Adolpho Lutz and dermatology in historical perspective

parasite in tissues, on which basis modern authors formulate a

specific diagnosis. In spite of that, the subsequent 25 years

were of a great deal of confusion about the matter and Lutz's

disease was regularly confused with cocciodioidomycosis. Only

in 1929, with Floriano de Almeida's comparative study of the two

funguses responsible for the affections, was it possible to

distinguish them.

In this interval, Carini (1909, 1915), Lindemberg (1909), Gaspar Vianna (1913), Carvalho (1911), Dias da Silva (1912, 1914), Portugal (1914) and Kehl (1915), among others, described cases of the disease originally described by Lutz.

Gaspar Vianna, who was a pathologist at Instituto Oswaldo Cruz and

died at a young age in 1914, had a strong interest 81 and published a paper on it, written in collaboration with Miguel Pereira (1911). The thesis he submitted to the Faculty of Medicine of Rio de Janeiro to obtain his post-doctoral degree (1913) was dedicated precisely to the "Posadas-Wernicke sickness". Splendore had indicated the clinical signs of location in the lungs and the presence of parasite in patients' sputum and urine. Vianna traced a more complete clinical and pathological profile of the disease, showing that after the initial cutaneous-mucous locations, it propagated itself through the lymph system to the whole organism (Fonseca Filho, 1974, p.91; Fialho, 1946, p.41-2).

reproduced itself by endosporulation alone. 82

Title page of Renato Ferraz Kehl's Ph.D. thesis on Blastomycosis

(1915). Above: man affected with either tubercular or nodular blastomycosis (Professor Rabelo cliché). Bellow: patient with

mucous blastomycosis. Kehl (1915, p.67,118).

Gaspar de Oliveira Vianna (1885–1914). Instituto Oswaldo Cruz

researcher, who prematurely died, at 29, of contamination during the

autopsy of a person who had died of tuberculosis. Fonseca Filho

(1974).

Front cover of Haberfeld paper Granuloma ganglionar maligno de

origem blastomycetica (Zymonema histoporocellularis) published in

São Paulo in 1919.

According to Fialho, with the exceptions of Haberfeld and Splendore, scholars of the subject thought coccidioides imitis were its agent until, in 1929, Floriano Paulo de Almeida (1898-1977) published a comparative study of coccidioidic granuloma in the United States and Brazil, showing that there were clear differences between the two diseases. He then proposed that the genus Paracoccidioides be created (Almeida, 1930), but Olympio da Fonseca Filho (1939), a mycologist at Instituto Oswaldo Cruz, defended a different classification and a new name for the disease, though this was not well accepted by their peers.

 

Histologic cut of a lung, drawn by Raymundo Honório from Instituto

Oswaldo Cruz, showing Paracoccidioides brasiliensis, the fungus that causes Lutz mycosis. They are the ovoid corpuscles, stained by

Gram-Weigert method, in different stages of development. Fialho

(1946, p.183).

According to Fonseca Filho, the authentic forms of fungus isolated by Splendore in his patients' tissues were associated to contaminating yeasts and the Italian parasitologists had described all of this as a single species and given it the name Zymonema brasiliense. According to the rules of botanical nomenclature instituted at the Brussels Congress in 1910, he had created a "confused name (nomen confusum), that is, a name initially applied to two or more different species" and that was not useful to designate "a species type of a new genus that was being or was going to be proposed." These were the reasons that Fonseca Filho questioned the genus that Floriano de Almeida created on the basis of Splendore's null species. "A revision of all of the literature on the subject allowed us to conclude that the first specific name used validly for the Lutz's disease mycete was Zymonema histosporocellularis, proposed by Haberfeld in 1919. Hence, in 1939, we based the new genus Lutziomyces on it."

