical uncertainty of our times and the risk of the dehumanisation of an excessively technological medicine.
Then, his example: Professor of a clinical area, who achieved his academic positions through merit shown in public competitions, who gained the recognition of his peers and was a clinical reference.
It never went well when other requirements and other methodologies were imposed in the choices of leadership in academic clinical medicine.
But the preparation for this talk was an opportunity for reflection and questioning about the paths we have been taking in the Medical School that was Pulido Valente’s.
What would Master Pulido Valente think?
How would he react to the decline in academic medicine now considered old-fashioned and dominated by the pragmatic and economic view imposed by health managers, with emphasis on production aims and the famous rankings, fragmented by perhaps excessive specialization and dehumanized by the increasing influence of technology?
I would like to believe that he would agree with the essential requirements for our university and medical education mission.
• To develop critical spirit and ethical respect throughout all teaching, to encourage the production of knowledge and the introduction of innovation.
• To accept as the essence of the profession that doctors, as scholars of the human body should defend the defence of the citizenship of the sick person.
• Medical education requires reflection, culture, acceptance of diversity and complexity: they are indispensable instruments for the human exercise of scientific medicine.
Medical schools should be a part of the university system; they are not higher technical schools.
I also have no doubt that he would approve the definition of the final product – as he termed our recently-graduated doctor – which we accept as the fundamental aim of our mission.
Would Pulido Valente approve the strategy followed for the reform of teaching, the fundamental aims of which are the development of cooperation among the fundamental sciences and clinical practice as a new vision of his concept “do anatomy, biology and histology at the patient’s bedside”, that is, science at the service of clinical medical practice, the introduction of areas of integration instead of the traditional well-compartmentalised subjects; in short, teaching based on students’ early exposition to clinical medicine and greater emphasis on the ethical and social dimension of medical practice?
As I do not doubt that he would be sitting in the front row using rigour, objectivity in support and critique of the research work done by our students, a faculty initiative in order to stimulate interest in science and research and that has become one more encounter that began today in a room adjacent to this auditorium
Pulido Valente would certainly be the greatest supporter of a new level of this organisation – the Academic Medical Centre – which we are making with the directions of the hospital and the hospital centre and Institute of Molecular Medicine, legalised by a joint law from the ministries involved and published last September, and which seeks to provide a model that might promote profitable use of the resources, bring Dynamics to innovation and the quality of medicine and consolidate educational reform.
I would like to end by mentioning the other dimension of Pulido Valente’s life: his friendship, his social sense, his fondness for freedom and his rejection of tyranny.
This is the famous work by Abel Manta: A Tertúlia do Consultório, with well-known figures from literature, from medicine and from culture; one can see Aquilino Ribeiro, Ramada Curto, Fernando Fonseca, Manuel Mendes and Câmara Reis, who marked the Portuguese time with their spirit of resistance and love of freedom.
And with this photograph, taken on one of those sunny days in Winter, which warm our souls, and for which I am indebted to João Monjardino, and which shows a serene, tranquil and secure man, who stands out from the shadows that surround him.
Francisco Pulido Valente’s action, which we recall today 125 years after his birth, was a landmark and an inspiration, and I am sure that we will do everything to be able to deserve and honour his memory and example.
Slide Show
Prof. Doutor J. Fernandes e Fernandes
cd@fm.ul.pt
Chairman of the Board of the North Lisbon Hospital Centre (CHLN)
Relatives of Professor Pulido Valente and Guests
Ladies and Gentlemen:
I wish to thank Professor João Monjardino, the Direction of the Pulido Valente Foundation and the Chairman of the Board of the CHLN for their kind invitation to participate in this act of homage to Professor Pulido Valente, one of the greatest figures in XX century Portuguese medicine.
