Adolpho Lutz and dermatology in historical perspective

jungle of vocabulary used in the scientific texts of the period. 31 The word undoubtedly complied with its basic function of conveying the ideas engendered in laboratories to other spheres of medical practice, as well as to society at large, where it was used in newspaper chronicles and literary pages. Nevertheless, microscopists, including botanists, zoologists and physicians, continued their heated debates on the terms and concepts that surgeon Sedillot had rejected. The main difficulty consisted in establishing a consensus as to the characteristics to be used in discriminating bacteria, algae, protozoa and fungi.

As Mazumdar (1994, p.4) has shown, these technicalities were associated with a basic and long-standing conflict between two currents or styles of thinking which, during that period in the development of life sciences, caused a split especially among botanists, but which also involved other professional categories interested in the biology of macroscopic and microscopic beings. On the one hand, there were the "unitarists," always seeking the basic unit underlying the diversity found in nature. On the other, the "pluralists" accentuated diversity, in their enthusiasm to organize it into increasingly detailed and precise classifications.

In Germany, the first to oppose the systematic botany practiced by the pluralists, who followed the methodology of Linnaeus, was Schleiden, one of the founders of the cell theory.

Schleiden lived during a period when many radical intellectuals

in the German-speaking world became involved in revolutionary

politics and even set up barricades in favor of democracy.

Schleiden, one such radical, opposed his predecessors, the

Linnean botanists of the Aristotelian tradition, in the same way

that his older but contemporary scientist, Johannes Müller, had

disagreed with his predecessors in physiology, the

Naturphilosophen. It is significant to note that, during this same

period, Karl Marx and "young Hegelians" were opposing their

predecessors in the areas of philosophy and theology.

(Mazumdar, 1994, p.16)

In the introduction to his book Grundzüge der wissenschaftliche

Botanik, 32 Matthias Schleiden proposed that the "medieval burg" of Linnean botany be replaced by a new inductive science whose purpose was to develop the unifying principles that would explain the multiform diversity of nature. Schleiden and his co-worker Theodor Schwann were the first to take the cell as the basic building block of plants and animals and as a bridge to the inorganic world, thus identifying the aspect that could give their new science the key for understanding the underlying unity of natural phenomena (ibid., p.17-8).

Unitarism was also the underlying theme of everything written by Carl von Nägeli, a disciple of Schleiden, his basic principle being Lex continui in natura. Nägeli was not looking for differentiation but for transitions between forms, the quantitative Abstufungen that connected them. The theories of Schleiden and Schwann regarding the formation of the cell, especially the idea that it consisted of a crystallization of matter around a nucleus similar to the formation of inorganic crystals, gave Nägeli a model for his phylogenetic theory (1856). According to this theory, there is a continuous production of simple organic beings based on inorganic matter, and the beings that first took on existence were the simplest unicellular plants, namely, fungi and molds (Mazumdar, 1994, p.31-5).

Nägeli published his first book on this topic in 1856, three years before Darwin published Origin of the Species. Nägeli compared the two theories (1865) and stated that they both arose from the principle that the higher species evolved from the lower. For Nägeli, besides competition and natural selection, another mechanism was also operating in nature: the impulse toward increasing perfection or progress, which continually leads organisms to evolve toward increasing complexity. In contrast with the umbelliferous tree of Darwin's families, Nägelli's evolutionary theory supposed "innumerable phylogenetic stalks" that are independent from one another. They float on the surface of the present and plunge into varying depths of the past (Mazumdar, 1994, p.39).

"If, in the material world, in causal terms, everything is related to everything else, if all phenomena have a natural origin, if all organisms are made of the same material as inorganic nature and finally disintegrate into it once again, then, in their origin, they must emerge from inorganic compounds. To deny spontaneous generation is the same as to claim a miracle," Nägeli wrote in 1884 in the work of his maturity, Mechanisch-physiologische Theorie der

Abstammungslehre. 33

Schizophytes, the simplest unicellular plants in terms of organization, were produced everywhere and all the time. Their multiple forms were so similar to one another and they were so easily transformed into one another that it was impossible to organize them into fixed species and genera.

In earlier articles, 34 however, Nägeli had distinguished unicellular fungi and algae. In contrast to the algae, fungi cells did not possess chlorophyll or coloring material and did not arise from germs but from fermentation, putrefaction or disintegration of organic substances.

When writing of mechanisms of production of diseases in a small book intended for physicians and lay readers (1877), Nägeli divided "lower fungi" into three groups: molds, ferments and "fissiparous fungi," and included bacteria among them. During his experiments, he had not observed transformations from one group to the other, but, individually, each group, especially the third, underwent

continuous transformation (Mazumdar, 1994, p.42). 35

The idea of spontaneous generation first arose in the Ancient World and was originally applied to worms, insects and even higher animals. In the 17th century it was used to explain the origin of the animalcules present in infusions made of animal and plant matter. The question posited by Leeuwenhoek himself was hotly debated by priests Lazzaro Spallanzani (1729-1799) and John Turberville Needham (1713-1781). Did those beings arise spontaneously through some vegetative force, or did they necessarily come from another similar living being? In religious terms, what they were discussing was whether God created the hierarchy of all living beings during the first six days of Genesis, or if He left some demiurge on the loose to undo His established order. In his classical study on microbe hunters, Paul de Kruif shows that the idea of spontaneous generation was, at the time, the most evident to common sense. Did not one constantly see insects coming out of old wood, worms from feces, flies from fruit? Needham and Spallanzani then conceived ingenious experiments, the first to confirm, the second to contest the appearance of animalcules in infusions sterilized by heat and isolated from the outside environment.