Fonseca also rejected the Adenomyces genus, created by Ezequiel Caetano Dias, "because it is based on a species, A. cruzi, that is, a mixture of several mycetes, as well as contaminant bacteria." Between 1914 and 1917, the period in which he headed up Instituto Oswaldo Cruz in Belo Horizonte (now named Instituto Ezequiel Dias), Oswaldo Cruz's son-in-law published a series of papers on an affection similar to tuberculosis, syphillis and leukemia that was mistakenly diagnosed as Hodgkin's disease, adenoma or lymphosarcoma. The most noticeable sign of the disease was cervical, submaxillary and supraclavical ganglia that were sometimes enormously engorged. Ezequiel Dias found a supposed fungus in them, named Adenomyces cruzi. Its accentuated polymorphism, explained Fonseca Filho (1974, p.77-8), actually was caused by Dias's mistakes when he described as a single microorganism the legitimate colonies of the fungus responsible for Lutz's disease contaminated by other fungus of the Isaria genus.

 

Adolpho Lutz at Instituto Oswaldo Cruz

In 1908 Adolpho Lutz moved to the institute directed by Oswaldo Cruz, in Rio de Janeiro. Founded in 1899 to provide the capital with serum and vaccine against the bubonic plague, like Instituto Butantã in São Paulo (Benchimol & Teixeira, 1993), the institute was at a critical moment of a change that made it, for several decades, the center of gravity of Brazilian experimental medicine and public health.

Lutz and Cruz had crossed paths fifteen years earlier, during the cholera epidemic in the Paraíba Valley (Benchimol, 1999). Oswaldo Cruz had just taken over his deceased father's clinic; he and Francisco Fajardo, Eduardo Chapot- Prévost, Miguel Couto and other young pioneers of bacteriology in Rio de Janeiro regarded Lutz, the "savant from Rio," whose training was solid and germanic, as a model to be followed. But Oswaldo Cruz's scientific writings as a bacteriologist and entomologist have stayed in the shadow of his extraordinary achievements as a sanitarian and science administrator. Thanks to his abilities as a public figure, leader of his staff and strategist of institutional policy, the modest Sorotherapeutic laboratory in Manguinhos became the dynamic Institute of Experimental Pathology, renamed Instituto Oswaldo Cruz in March 1908. The change took place during Afonso Penna government (1906-1909), which followed that of Rodrigues Alves (1903-1906) and confirmed Oswaldo Cruz in the post of Director-General of Public Health.

The increased importance attributed to the institute at Manguinhos was in part due to the euphoria of public opinion because of the successful campaigns against yellow fever and bubonic plague in Rio de Janeiro. The city's new avenues and palaces gave the impression that the capital of Brazil had finally become civilized. The "rabble" that had led the revolt against mandatory antiviral vaccination – the Vaccine Revolt (Benchimol, 2003; Sevcenko, 1984; Chalhoub, 1996) – had been expelled from the part of the city that Mayor Pereira Passos had renovated. A good number of adversaries of the new urban order had surrendered to the rhetoric of Brazil's "regeneration," backed by monuments like the imposing Moorish castle built on the Manguinhos property. But the decisive factor that led Congress to give in to Oswaldo Cruz's project was the gold medal he won at the 14th International Congress of Hygiene and Demography and the concurrent Hygiene Exhibition, held in Berlin in September 1907. Four years later, Instituto Oswaldo Cruz shone at the International Hygiene Exhibition, held in Dresden in June 1911. At the first exhibition, the pièce de resistence was the documentation of the successful campaign in Rio de Janeiro against Stegomyia fasciata, currently known as Aedes aegypti, the transmitter of yellow fever. In Dresden, the work on the disease produced by Trypanosoma cruzi, which became internationally known as Chagas disease, was presented. The discovery of the transmitter consolidated protozoology as one of the most important fields of research at Instituto Oswaldo Cruz, not only because of Chagas's talent, but also because of the intrinsic qualities of the whole group, which had published a substantial number of papers related to prevention of malaria, the evolution of parasites in hosts, the systematics and biology of insects that transmit human and animal diseases.