Someone once wrote that “the past is a foreign country” and that in order to visit it one needs a skilful and knowledgeable pilot. I confess the difficulty of the mission. I have made use of the memories of family members, of those who were students or patients of Professor Pulido Valente, and of the remarkable testaments through which his disciples and family members have praised the meaning of Pulido Valente’s personality and work in Portuguese medicine.
With such illustrious guests who will deal with other aspects of his personality and work, allow me to keep to Pulido Valente’s medical work which has remained and stood up to time and to the ignominy of the dictatorial political sectarianism that surrounded the continuity of his academic and hospital action.
Pulido Valente was the most prominent figure in Internal Medicine of the Portuguese XX century, and his influence was incomparable for successive generations of doctors; for this reason he is a reference, a pillar of the Faculty of Medicine.
His dimension is multifaceted, and thus this mission is difficult. An unusual man with a unique and striking personality, with great intellectual and civic coherence, he was at the time in Portugal the doctor scientist who had trained in experimental activity in the laboratory, and led the great metamorphosis of clinical medicine here, making it evolve, as Diogo Furtado has pointed out, from an art based on observation, to a true science in its permanent search for experimental understanding of pathological phenomena. For this reason he was an uncontested master, demanding, intolerant of ignorance and incompetence, and aroused that intellectual seduction that Steiner talks about, which is a mixture of admiration and fear.
Juvenal Esteves has synthesised these feelings in a telling phrase “The name of Pulido Valente, when stated at the time of his leadership, always rang out forcefully”.
He was the founder and head of a school for medical action and thought, and as an academic and doctor was a committed spectator and active citizen in the defence of the essential values of freedom and democracy.
He was born on the 25th of December 1884, in Lisbon, but His family origins came from the south, the Alentejo and the area of the Spanish border, with no direct roots in medicine with the exception of an uncle, Dr. Francisco Martins Pulido, who was a distinguished doctor at the Rilhafoles Hospital.
(Slide Bibliography I, Bibliography II)
He did all of his training at the Lisbon Medical-Surgical School, founded by King Dom João VI after his return from Brazil, and finished his course in 1909 with the mark of 19 on 20. He was an active student leader in the academic revolt of 1907 against the dictatorial government of João Franco, and a committed defender of the recently-established Republic. His final thesis was on Hysteria, a controversial subject at the time, and from then on he showed the strong characteristics of his personality, as Diogo Furtado stated: unusual intellectual rigour and demand, scientific knowledge and a critical sense, rejecting a priori identifications with conceptions about the anatomical foundations of Hysteria, then fashionable in the positivist and materialist philosophy that attracted him so much. He showed intellectual independence.
All of His school career was remarkable and distinguished him: he received several academic prizes and “Acessits”, which is proof and acknowledgement of merit.
In 1911, through public competition, he became a doctor on the Consultative Board of the Civil Hospitals of Lisbon and, in January 1912, was appointed first provisional assistant in the subject of Psychiatry, directed by Júlio de Matos, a period which had a decisive influence on the future development of Pulido Valente’s skills and clinical method.
The other decisive influence that stands out in his biographical path was that of Aníbal Bettencourt, who provided him with the experimental dimension and laboratory skill, which were fundamental in establishing Scientific Medicine, of which he would be a pioneer and master. Indeed, from August 1914 to July 1917 Pulido Valente attended the laboratory of the Câmara Pestana Institute, headed by Aníbal Bettencourt, who started Experimental Medicine in Portugal and who, in the wake Câmara Pestana, had transformed the Bacteriological Institute into a pole of attraction for new talents and a centre of radiation for new talents within a modern view of medicine.
In a text paying homage to Aníbal Bettencourt, Pulido Valente states the importance of experimenting in medical education and the impact of that period in his own training. He mentions Bettencourt’s role in the opening up of new scientific horizons, besides the traditional French influence and states: "there is no competent doctor without a strong laboratorial preparation because in diagnosis laboratory and clinical elements are constantly at play... they call upon each other, they clarify each other and they correct each other".