Polymorphism survived the demise of spontaneous generation in the famous controversy of Pasteur versus Pouchet (Martins and Martins, 1989, p.7-32). The concept of heterogenesis continued to affirm the alternation of generations, in the light of which important experimental results with fungi and algae – objects of great interest to naturalists – were obtained. In addition, studying them provided cognitive fuel for the differentiation of zoology, botany and mycology as specialties.

In their historical analyses, bacteriologists consider that the first labor pains for the birth of their discipline also occurred between 1830 and 1850, but the process was ambiguous, because, simultaneously, it privileged the efforts made to correlate diseases with living organisms and repudiated the invasion of fungi into the domain they wanted to preserve for the bacteria.

In 1835, Agostino Bassi (1773-1856) demonstrated the relationship between a fungus and muscardine, a disease that attacked silkworms and that would be an important subject of study for Pasteur. In the 1840s, it was discovered that these plant parasites were responsible for diseases (rust, smut, etc.), and many investigators, including Bassi, related them to diseases that affected the teguments and mucous membranes in humans and animals (Robin, 1853, 1847). Mycotic diseases in humans were described especially by David Gruby (1810-1898). In a series of articles published between 1841-1844, this Hungarian physician living in Paris described the fungi associated to four of the most common types of tinea.

As Ainsworth observes (1976, p.15) in his informative study on the history of mycology,

after a brief and overly enthusiastic reception, fungi were

eclipsed first by bacteria and then by viruses as pathogenous to

humans, and medical mycology remained almost completely

ignored until the last decade of the century, when Raymond

Jacques Sabouraud (1864-1938) had to rediscover and confirm

findings made by Gruby 50 years earlier.

William Bulloch places the high point of "fungomania" between 1865 and 1875, when these parasitic and mutant plants, sometimes appearing to be micrococci, were incriminated as agents of

countless diseases, ranging from malaria to endocarditis.36 Bulloch identifies two opposing viewpoints regarding the role of plant and animal microorganisms. One was the result of Pasteur's work on fermentation. He argued that their emergence and diversity were due to the action exerted by different microbes, which are recognizable by their constant morphology. Although he had no way of proving this, due to his limited knowledge of botany and his use of liquid media for cultures, Pasteur insisted on the existence of fixed forms, indispensable for sustaining the notion of the specificity of ferments and, therefore, of the etiological agents of diseases.

Koch, on the other hand, provided ammunition to those who argued against polymorphism – and he himself was its most radical adversary – by developing cultures in solid media, a technique that reduced the undesirable co-existence of numerous species of bacteria.

In addition, the research by brothers Louis René (1815-1885) and Charles Tulasne (1816-?), and of Anton De Barry (1831-1888) on the polymorphism of certain fungi gave strength to the conviction that this property could also be found in ferments and bacteria. Ernst Hallier (1831-1904), professor of botany in Jena, took this doctrine to extremes in the 1860s. For him, the microscopic forms of these organisms consisted not of genera and species, but merely of stages in the development of more complex fungi, accompanying changes that take place in the moisture, the temperature and other environmental factors. Hallier studied plant and animal parasites and altered these factors to induce changes in form. He concluded that if mold spores were placed in a mixture of sugar, water and ammonia salt, the plasma of the spore would divide into small nuclei (cocci) that would in turn continue to multiply by division. This was the basis of all fermentation in rich-in-nitrogen media, that is, in putrid fermentations, and their agent received the name of nucleated yeast (Kernhefe) or Micrococcus. If the nitrogen were consumed to a certain point, the nuclei changed, then producing a membrane that expanded and gave them the aspect of yeast cells that reproduced, now by gemination. The fermentation became alcoholic and the fungus entered the Cryptococcus stage. Then came acetic fermentation, when the yeast entered the Arthrococcus stage. When filaments appeared, it became a Leptothrix or a Mycothrix.

The most common criticism of polymorphism was in reference to accidental contamination of cultures by microbes carried in the air or already present in the inoculum before being inseminated. Hallier's theory nevertheless influenced a number of researchers, some quite renowned in the history of bacteriology, such as Lister (1873), Ray Lankester (1873), Huxley (1870), Klebs (1873), Warming (1875), Nägeli (1877, 1882), Cienkowski (1877), Büchner (1882), Metchnikoff (1888) and, especially, Billroth (1874) and Zopf (1879-

1885).37

 

Ferdinand Cohn and the classification of bacteria

Neither the spontaneous generation nor the pleomorphism that these investigators saw in the microbial world was acceptable for the Linnean botanist Ferdinand Cohn. Unicellular forms had stirred up his interest thanks to the speculations of Schleiden and Schwann on the origin of cells.

In an article published in 1854, Cohn sought to untangle the confused systematic relationships in this domain in order to clearly define good species. Among the unicellular forms, there were those that Christian Ehrenberg (1838) classified into the family Vibrio, placing four genera into it: Bacterium, Spirillum, Spirochaeta and Spirodiscus. Due to their vigorous movements, he had included them in the animal kingdom, but Cohn considered them plants and, to demonstrate this, he described the life cycle of the organism that Ehrenberg called Vibrio lineola. He found it in putrefying matter, where it formed gelatinous masses similar to those of the alga Palmella. Cohn therefore proposed the inclusion of vibriones among the colorless microscopic plants that lived in infusions, specifically among the aquatic fungi, or Mycophyceae. But this arrangement did not satisfy him because it artificially brought together plants that belonged to different families and genera. He held that these organisms should be classified with the algae to which they were similar, in spite of their lack of color (Mazumdar, 1994, p.49).