The extraordinary zoological knowledge that Adolpho Lutz took to Manguinhos was decisive in building its biological collections and in the training of young doctors, all of them in their twenties, who Oswaldo Cruz had recruited to his "scientific kindergarten" (Aragão, 1950, p.14). These young doctors right out of medical school learned many of the tools necessary to investigate complex cycles of parasites and their hosts from Adolpho Lutz. His arrival coincided with the height of German influence on Manguinhos. In the interval between Berlin and Dresden, it welcomed Max Hartmann from the Institute of Infectious Disease in Berlin, and two professors from the School of Tropical Medicine in Hamburg: Stanislas von Prowazek, author of important works on chlamydozoans, and G. Giemsa, inventor of the staining method most used to observe hematozoans. Later on, Hermann Duerck, who taught pathology at the University of Jena, came to Manguinhos. The Memórias do Instituto Oswaldo Cruz, first published in 1909, publicised the work of its scientists, almost always in Portuguese or German, and Adolpho Lutz had the arduous and humble task of translating Portuguese into German, the hegemonic language until World War I. His good relations with European and North American universities, museums and research institutes must have contributed to the consolidation of Instituto Oswaldo Cruz's international reputation.

Lutz was the keystone and catalyst of innovation of the Bacteriological Institute of São Paulo. When he left, it went increasingly into a crisis that was lucidly described by Martin Ficker, the Berliner professor the São Paulo government hired to rebuild the institution. Besides the dubious quality of its facilities and equipment, Ficker said, its work had taken the wrong direction because it was restricted to routines aimed at public health to the detriment of

training on a more solid scientific foundation.83

Lutz was a scientist who liked solitary laboratory and field work. The decision to migrate to Instituto Oswaldo Cruz seems to be related to the possibility of withdrawing into the environment where he felt completely comfortable, returning to the research in zoology and botany that had taken second place during the time he was immersed in the conflict-filled terrain of bacteriology and on the front line of public health. During the final third of his professional life, in Manguinhos, he was prolific on themes of medical interest, like schizotsomiasis, or purely biological interest, like anurous amphibians, and remained distant from the internal and external conflicts that marked the institution's arrival at maturity.

Authors describing the history of Brazilian dermatology consider Instituto Oswaldo Cruz to be as important as the chairs created in Brazilian medical schools as catalysts of transformation of a clinical specialty into a specialized branch of scientific research. The relations between doctors that taught, cared for clinical assistance or carried out research into skin diseases gained density and national scope after the Brazilian Society of Dermatology was founded in 1912, at the initiative of leaders from Manguinhos and the Faculty of Medicine of Rio de Janeiro.

We have already observed different IOC researchers in action, studying Lutz's disease. They studied other pathologies that, in principle, were within the field of dermatology but they were not "specialists" in the sense we understand the word today.

At the time Adolpho Lutz migrated to Instituto Oswaldo Cruz, none of its technical staff were specialists nor was there any separation between the routines of research, teaching and manufacture of biological products. At the end of 1906, for example, Figueiredo de Vasconcelos, the more senior of the two department heads supervised the production of malleina, serum and vaccine against the plague, studied glanders and the transmission of chicken spirillosis to bedbugs. Vasconcelos had attended the classes of Pinoy and Sabouraud in Paris (Lacaz, 1983, p.265) and discovered, some time afterward, a new species of tricophyte, the Trichophyton griseum (Fonseca Filho, 1974, p.76).

Henrique Aragão, for his part, diagnosed the plague, prepared anti-streptococcal serum, studied equine piroplasmosis and the systematics of a family of ticks, the ixodids. As we showed in Book 2 of this collection, in the 1910s he and Adolpho Lutz participated decisively in debates over the transmission and prevention of leprosy.

In 1906 the other department head at Manguinhos, Henrique da Rocha Lima, recently arrived from Germany, investigated the pathology of yellow fever and organized a specialized course that taught PhD students and graduate doctors theoretical and practical lessons in bacteriology, parasitology, pathology and histology. Many professionals who took the course later became prominent in clinical practice and teaching of dermatology, during the phase historians of the field call "scientific" (see, for example, Carneiro, 2002, p.41; Padilha-Gonçalves et al., 1999, p.31). In 1912, at the Institute of Tropical Medicine in Hamburg, Rocha Lima showed that Histoplasma capsulatum, the etiological agent of histoplasmosis, was a fungus and not a protozoan.

On a patient's leg, a case of mycetoma, a disease caused by the

fungus Nocardia asteroides. Carini (1939, ill. 3 and 4).