It was at the Bacteriological Institute that Pulido Valente’s restless and unsatisfied spirit found itself, as a volunteer researcher, beginning a remarkably productive period from the scientific point of view. Here a set of research activities were carried out on a common disease – Syphilis – a decision that was coherent with his pragmatic and utilitarian view of research, which should be concentrated on seeking an effective solution for relevant clinical problems.
Syphilis was the experimental model that allowed him new horizons into pathological research, into the mechanisms of disease and of the patient’s biological reaction, always with the final aim of treating the social scourge that was, at the time General Paralysis.
Three important monographs are from that period, and are about the experimental model of the disease introduced into a rabbit, about early infection and the mechanisms of its progression to the encephalon and about the etiopathogeny of General Paralysis, and which were the subject of a lesson for his competition to become a full professor. Some of his observations represented a scientific advance at the time, namely the demonstration of the presence of the infecting agent in the cortex of 70% of the patients observed, a new fact in the scientific literature of the time, as well as the mechanism for early contamination of the cephalic-rachidian liquid after contact with the infecting agent.
This period of innovating clinical research was very important and productive, and was the expression of the influence of German medicine, the paradigm of which would be the inspiration for his future action as a clinical head doctor and teacher.
Simultaneously, from 1915 he begins collaboration as a free assistant at the 1st Surgical Clinic under the direction of Francisco Gentil, where he becomes familiar with pathological research through the study of operational pieces and collaborates on medical accompanying of surgical patients.
This was a very fruitful collaboration. Diogo Furtado and Jaime Celestino da Costa agree in their interpretation that Francisco Gentil saw in Pulido Valente the qualities that would make him the mentor for new generations and indispensable medical skill. For Pulido Valente the anatomical-pathological experience gained in a major surgical service was important, marking the final stage of his training in a path towards the top position in the university hierarchy and gave rise to the importance of medical-surgical collaboration, of its advantages for teaching and for treating patients, as he clearly stated later: “practice has shown that teaching is seriously harmed by the lack of connection between medical and surgical teams” having proposed practical solutions in order to reinforce that medical-surgical cooperation.
This desideratum in the life of public hospitals would be achieved in the final years of activity, when Reynaldo dos Santos took over the Chair of Clinical Surgery at Santa Marta Hospital in 1941. Jaime Celestino da Costa refers to that short period, contemporaneous with Wolwhill, as a perfect educational triangle: medicine with Pulido, surgery with Reynaldo and Pathological Anatomy with Wolwhill.
All of this period, which was one of consolidation of the teaching and scientific production, would be interrupted by his being called up for service on the World War I Expeditionary Force.
In France he is firstly placed in the Merville Blood Hospital, then in Hendaye and finally at the Base Nº 2 Hospital, always occupying head positions in these services.
The experience of war medicine would produce within him a critical attitude in relation to the structure of medical teaching in Portugal, as we will see, a facet of his that is usually given less attention in his biography, but which Miguel Carneiro de Moura analysed in a conference he gave in 1993 at a Pulido Valente Prize award session.
On his return to Portugal in 1919 he resumed his university career, and in September of that year he applies and is accepted as Assistant in 1st Clinical Medicine, being awarded 20 on 20 and finishing in first place, and in December he was put in charge of the chair in the Course of Medical Pathology.
In February 1921 he successfully applied to the position of Full Professor of Pathology and Medical Therapeutics.
The organisation of medical teaching, the selecting and preparation of assistants and the development of clinical services, fighting for the incorporation of laboratory diagnostic sectors that are indispensable to research on patients become his priority and will definitively mark out his future action. He will do this in detriment to the innovating scientific research that he had carried out during his period of work at the Câmara Pestana Institute.
The paradigm that influences him is that of the University Clinic of German Medicine, which brings together laboratory research as an indispensable instrument for a medicine with a scientific basis and excellent and innovating medical practice. For this reason he insisted during the discussion of the plans for the new school hospital that the clinics should have separate laboratories.