Nägeli, as we saw above, separated fungi, which were colorless, from algae, which had chlorophyll or some other pigment, classifying the green ones as Protococcus and those that had blue-green or orange pigments as Chroöcoccaceae and Nostocaceae. Cohn's studies on pigments led him to the discovery of new relationships among algae, which he then divided into two groups, the Chlorosporaceae, that contained only chlorophyll or a modification of it, and Phycochromacae, that contained chlorophyll associated with some other pigment. Taxonomic categories based on shape and the mode of reproduction derived from this basic division.

The tradition of classifying plants mainly on the basis of their reproductive organs went back to the 16th century, to the Aristotelian botanist Caesalpino, for whom the essence of these organisms was their vegetative soul, that is, their ability to grow and reproduce. Linnaeus was faithful to this principle, but he adapted it to phanerogams, plants whose reproductive organs are very evident. Cohn sought to respect Linnaeus when, in 1872, he produced a more elaborate systematization of cryptogams. He thus gave up the tripartite division of Algae, Fungi and Lichen and based his scheme only on secondary markers (habitus, vegetative organs, anatomy and means of life), and divided the class Thallophyta into seven orders, each containing several families. The first order, the Schizosporeae, that reproduced by simple cell division, included the families Schizomycetae, Chroococcacea; Oscillariaceae;

Nostocaceae, Rivulariaceae and Scytonrmaceae.38

Ernst Haeckel in his laboratory (Johann e Junker, 1970, fig. 67).

Contrary to the prevailing trend among his colleagues, Cohn considered it possible to discern species among the bacteria, now

classified with the algae,39 but he was aware of the difficulties involved.

Even if we ignore the transformism of those mycologists who

think that everything can arise from anything and develop into

anything else, when we see an agglomeration of bacteria, we

are beset with the doubt that these countless tiny bodies, of

every conceivable form, can be separated into natural species

... I am nevertheless convinced that bacteria can be classified

into species that are as clear and unmistakable as those of

other lower plants and animals. It is only because of their

exceptionally small size, their habit of living among many

different types associated with one another, and the variability of

types they become, that differentiation is often impossible with

the means we now have at hand. (Cohn, 1875, p.133, quoted in

Mazumdar, 1994, p.57)

It was difficult to apply the rules of Linnean tradition to bacteria because they did not seem to have any special means of reproduction, nor could any complete life cycle be determined by observing any given individual. In many cases, not even any form could be detected, and classification had therefore to be based on pigments or on the fermentation produced.

Indicated by many historians as the founder of bacteriology as a specialized branch of biology, Ferdinand Cohn set down the bases of his taxonomic system in the classic work entitled Untersuchung über

Bacterien (1875).40 It was imperative to settle the controversy over the fixity or variability of bacteria in order to establish the science of bacteriology and realign the map of diseases accordingly. As we saw above, the notion of etiological specificity presupposed the reduction of the microbial magma to fixed categories with unmistakable morphological features.

Although Cohn underscored the insufficiency of morphological criteria, his system was nevertheless based essentially on the form of microbes – and the reader will undoubtedly note how often Adolpho Lutz uses this word "form" to designate every organism that appeared under the lens of his microscope. Cohn classified bacterial cells into four groups or tribes, with their respective genera and

species.41 Learning to recognize these typical forms – micrococcus, bacterium, bacillum and spirillum – medical students were introduced into the science of microbes during the same period that Adolpho Lutz published his book on the new genus into which he intended to include the "fungi" or "myxomicetes" of leprosy, tuberculosis, malaria

and syphilis.42

One year after the publication of his article, on 22 April, 1876, Cohn received a letter from Robert Koch, then an unknown physician working in Wollstein, a remote village in the Province of Posen. In the letter, Koch told "Herr Professor," Director of the Institute of Plant Physiology in Breslau, that after working for some time with the contagion of anthrax, he had succeeded in mapping the life history of this bacillus. Before publishing his study, he wished to hear Cohn's opinion, because this latter seemed to be the only botanist seriously interested in giving some order to bacteria.

According to Mazumdar (1994, p.58-70), Koch's observations and arguments made a very positive impression on all his listeners. The growth of the anthrax bacterium from spores, the conditions under which they are formed, and the relationship of both with the disease – answered all of Cohn's questions on the matter. One of his most serious problems was how to establish the specific identity of a given organism and the limits within which it varied during the different stages of its life cycle. Koch explained that bacilli did diversify beyond prescribed boundaries, had a well-defined life cycle, produced a clearly determined disease, and belonged to a single species.

Robert Koch (1843 -1910) Laboratory. Prussian Bildarchiv

Collection. Johann & Junker (1970, p.33, ill. 29).

Nucli and granules of bacteria cells, showing the formation and

germination of spores. 1. Anthrax bacillus. 2. Proteus vulgaris. 3. Megatherium bacillus, with Romanowski nucleus, stained according

to his method. 4. Anthrax bacillus with metacromatic granule. 5.

Anthrax bacillus with Babes-Ernest granules. 6. The same bacillus,

isolated by Ernest staining. 7. Bunges sporogenic granule. 8. Babes-Ernest granules in a bacterium of Sarcina genus; 9. In Pyocyaneus;

10. Staphylococcus pyogen. aureus. 11. Typhoid fever bacillus. 12.

Anthrax bacillus (vegetative form). 13. Finkler-Prior Vibrio. 14.

Anthrax spores. 15. Subtilis bacillus spores. 16. Tetanus spores. 17. Anthrax spores germination. 18.Tetanus spores germination. Kolle &

Wassermann (1912, v.1, plate II).

Sketch of Bacillus anthracis F. Cohn et R. Koch (carbuncle). I.

Preparation of blood from mouse spleen. II. Preparation of agar cultivation. III. Involute forms in preparation of agar stained with

fucsine. IV. Anthrax and agar filament. V. Colorless preparation

dropping from cultivation liquid; the spores begin to show. VI. Preparation with guinea pig lungs: formation of capsules. VII.