Gaspar Vianna (1885-1914) took over responsibility for the pathology laboratory in 1909, replacing Rocha Lima when he left the Institute. Besides the studies of blastomycosis, he discovered Leishmania brasiliensis (1911) and the therapeutic value of antimony in curing leishmaniasis, as an emetic tartar in intravenous injections. Later, the substance was also used to treat donovanosis and schistosomiasis. Besides classifying as leishmaniases the Bauru ulcer and the "wild ulcers" of the Amazon River, Vianna investigated the evolution of Trypanosoma cruzi in human and animal tissues.

Paulo Parreiras Horta (1884-1961), who worked for a time in Manguinhos, published a fundamental study in 1911, on a disease called black piedra, in whose nodules he found formations he called cysts. In 1928, Fonseca Filho and Arêa Leão verified that they were actually ascus, or small organs in the form of a sack inside of which a fungus's sexual spores were formed; they created the genus Piedraia, baptizing Piedraia hortai the agent of ascosporic piedra. Parreira Horta also described a new species of Microsporon flavescens, and studied a fungus isolated by Oswaldo Cruz in the Amazon from a case of pedal mycetoma, which he described in 1919 as a new species called Madurella oswaldoi (Fonseca Filho, 1974, p.76).

Carlos Chagas was Oswaldo Cruz's successor as director of Manguinhos Institute and during his administration, from 1918 until his death in 1934, the tendency towards specialization increased, though more in some fields than others. The regulations of 1919 and 1926 demarcated "sections" for the first time, covering established and new laboratories, separating their routines more clearly from the production of serums and vaccines.

The old sections of Medical Zoology was responsible for maintaining collections and studies related to protozoology, helminthology, entomology and any vehicles for parasites. This section was, in fact, the laboratories of entomologist Ângelo Moreira da Costa Lima, helminthologists Gomes de Faria and Lauro Travassos and the multivalent Adolpho Lutz, who was then researching tabanids and Nematocera as transmitters of human diseases.

Mycology stands out among the new sections created under Chagas. It aimed to provide a firmer base for the work of the institute "especially in botany ... almost entirely neglected." Olympio da Fonseca Filho, who made this comment (1974, p.78), directed the section from 1922 to 1937 and was, in Lacaz's opinion (1983, p.265), the soul of "Manguinhos school of mycology", which trained,

among others, Floriano Paulo de Almeida. 84

Fonseca Filho was already involved with botany when he taught Natural Medical History at Rio de Janeiro Faculty of Medicine and tended to its herbarium. In 1916 he had taken a general mycology course in the Botanical Garden, taught by Eugênio Rangel, an agronomist who was a disciple of André Maublac, a renowned French mycologist. When Carlos Chagas decided to invest in mycology in Manguinhos, he obtained a scholarship for Fonseca Filho to study in the United States. Chagas had just been appointed director of the National Public Health Department and, that same year of 1920, he applied for help to Lewis Wendell Hackett, representative of the Rockefeller Foundation. Brazil was one of the main theaters of Rockefeller Foundation's campaign to erradicate yellow fever in different countries of the Americas and Africa (Benchimol, 2001).

Important discoveries in medical mycology had been made in the United States but in the two decades since his visit, observed Fonseca Filho (1974, p.80),

American literature on mycosis, besides an increased number of

case histories, focused almost solely on clinical and anatomo-

pathological aspects of the same morbid entities. During those

twenty years, there seems to have been little interest on the part

of American researchers in researching the etiological agents of

mycosis in man ... In contrast, there was a lot of research

activity in mycology ... among botanists at the universities and in

phytopathology services of the US Department of Agriculture

and its equivalents at state level; they were concerned about the

biology of fungus and the plant diseases they produced.