In fact, at that time, at the beginning of the nineteen twenties, it is Pulido Valente who takes on and leads the renewal of medical teaching, bringing the spirit of renewal that had marked out the basic sciences to clinical practice. He does not conform to the norm and his determination is remarkable.
In the report he made for direction of the faculty about his activities as Chair of Medical Pathology he points out new paths indispensable to this strategy of renewal.
He indicates the structural deficiencies, the lack of means, the extremely poor conditions of the wards and the absence of a working laboratory.
He clarifies his teaching strategy, stating that the subjects dealt with were whenever possible shown on patients, macroscopic works and histological preparations.
This view likened him to Sir William Osler, who is not mentioned in Pulido Valente’s work, perhaps because of the dominant Germanic influence, and who had stated that “one should only teach with the patient, he is the compendium”.
He defends the fundamental unity of the course when he states he does not miss a single occasion to stress the importance of the subjects in the First Degree Cycle and the need for the students to remember these subjects. All the teaching should be guided towards clinical medicine, because that is what the mission of a medical school should be.
He sums up his pedagogical philosophy in an exemplary manner “do anatomy, histology, immunity and bacteriology at the patient’s bedside, with simplicity and practical sense.
The teacher, he added, is no more than a guide; the true and profitable learning can only be done by the student in contact with the patient”.
Despite the endemic backwardness of Portuguese culture, one may say that it accompanied the dynamic of renewal that, starting from Johns Hopkins in Baltimore, began the revolution in teaching of Scientific Medicine that marked the first decades of the XX century.
"Only the knowledge that students acquire through laboratory experience is real and authentic"
W. Welch, 1878
“ ... and the student is not just limited to observing, listening or memorising: he does! His activities in the laboratory and in the clinic are the main factors for his instruction and discipline” A. Flexner, 1912
In this report Pulido Valente is deeply critical of the teaching methodology followed after the Reform of 1911.
This Reform of 1911, the precursors and some protagonists of which were portrayed by Columbano, whose canvases now decorate the Council Room and the Office of the Faculty Direction marked an irreversible evolution in Portuguese medicine through a meritocratic policy for the renewal of the teaching staff, the creation of autonomous institutes for the Basic sciences directed by noteworthy personalities with scientific training acquired in Europe.
Concerned about the renewal of clinical teaching and with the need for means towards this end, Pulido Valente analysed the impact of the reform in what he called the final product – the practical doctor who comes out of the medical school wondering whether the training for the recently graduated doctor is better than that of the graduate ten or twenty years ago at the old Lisbon Medical-Surgical School.
This was not a view that longed for the past nor a destructive criticism of the effort to renovate and create science that these figures stimulated at the head of the then created institutes and which were effectively the base for scientific medicine in Portugal.
What Pulido Valente in fact denounced was the deficient translation, using today’s terms, between that scientific education and the acting reality – the practical doctor.
The experience acquired during the war gave him awareness of the true dimension of this problem, which he did not consider exclusively a Portuguese deficiency and about which he wrote “for States, the war has provided the unique opportunity for a thorough and conclusive experience on the incompetence of the practical doctor when leaving university courses”.
He spoke about the "hypertrophy of the basic subjects in detriment to clinical teaching, as if clinical qualification resulted from the algebraic sum of the knowledge granted in the first period of the course”.
And he drew up one of the most lucid descriptions I know of the true essence of medical education “that he considered to be a work of education and culture, as it requires the developing of special psychological qualities, the fixing of mental attitudes and the progressive enriching of the sensorial memory with images of reality to the acquisition of a subtle technique”, in order to state that one was facing a “complex learning of an art in which enter elements of the subconscious and intuition, that are not confused with the conceptual knowledge of their rational bases”.