Preparation with rabbit liver: forms called "bamboo". Lehmann &

Neumann (1910, plate 43).

Through Cohn, Koch came into contact with the medical-intellectual elite of Breslau, especially with Julius Cohnheim, director of the Institute of Pathology, and his assistant, Carl Weigert (cousin to Paul Ehrlich), who was developing staining methods for bacteria based on aniline, referred to above.

During this period (1876-1878) Koch introduced improvements in microscopic techniques and in the methods for fixing, staining and photographing microorganisms (he was convinced that microphotographs would be much more convincing than drawings to prove the existence of different species of bacteria). The use of the new microscopic techniques developed by the physicist Ernst Abbé for Carl Zeiss's company in Jena allowed Koch to see bacteria in animal tissues without interference from shadows projected by the tissues themselves. In his articles on the etiology of infections in wounds, published during this period, Koch added a new method for verifying bacterial species: the types of diseases with which they were associated. "Every disease corresponds... to a different bacterial form, and this form is always the same, no matter how often

the disease is transmitted from one animal to another." 43 Animals' bodies thus became for him a medium for producing pure cultures of microorganisms and, at the same time, indicators of the properties of the species that was being cultivated.

One drawing presented by Nägeli in the book he published in 1877 (Die niederen Pilze), reviewed by Koch in Deutsche Medizinische Wochenschrift, showed different types of schizomycetes (Spaltpilze). There, a wavy line of interconnected cells led to the perception that the spiraled forms were nothing more than cords of cocci.

Koch referred to this image in a letter to Ferdinand Cohn, and commented that:

I was especially attentive to this point from the very beginning of

my investigations ... [namely], the disintegration of Bacilli into

Micrococci and vice-versa [and] the formation of rods from

micrococci. Our understanding of bacteria will change

completely whether this is confirmed or it is proved to be wrong.

This, then, is the most important issue in bacteriology. It must be

settled if there is to be any consensus among bacteriologists...

(quoted by Mazumdar, 1994, p.65)

 

Adolpho Lutz in contradiction with Koch

"The form of bacteria is constant," wrote Kolle and Hetsch (1908, p.18), authors of one of the best-known treatises on bacteriology in the early 20th century (La bacteriologie expérimentalle). Continuing, they said: "By this we mean that, in their normal state, cocci always produce cocci, rods produce rods, and spirilla produce spirilla."

"Many transitions occur among micrococci and to this day some forms are designated as bacilli", Lutz responded in his second article on the agent of leprosy, published in 1886. In fact, rods could disintegrate into shapes similar to cocci, but the bacteriologists who observed this phenomenon – in the tuberculosis bacillus, for example – tended to consider it an artifact resulting from the way the microorganism was handled, or else an expression of its degeneration.

"When a rod breaks down into small round cells, this is not necessarily a dying process," wrote Lutz. The typical forms of bacterial morphology were easily identifiable by well-known methods, but the specific methods of preparation he developed proved to be indispensable to give meaning to certain forms that to some looked like rods and to others like cocci or micrococci. Combining the new techniques with the precision and meticulousness that characterized his way of working, Lutz began researching the media and the envelopes that gave form to these anomalous cells, as well as their modes of reproduction. He concluded that there was no justification for separating forms with and without chlorophyll forms into different orders, and that certain properties seen in algae were pertinent to those seen in bacteria and

fungi. Coccothricaceae, 44 the family that Lutz created to include the microbes of leprosy, tuberculosis and their correlates, gave meaning to the properties that he had brought together in such an original way at Unna's laboratory. It had the characteristics of two bacterial families – the Coccaceas and Bacillaceas – but was essentially classified in the kingdom of Fungi.

His proposal was advanced ten years later (1896) by that of Karl B. Lehmann and R. O. Neumann, who included the agents of leprosy and tuberculosis in the genus Mycobacterium (from the Greek word

Mykes, fungus).45 According to Obregón (2002, p.34), they coined that name because of the fungus-like appearance of stems cultivated in liquid media. According to current definition, mycobacteria are aerobic and alcohol-acid-resistant bacteria with thin, sometimes ramified rods that are either straight or slightly curved in shape. This genus includes thirty species that differ from other bacteria in a number of ways, many related to the amount and type of lipids contained on their walls (Bier, 1963, p.129; Trabulsi, 1991, p.188).

For Bertha Lutz (Lutziana), Arthur Neiva (1941, p.iii) and other Brazilian biographers, Adolpho Lutz provided the evidence needed for Coccothrix to be the valid name for this genus. In 1936, Lutz himself (Neiva, 1941, p.373-81) complained that

The germ considered the cause of leprosy is generally called

leprosy bacillus or Hansen bacillus. In fact, it is not a real

bacillus. In 1886, I proposed the generic name of Coccothrix for

it and for the tuberculosis germ, which should have priority over

the name Mycobacterium, which is generally used.

The priority claimed by Lutz was denied by a decision handed down by a Judging Commission designated at the First International Congress on Microbiology, held in Paris in 1930. The Committee for Bacteriological Nomenclature, set up on that occasion, named the Judging Commission and assigned them the duty of preparing a Code of Nomenclature for Bacteria to settle the disputes that had accumulated in this area of study. The code was approved at the International Congress on Microbiology held in Copenhagen in 1947 and revised by decision of the subsequent congress, held in Rio de Janeiro in 1950. The International Code of Nomenclature for Bacteria and Viruses, approved in Rome in 1953, was submitted to further revisions consequent to decisions determined by the Judging Commission. In 1958, it decided that the genus Coccothrix Lutz 1886 had not been published in a valid manner because the author failed to use that generic name in binary combination with one and another species included by him in the genus (the leprosy and tuberculosis bacilli). He had also failed to refer to descriptions of these species previously published under other names (Lessel Jr.,

1960, p.117).46

For Otto Bier (1963, p.538), the granulations found in the leprosy bacillus should be called Lutz's granulations because they were thoroughly studied by him. Although having underscored the similarities between the bacilli of Koch and of Hansen, arguing for the inclusion of both in the same genus, there are very few references to his work in the literature on leprosy. Lutz himself did not persist in this line of investigation. In 1906, he wrote in a letter to Unna stating that "I am very sorry that you never again concerned yourself with the question of the grains of bacillus (Coccothrix) and completely abandoned Ernst, Babes and Neisser at that time. Now the issue is up in the air and there is still much to be done. I wonder

if you still have the energy?"47 We hope the material made available in this edition of the writings of the Brazilian scientist Adolpho Lutz will encourage biologists and historians to go more deeply into the analysis of this question and deal with it better than we have done. Other articles and papers on dermatology by

Adolpho Lutz(1886-1889)

During his stay in Hamburg, Lutz worked with Unna in research on other microorganisms related to skin diseases. These studies gave rise to an article in Monatshefte für Praktische Dermatologie about a schizomycete very similar to that described by Ferrari in an article reviewed by Lutz himself (1886d) in that same journal. Ferrari distinguished only two types of pityriasis, the versicolor and the erythematous forms. Examining the literature on the disease, he came to the conclusion that the organisms described by Malassez, Bizzozero and Rivolta were identical and should be called Saccharomyces furfur, differing from Mikrosporon anomaeon Vidal. Based on his own experience, he concluded that erythematous pityriasis, in hairy parts, was produced by a Saccharomyces and, in bald parts, by Mikrosporon anomaeon. The fungus that Lutz and Unna found in the scales of an eczema similar to psoriasis seemed to be the same as that which Ferrari had related to erythmatous pityriasis and was also similar to the spores of herpes tonsurans (known today as tinea tonsurans). However, inoculations that Lutz performed on himself "on the skin of his lower arm and between his toes" gave negative results, leading him to doubt whether the fungus really had any pathological importance (Lutz, 1886e).

Pityriasis rubra pilaris, histologic cut. Vivier (2002, p.93).

While in Hamburg, he wrote three other reviews for Unna's periodical (Lutz, 1886f; 1886g; 1886h). He summarized a new communication by Ferrari to the Academia Gioenia di Scienze Naturali on micrococci and bacilli present in the secretion of soft ulcer; another review was about an article by G. Lewin on cysticercus, a larval form of cestoid platyhelminths, that are parasites in vertebrates and become tapeworms when ingested by humans in infested pork or beef. The evolutionary cycle of this parasitic worm, how it infects humans, and the diagnosis of the disease it causes were still being studied. In the text on Lewin's article, Lutz included observations he himself had made in Brazil of the presence of cysticercus under the skin of two of his patients. The third review he published in Monatshefte für Praktische Dermatologie was also related to parasitic diseases, specifically, about an article written by Sigmund Theodor Stein on the evolution of human cestoids.

After returning to Brazil in mid-1886, Adolpho Lutz stayed only a short time in Limeira, even though his clinical work there had been reborn like "the phoenix from the ashes" and had evolved "magnificently". These are Unna's expressions, and they represented the feeling he had when reading Lutz's enthusiastic letters. At Unna's suggestion, Lutz soon moved to São Paulo, about 200 kilometers south of Limeira. In this growing metropolis, and even more so, in Rio de Janeiro, Unna saw better opportunities for Lutz to develop his "talent as a consultant". Lutz continued to publish, in Germany, articles related to dermatology and helminthology, and his name appeared on the first page of Unna's journal "as the

correspondent on South American literature in Portuguese". 48

The difficulty bacteriologists faced in cultivating in vitro and replicating in animals the Bacillus leprae – or, if we are to use Lutz's terminology, the Coccothrix leprae – made it essential for him to have constant contact with lepers and the cadavers of persons who had died of leprosy, in order to renew the organic material he needed for his studies on the morphology and biology of the microorganisms and how the bacillus becomes distributed in organs and limbs. These lines of investigation led Lutz to spend some time during 1887

at the Hospital dos Lázaros, in Rio de Janeiro (see Lutz, 1887a).49

In fact, this was a very prolific year for Lutz's scientific production. He published two further reviews (Lutz, 1887b; 1887c) in Unna's periodical. In one he analyzed the data presented by Beaven Rake in his report on leprosy in Trinidad and, in the other, he developed ideas on the etiology and prophylaxis of the disease presented by J. L. Bidenkap. In 1887, based on observations made in Limeira, Adolpho Lutz sent another important article about Hansen's disease to Monatshefte für Praktische Dermatologie. This time, he emphasized clinical and therapeutic aspects and, especially, the disease's mode of transmission (Lutz, 1887d). This study was reproduced, almost in full, in the Annales de Dermatologie et de Syphiligraphie, through the initiative of its editor, Adrien Doyon (1887).

Lutz's medical practice in São Paulo provided him with the elements he needed to publish two clinical studies on skin diseases that were rare in Brazil: rhinoscleroma, described for the first time by Ferdinand von Hebra, and lichens, a group of dermatoses that Hebra had divided into two groups: lichen scrofulosus and lichen rubber,

this latter having two varieties, acuminatus and planus. 50

Lutz's article (1887e) on lichen ruber was based on only one case, that of a young pharmacist, approximately 25 years of age, who had become ill in December, 1885, with intense cardialgias. The patient later presented red blotches on his forearms and the back of his feet. The blotches disappeared spontaneously three weeks later but, in August, 1886 – Lutz had just returned from Hamburg – they returned and spread to the patient's entire body. At the end of that year, after self-medication with Fowler's solution and ointment of chrysarobin, the pharmacist went to see Lutz. This latter, having made a diagnosis that he considered correct, prescribed Unna's sublimate carbol ointment, which gave positive results.