For these reasons, I have for years been insisting during reception for freshmen that medicine is a higher education that requires culture, and I remind my students of Introduction to Clinical Medicine that the so-called Clinical Art is no more than “organization of the mind, structured knowledge, method and minuteness in observation and promptness in memory”.
What would Pulido Valente think about the cultural disarmament of the new generations, about the selection of students for the course in medicine based on the capacity to memorise and obtain high marks in specific areas, increasingly narrowing the horizons of culture and the formation of the mind?
And of the recently approved 40-hour week, an invitation to the total functionalising of the profession, to the impoverishing of medical education and the loss of values essential to medical professionalism, namely availability and the spirit of service, he who organized the famous clinical-pathological with Wolwhill on Saturdays, without any doubt an impossibility nowadays?
How often, outside of working hours, have I lived clinical experiences that have marked me and enriched my sensorial memory with unrepeatable images that have turned out to be so useful!
What can one do?
I will now come back to the document referred to, and which is profoundly enlightening as to Pulido Valente’s thoughts and on his action as a leader of the renewing of teaching clinical medicine in Portugal.
He then added “whoever reads what is being written today in Europe and in America will see that one is again return to the healthy good sense of considering first degree subjects not as autonomous sciences and speculating in biology, but as mere subjects in the medical-surgical course, existing for the needs of Professional education and progress”
Some critics of his action have interpreted these concepts, as well as his demand for scientific culture as an essential requirement for serious and truly innovating scientific research, as a limitation imposed on that dimension that is fundamental in academic medicine, and the appanage of our threefold mission: to teach, care and research.
In fact evolution has gone the opposite way. The institutes of fundamental science are today essential to a modern and dynamic medical school, and should be centres for scientific creation, capable of responding to the clinical issues and making instruments available for questioning nature, beyond the “knives, forks and spoons” of which my Master João Cid dos Santos used to speak.
The person who produces knowledge and is not restricted to repeating others’ knowledge will surely be a better teacher, and the scientific training of doctors is an indispensable requirement for XXI century medicine.
His action in renewing medicine and the creation of a School of Medical Thought and Clinical Action would require people, and Pulido Valente surrounded himself with a remarkable group of disciples, whom he meticulously prepared, sending some to centres of excellence in Germany in order to improve their knowledge in the new areas of development in internal medicine.
Jaime Celestino da Costa wisely states: Pulido brought scientific Germany to us! And it is worth reading the correspondence exchanged and published in the “In Memoriam”, which shows the care with which Pulido Valente accompanied his collaborators’ vicissitudes and guided their action from afar.
He was acknowledged by all of them as an unquestioned Master.
He had authority, character, demand, competence and vision, and these are in fact the attributes of a master.
This is the tree with its branches through which his influence radiated out: the people are well-known, and over a decade and a half, until the brutal and unjust withdrawal imposed by the political sectarianism of the dictatorship in 1947, he irreversibly stimulated clinical and academic medicine and in Lisbon.
His removal and that of his main collaborators may have stopped him completing more publications, like his contemporaries Jimenez Diaz and Gregório Marañon in Spain.
Some separata of his lessons remained, of which I have mentioned some, and one which intrigued me as a specialist in vascular disease.
This refers to an analysis of a theory that was fashionable at the time on the physiology of circulation; it is hermetic, deeply mathematical – Bento de Jesus Caraça’s guidance was decisive for this – and it clearly reveals Pulido Valente’s capacity to deepen a subject until its most complex dimension.
I confess my inability to read it, which is certainly not a recommendation in my favour!
Diogo Furtado, in the essay published as a homage on Pulido Valente’s 70th year, stated his “extraordinary intellectual organisation, exceptional memory, capacity for systematisation and timely innovation, and added “I never met anyone who could give such an impression of accumulation of knowledge and of its prompt use”.
Jaime Celestino da Costa admirably synthesised this with sharp clarity, “Pulido didn’t just know more, he knew better”, and this was the basis of the indisputable intellectual seduction that captivated the best and formed a School.
His collaboration with Wohlwill, a Jewish German pathologist who had fled Nazism, had an extraordinary striking influence on Pulido Valente’s action: he finally embodied the essence of the anatomical-clinical method he had cultivated since the beginning of his training, and had been the base for the remarkable development of German medicine in the first two decades of the XX century.
Wohlwill’s action was decisive for the progress of medicine in Lisbon and of the Faculty of Medicine; he created a School and an important group of followers, among whom were Jorge Horta and Arsénio Nunes, and I had the privilege of having been a student of the two.
This was pathology stopping the whims of clinical medicine: a model imported to the famous anatomical-clinical meetings on Saturdays, in which the making of the diagnoses was confronted with the cruel and harsh reality of pathology and the cases discussed were published in the magazine Lisboa Médica.
Their repercussion on the medical life of the city has reached our times, and, unfortunately for us, were unrepeatable.
Wohlwill and Pulido Valente’s relationship was based on mutual admiration, between two figures with solid scientific and medical knowledge, and was summed up like this: “Pulido had finally med an interlocutor of his own calibre”.
His action was decisive for Wohlwill to stay in Portugal for some time and create a school of pathological Anatomy in the Faculty of Medicine, as can be seen in this letter by Francisco Gentil.
Pulido Valente was indeed the interlocutor for Wohlwill’s being transferred from the IPO to the Medical School, where he remained until he left for the United States in 1946.
Pulido Valente was critical of some scientific research, which he considered amateurish, unprofessional, removed from concrete reality and sometimes dangerous, and that was a reality that may have diminished the academic dimension in his extraordinary renovating action for thought and medical culture in Portugal.
He would have been indifferent to angiographic research, which was started by Egas Moniz and later continued by Reynaldo dos Santos and João Cid dos Santos and others, and which was an unusual scientific research, inappropriate in a backward country distant from the scientific world its time.
And in fact, ladies and gentleman, it was the Portuguese School of Angiography, with its innovating action, that was the most important Portuguese contribution to medicine, and is still today referred to and well known, that was the basis for the original work by Cid dos Santos on the unblocking of arteries indispensable to the development of vascular surgery, for which he is recognized as the founder throughout the world.
Angiography was the Great contribution made by Egas Moniz and his followers, more than prefrontal Leucotomy, of which Pulido was a critic avant la lettre and which only know, thanks to the new developments in imaging the brain and locating some points of dysfunction, may regain importance and usefulness.
In an unbiased analysis, I agree with the observations published by João Monjardino in the book “In Memoriam” by Pulido Valente about the lesser importance that research had on his action.
The expression “on my service scientific discoveries are forbidden” was well known, but more than the hostility towards the spiritual disquiet indispensable to research, it was an appeal to rigour, to exhaustive study of current knowledge, the only way of avoiding “successive ongoing rediscoveries” which ignorance and a somewhat provincial approach sometimes tend to overvalue, and is the expression of intellectual and scientific underdevelopment that unfortunately still persists among us.
Perhaps what Pulido Valente meant was the need for a scientific attitude that would generate the small conquests of research and created ecology favourable to discovery and innovation.
He perhaps undervalued the impact of the individual and solitary creative mind.
I am quoting Jaime Celestino da Costa when he relates an episode that took place during the famous application competition by Cascão de Anciães, a disciple of Pulido’s who was also removed from the faculty in 1947, during which after speaking about the “joy of the mind that was research”, Pulido Valente sternly responded: “Research is a social function!”.
Excessive zeal for some intellectual orthodoxy that tended to undervalue the individual’s creative dynamic faced with imposed aims and rules? Excessive condemning of what might be taken as an expression of intellectual dilettantism?
I will leave the history and interpretation of the facts to historians, as I accept I am incapable of doing so!
Pulido Valente’s medical and educational influence lasted through time and has marked successive generations.