During the first examination of this patient, Lutz discarded eczema papulosum and syphilitic papules, and saw that this was a case of lichen ruber, part of the efflorescence showing characteristics of lichen planus and another part, those of lichen obtusus. Lutz found no signs of the lichen acuminatus indicated by Hebra.

Patient with rhinoscleroma before and after radio therapy. Terra

(1921, p.16-8, ill. 4 and 5).

This case brought up interesting questions as to the relationship of the cardialgias with the disease; the possibility, even if temporary, of spontaneous cure; the location of lichen planus in the palm of the hand, something new even for Unna; and, from the "medical-geographical" point of view, the occurrence, finally proven in a "tropical" region of Brazil, of lichen ruber, a rare disease anywhere (Lutz had no word of any other case of lichen in South America).

The brief communication about a case of rhinoscleroma was published in July, 1890. It also was based on a clinical case seen in São Paulo that Lutz considered important to divulge because of "the place of observation and the race of the person affected".

Florentino, a 30-year-old black man, had noticed the onset of the disease two years and six months earlier. It started on his neck, attacked his upper lip and then a nostril that was entirely closed when Lutz started treating him. When Lutz first examined him, four years earlier, the patient had already sought out various doctors in São Paulo and Limeira, and they had diagnosed cancer and syphilis. Only Dr. Vergueiro, a colleague trained in Europe, recognized the rhinoscleroma and called Lutz's attention to that rare case. Lutz confirmed the diagnosis and proposed re-establishing breathing through the nostril, which he succeeded in doing with medicated tampons and in introduction of cannula of varying calibers. However, he was unable to cure the patient. Without having much success either, he tried carbolic salicylic acid, pyrogallic acid, chrysarobin and corrosive sublimate. The treatment recommended by Doutrelepont had no effect either. He was unable to try out other medications because the patient moved to another city.

Florentino – the only full-blown case Lutz had encountered in his clinical practice – showed him, first of all, that this was not a disease to be cured rapidly and permanently, even though its anatomical and etiological study was almost complete. Secondly, it proved the occurrence "there," in Brazil, of that disease which, like lichen ruber, was very rare.

Lutz published this article when he was already in Honolulu, as Government Physician for the Study and Treatment of Leprosy. In the period between his return from Hamburg to Brazil and his next trip abroad (1886-1889) he published no fewer than nine articles of great value in the field of parasitology, as well as his first article in protozoology, in another major German periodical, the Centralblatt für Bakteriologie und Parasitenkunde and in the Giornale della R. Accademia di Medicina di Torino (Lutz, 1887f; 1888a; 1888b; 1888c; 1888d; 1888e; 1888f; 1888g; 1889h). Through these articles, Lutz began interacting more regularly with the community of colleagues comprised of Leuckart, Grassi, Laveran and other physicians, zoologists and bacteriologists that had been developing what would soon be called "tropical medicine" (Worboys, 1996).

As we show in the historical presentation to Book 2, the president of the Board of Health of the Kingdom of Hawaii asked Unna to name a doctor to apply his therapeutic methods in a leprosarium recently founded on the Island of Molokai. Unna indicated Adolpho Lutz and, in July, 1889, Lutz visited Unna, who helped him gather everything he would need on Molokai. According to biographers, this meeting took place in Hamburg, but all indications are that Unna and Lutz were together at an event that was very important for the consolidation of skin diseases as a medical specialty in its own right: the First World Congress of Dermatology, held in Paris from 5 to 10 August, 1889 (Shelley & Shelley, 1992, p.12-3).

 

The international congress and the institution of

dermatology in Brazil

Paris was the center of worldwide attention. Thousands of visitors, of all nationalities, were visiting there, including intellectuals, important dignitaries, politicians and statesmen, men of commerce, of industry, of finances or those simply dedicated to the idle enjoyment of their wealth, sometimes with their families and servants, all euphoric over the grandiose international exposition that had been organized to celebrate the first centenary of the French Revolution in 1789. They were celebrating the revolution where first the heads of kings and aristocrats of the ancien régime had rolled and then those of the Jacobins and other revolutionaries – all now dissolved in the conservative humus that made possible the vigor of French industry and culture, symbolized at the moment by the impressive Eiffel Tower.

At the same time as this cosmopolitan celebration was taking place, the sessions of the World Congress of Dermatology were also being held at the world's oldest hospital specialized in this type of pathology, Hospital St. Louis.

It was built in response to the epidemic of the black plague in 1562, which caused 68,000 deaths in Paris alone and which the only "asylum'' in the city, the Hotel-Dieu, was utterly unable to handle. Henry IV therefore determined the construction of a new establishment for the victims of contagious diseases and for all the poor who were cast in such places. The complex, designed by Claude Vellefaux, was named St. Louis in honor of King Louis IX, who had died of the plague near Tunis, in 1270. The hospital was opened in 1610, when Louis XIII rose to the throne, and received its first patients during the epidemic of 1618, holding six patients per bed. It had been requisitioned for other functions on several occasions, until Hotel-Dieu burned down in 1773, thus requiring it to operate permanently. Jean Louis Alibert installed his dermatological clinic there in 1801. The worldwide reputation of the St. Louis as a dermatological center was built up by generations of physicians, including Alibert himself, Gibert, Devergie, Biett, Lugol and, later, the generation of Cazenave, Bazin, Hardy, Vidal, Besnier and Fournier. The hospital underwent considerable remodeling to house the 1889 Congress. Its participants were received in the grand hall of the museum that now housed the extraordinary representations of skin

diseases modeled in wax by Jules Baretta. 51

According to Tilles (2002), French dermatologists organized the congress to restore their international influence, which had been overshadowed by the prestige of the School of Vienna and the dynamism in other centers in Central Europe. These groups were nevertheless solidly represented at this prestigious event, which strengthened the prominence of St. Louis Hospital. There, differently from the organization in German-speaking countries, the study and treatment of skin diseases were symbiotically bound to those of syphilis.

As Carrara (1996, p.39) has shown, syphilis was thought to have the ability to manifest itself through so many different forms that it constituted a type of general etiological principle. "It was no longer seen as just a disease, but as a generating principle of diseases."

Saint-Louis Hospital in Paris, where the First International Congress

of Dermatology and Syphilography in 1889 took place Congrès

International de Dermatologie et de Siphiligraphie (1889).

The Société Francaise de Dermatologie et Syphiligraphie was

founded on 22 June, 1889, one month before the congress.52

Chronologically, the first important moment in the process in France was the establishment, in 1868, of the Annales de Dermatologie et de Syphiligraphie, mentioned above, through the initiative of Pierre-Adolphe-Adrien Doyon (1827-1907), a physician who was to exert great efforts to make the work of Germanic dermatologists better known at a time when the relationships between France and

Germany were the worst possible. 53

Similar journals had already been founded with more or less ephemeral histories, including Syphilidologie, published in Leipzig in 1838 by F-J. Behrend. It remained in circulation until 1862. Annales des maladies de la peau et de la syphilis, an initiative of A. Cazenave, were published from 1843 to 1845 and, later, in collaboration with Maurice Chausit, from 1850 to 1852. The Journal of Cutaneous Medicine and Diseases of the Skin, founded in London in 1867 by Erasmus Wilson, lasted only four years. The Giornale italiano delle malattie veneree e delle malattie della pelle was founded by G. B. Soresina in Milan in 1866 .

 

"Ricordo dell'Esposizione del 1889 con la Torre Eiffel". Despite the

opposition of Parisian artists, the Eiffel Tower became the main

symbol of the city of Paris after the celebration of the French

Revolution centennial. Inaugurated at the 1889 World Fair, the tower

was visited by two million people. II Secolo XIX. Parigi

Contemporanea. L'esposizione del 1900 (p. 12).

Advertisement of Saint-Louis Hospital Museum in Paris, published

on Lepra inside cover. Bibliotheca Internationalis, periodical

published in London, Leipzig and Paris by Besnier et al. (1900).

According to the editorial of the first issue of Annales de Dermatologie et de Syphiligraphie, in 1868, this periodical would provide specialists with a tribune for an open debate on numerous obscure aspects in the field of dermatological diseases. Progress in this field would be assured by the publication of original papers, theoretical and practical critiques of new diagnostic methods, treatment and statistics related to syphilis and skin diseases, and an inventory of everything published in the field around the world. Abstracts and reviews of congresses, books and articles produced in various countries would assure the cosmopolitan character of Annales. In fact, as Wallach (1994) has noted, this section of reviews and abstracts, written by Doyon himself, was to occupy an important place in the journal.

Another important historical fact was that Annales began circulating at a time when the teaching of dermatology was being contested in France. In addition, the long-awaited establishment of the professorship in clinical treatment of skin and syphilitic diseases at the Paris Medical School – which Tilles (n.d.) describes as "an essential part" of the institution of French dermatology – had faced considerable resistance. Tilles attributes this resistance, on the one hand, to the intellectual climate hostile to anything that could not be considered encyclopedic knowledge and, on the other, to the conflicts of jurisdiction between two pillars of the health system in France, Paris Medical School itself, and Assistance Publique, responsible for caring for patients in the hospitals.

After the revolutionary events of July, 1830, the Minister of Public Instruction of the restored monarchy, the Duke of Broglie, summoned a commission to re-examine the organization of medical teaching. The report, written by a leader of French social medicine, Jules Guérin, called for the establishment of specialized professorships an essential step toward the improvement of medical education. He thus suggested not only a professorship in skin diseases, but others in different areas, including: the history of medicine; general, compared and pathological anatomy; general pathology and treatment; and clinical work with children's diseases. The opposing resistances exerted by the Medical School on the one hand and Public Assistance on the other resulted in the fact that only free courses were given, outside the regular curricula. The course on skin diseases became the responsibility of Cazenave from 1841 to 1843, and was taken over by Alfred Hardy after 1862. Verneuil gave free courses on syphilitic infirmities.

Thus, while medical schools in Germany and England were resolutely promoting specialties, those in power at the Paris Medical School rigidly insisted on encyclopedic teaching , considering specialized clinics and hospitals as fatal "to science and to art" (Tilles, n.d.).

Only after France's humiliating defeat from the Germans in the War of 1870-1871 did the French State succeed in forcing the school congregation and the physicians at hospitals to establish a common ground where specialized teaching could make use of patients, a practice that was indispensable for clinical demonstrations. The professorship in skin and syphilitic diseases was formally set up, by decree, on 31 December, 1879. Installed at St. Louis Hospital on 8 January, 1880, its first director was Alfred Fournier, the leading

organizer in the 1889 International Congress. 54

During this same period similar processes were taking place at the medical schools in Rio de Janeiro and Salvador, Brazil, as the result of the reform carried out by Leôncio de Carvalho, the Viscount of Sabóia (1882-1884), commented on by Adolpho Lutz early in his

medical career in Brazil. 55 The discipline named, in the French fashion, Clinic of Cutaneous and Syphilitic Affections, was founded in 1883, and its most important professors were João Evangelista de Castro Cerqueira (1855-1935), in Salvador, and João Pizarro Gabizo (1845-1904), in Rio de Janeiro.