His concept of a clinical medicine with a scientific base has lasted, as well as the rigour and methodology of the clinical exam, the careful semiology and the empathy he established with his patients, and his solid psychiatric training has influenced doctors and patients.
Allow me to recall an aunt of mind who has died, who was a patient of Pulido Valente’s, and who insisted on describing her consultation with him to me, always repeating “learn from that, son!”. He was deeply admired, almost idolised by his patients!
Pulido Valente’s continued influence through his disciples who marked out the medical practice of Lisbon, in its widest sense, has reached us and continues to be the most secure weapon against the medical uncertainty of our times and the risk of the dehumanisation of an excessively technological medicine.
Then, his example: Professor of a clinical area, who achieved his academic positions through merit shown in public competitions, who gained the recognition of his peers and was a clinical reference.
It never went well when other requirements and other methodologies were imposed in the choices of leadership in academic clinical medicine.
But the preparation for this talk was an opportunity for reflection and questioning about the paths we have been taking in the Medical School that was Pulido Valente’s.
What would Master Pulido Valente think?
How would he react to the decline in academic medicine now considered old-fashioned and dominated by the pragmatic and economic view imposed by health managers, with emphasis on production aims and the famous rankings, fragmented by perhaps excessive specialization and dehumanized by the increasing influence of technology?
I would like to believe that he would agree with the essential requirements for our university and medical education mission.
• To develop critical spirit and ethical respect throughout all teaching, to encourage the production of knowledge and the introduction of innovation.
• To accept as the essence of the profession that doctors, as scholars of the human body should defend the defence of the citizenship of the sick person.
• Medical education requires reflection, culture, acceptance of diversity and complexity: they are indispensable instruments for the human exercise of scientific medicine.
Medical schools should be a part of the university system; they are not higher technical schools.
I also have no doubt that he would approve the definition of the final product – as he termed our recently-graduated doctor – which we accept as the fundamental aim of our mission.
Would Pulido Valente approve the strategy followed for the reform of teaching, the fundamental aims of which are the development of cooperation among the fundamental sciences and clinical practice as a new vision of his concept “do anatomy, biology and histology at the patient’s bedside”, that is, science at the service of clinical medical practice, the introduction of areas of integration instead of the traditional well-compartmentalised subjects; in short, teaching based on students’ early exposition to clinical medicine and greater emphasis on the ethical and social dimension of medical practice?
As I do not doubt that he would be sitting in the front row using rigour, objectivity in support and critique of the research work done by our students, a faculty initiative in order to stimulate interest in science and research and that has become one more encounter that began today in a room adjacent to this auditorium
Pulido Valente would certainly be the greatest supporter of a new level of this organisation – the Academic Medical Centre – which we are making with the directions of the hospital and the hospital centre and Institute of Molecular Medicine, legalised by a joint law from the ministries involved and published last September, and which seeks to provide a model that might promote profitable use of the resources, bring Dynamics to innovation and the quality of medicine and consolidate educational reform.
I would like to end by mentioning the other dimension of Pulido Valente’s life: his friendship, his social sense, his fondness for freedom and his rejection of tyranny.
This is the famous work by Abel Manta: A Tertúlia do Consultório, with well-known figures from literature, from medicine and from culture; one can see Aquilino Ribeiro, Ramada Curto, Fernando Fonseca, Manuel Mendes and Câmara Reis, who marked the Portuguese time with their spirit of resistance and love of freedom.
And with this photograph, taken on one of those sunny days in Winter, which warm our souls, and for which I am indebted to João Monjardino, and which shows a serene, tranquil and secure man, who stands out from the shadows that surround him.
Francisco Pulido Valente’s action, which we recall today 125 years after his birth, was a landmark and an inspiration, and I am sure that we will do everything to be able to deserve and honour his memory and example.
Slide Show
Prof. Doutor J. Fernandes e Fernandes
cd@fm.ul.pt