Castro Cerqueira identified tinea nigra in 1891, but the observations he made after experimentally reproducing the disease by inoculating a volunteer with scales extracted from a lesion were not published. This fact is mentioned in the doctoral thesis of this physician's son, Antônio Gentil de Castro Cerqueira Pinto, on "Keratomycose Nigricans Palmar" (1916). Gabizo, the professor in Rio de Janeiro, was not known for the excellence of his scientific work. Although he had spent some time in training at the clinic of Hebra and Kaposi in Vienna, he published only one article on the regulation of prostitution, one conference on leprosy, and another on venereal diseases (Carneiro, 2002, p.44-6; Mota, 1944, p.102).

The most creative figure in Brazilian dermatology was undoubtedly Antônio Pereira da Silva Araújo. He was trained at the Tropicalist School in Bahia and since 1875 had been dealing with topics related to parasitology and microbiology in the so-called Gloria Conferences (Fonseca, 1996). He also published important articles on filariasis (1875, 1878), Demodex folliculorum (1877), and the "Treatment of Elephantiasis by Electricity" (1876).

In 1881, with Júlio de Moura, Moncorvo de Figueiredo, Cypriano de Freitas and Moura Brasil, Silva Araújo founded the journal União Médica, which began "pressuring the authorities to take measures in public health against the spread of syphilis in the country" (Carrara, 1996, p.82). In that same year, he participated with Figueiredo and other physicians and "benefactors" of the foundation of the General Polyclinic of Rio de Janeiro, inspired on the analogous institution in

Vienna.56 One year before establishing the dermatological professorships at the schools of Rio and Salvador, Silva Araújo opened the Service for Skin Diseases and Syphilis at the Polyclinic and began lecturing on this topic to classrooms packed with students, "impregnated with pasteurian ideas" (Rabello, 1974, p.262). He then carried out studies on syphilitic chancres and on dermatoses such as yaws, which, at the time, was considered "a very malignant tropical form of syphilis, especially affecting individuals of the black race. With his disciple Bruno Chaves, Silva Araújo established the therapeutic value of a mercury salt for treating

syphilis, that would be used to treat the disease until the 1940s."57

In approximately 1894, Oswaldo Cruz, a recent graduate, was invited to organize a laboratory to diagnosis syphilis and internal diseases at Silva Araújo's clinic. These two clinicians, together with Salles Guerra, Werneck Machado and Alfredo Porto, were known as the "group of five Germanists," due to their efforts to learn German, the language of the most advanced medical texts of the period (Benchimol, 1990).

In 1882, Silva Araújo was elected full member of the Imperial Academy of Medicine. In the following year, to accompany the first courses in dermatology in Brazilian schools, he published Atlas de doenças da pele [Atlas of Skin Diseases] (1883), with colored engravings and texts in French. Also in 1883 he gave conferences on "The Sanitary Regulation of Prostitution," a theme he would return to in 1890 with an article entitled Prophilaxia pública da

syphilis [Public Prophylaxis of Syphilis] (1891).58

The emerging Brazilian dermatology was represented at the Congress in Paris by Silva Araújo, one of the foreign assistant secretaries on the organizing board for the event. The other Brazilians present were Pizarro Gabizo, Bruno Chaves, Oscar de Bulhões and Adolpho Lutz.

The organizers of the congress scheduled a number of topics to be debated, an indication of the extent of the uncertainties and controversies related to the field of dermatology. The first question and, in fact, the most debated, was in regard to the lichen "genus," under which the older dermatologists classified a great number of diseases that the more "modern" professionals considered different from one another. The organizers asked which "species" should be kept in this genus and which others should be taken out and classified elsewhere. Similar doubts were brought up about dermatitis exfoliativa, including the distinctive characteristics of pityriasis rubra. Should pityriasis rubra pilaris be considered an independent disease or a species of some other genus, such as psoriasis? What are the relationships between skin diseases called erythema scalatiniforme and primitive generalized exfoliative dermatitis.

Pemphigus was also brought up for discussion at the congress to decide whether diseases until then classified under this name should or should not be considered distinct species. Another disease, trichophytosis, was the subject of the fourth question. Its natural history, manifestations and transmission by contagion were well known, but there were still doubts as to the best treatment, which could not be the same in all countries.

There was already reasonable consensus among specialists in syphilis regarding the evolution of trichophytosis, the distinctive characteristics of its manifestations and the necessary sanitary and therapeutic measures involved. But there were serious disagreements among clinicians as to the opportunity and duration of the treatment and the preventive value of the medications prescribed. The organizers of the congress therefore asked at what stage in the disease should treatment of syphilitic infections begin and with what therapeutic methods? When should iodine-based preparations (especially potassium iodide) be associated with, or replace, mercurial treatment, and what are the counter-indications of each? Tertiary syphilis was also a major issue for debate, in terms of its relative frequency and the real influence of the causes supposedly favorable to its onset: age, constitution, personal or family medical history, occupation, alcoholism, depression, etc.

Besides these basic issues, the Organizing Board listed other topics that participants could decide whether or not to debate, namely, fungoid mycosis, Pruritus hiemalis, the contagiousness of leprosy and the number of its victims in Europe, the state-of-the-art regarding the parasitic nature of diseases such as dry circinate eczema, Gibert's pityriasis rosea, seborrheic eczema, and others. The Organizing Board also suggested a debate on the relationships between syphilis and certain diseases of the nervous system, such as tabes and general paralysis, the unicity and duality of venereal chancres, the relative frequency of soft chancre in different countries, the value of amputation of syphilitic chancre, experiences in different countries regarding regulations and prophylaxis for wet nurses and abandoned children still being breast fed, and the teaching and practice of dermatology.