In the eight months he spent at John Hopkins University in Baltimore, Fonseca Filho often visited the cryptogamic botany laboratory of Duncan S. Johnson; the Pathology Department, where William MacCallum worked; and the clinics of T. C. Gilchrist, who was head of the Dermatology Department at John Hopkins and the University of Maryland. Fonseca Filho interned for three months in Washington, in the laboratories of the Bureau of Plant Industry and the Bureau of Chemistry, with Erwin F. Smith, who researched plant diseases, and Charles Thom, a specialist in Penicillium and Aspergillus. On the same Rockefeller scholarship, he worked at St. Louis Hospital in Paris and its Lailler School for children with scalp ringworm, and the Municipal Laboratory of the City of Paris, under the direction of Raymond Sabouraud, "the founder, one might say, of modern medical mycology." In the parasitology laboratory of the Faculty of Medicine, Fonseca Filho spent ten months studying mycology applied to human and veterinary medicine, with Emile Brupt and Maurice Langeron (the former was then studying tick fever or bovine pirosplamosis). Then he spent three months in Lyon, with Alexandre Guilliermond, "whose studies of vegetal cytology and the sexuality and systematics of yeasts were then being applauded." In the second half of 1922, before returning to Brazil, he visited the most important European centers for mycology, including the laboratory of Christine Marie Berkhout, creator of the Candida genus, in Holland (Lacaz, 1983, p.265).

"We carried more than eight hundred cultures of fungus in two heavy cases. They constituted, at the time, one of the largest collections of live cultures of these lower vegetals," wrote Fonseca Filho (1974, p.81).

Armed with know-how and valuable inputs, he began to organize the Mycology Laboratory at Instituto Oswaldo Cruz, with Antonio Eugênio de Arêa Leão (1895-1971) as his principal collaborator; the latter was responsible for Wassermann reactions done by the dozens every week, at the request of Santa Casa da Misericórdia Hospital in Rio de Janeiro. Arêa Leão had been an intern and then a volunteer assistant at the dermatological clinic of Rio de Janeiro Faculty of Medicine, whose chaired professor, Fernando Terra, gave IOC access to the patients in that clinic. In one of his reports (1929), Carlos Chagas called the mycology section "one of its kind in the country", and its collection of fungus cultures, with more than a thousand species, "one of the richest and most precious in the world." Starting in 1930, the section began to free itself from the burdensome routine of microscopic exams, cultures and innoculations by which it provided care to 6,841 clinical cases that year alone, in the Institute or in the laboratory linked to the chair in Dermatology and Syphillography at the Faculty of Medicine, occupied by Eduardo Rabello since 1925 (Benchimol, 1990, p.62).

In 1906 he and Fernando Terra competed for a substitute teaching position in the clinic. They tied for first place. Terra was chosen because he had been an assistant to the chair in the field since 1891. In 1910, when Chaves Faria, the chaired professor, died, he took the post and invited Rabello to replace him at the Dermatology Clinic. They gave it a new direction, reinforcing lab practices, clinical experimentation and interaction with Instituto Oswaldo Cruz, where both had been interns (Carneiro, 2002, p.51-5).

Important contributions came from the Clinic of the Faculty of Medicine, showing its dynamic role at the center of dermatological research (Carneiro, 2002, p.53). In 1910, Rabello published a monograph on "Dermatomycoses" and, two years later, began the research that led to the first revelation, in Brazil, of Charles Donovan's corpuscles, the agents of donovanosis, then called ulcerous or venereal granuloma. Everything known about the subject had been catalogued by Souza Aranha in his doctoral thesis (1917).

Fernando Terra was one of the first dermatologists to describe the treatment of rhinoscleroma by radiation therapy. He published a textbook on Dermato- Syphilography for students (Carneiro, 2002, p.55) and studied blastomycosis with particular interest. In 1923, he produced an important article with Fonseca Filho, Arêa Leão and Magarino Torres about chromoblastomycosis, a term they created to designate "a morbid entity until then ... covered by cutaneous manifestations of other diseases under the name 'verrucous

dermatitis'." 85

What role did Adolpho Lutz have in the new conjuncture of Brazilian dermatology? On the one hand, as a scientist oriented to medical zoology, he enriched this clinical specialty with enigmas and approaches that were on the agenda of tropical medicine. On the other, as an 'authority' recognized in Brazil and abroad, he lent his name to the initiatives of a younger generation and placed his vast knowledge and mania for precision at the service of those who acted more directly to produce original knowledge about skin diseases.

Lutz was present at the inaugural session of the Brazilian Society of Dermatology, on Sunday, 4 February 1912, in the Miguel Couto Pavillion of Santa Casa de Misericórdia. There the other 17 physicians were all from Rio de Janeiro, three from Instituto Oswaldo Cruz: Gaspar Vianna, Parreiras Horta and Werneck Machado. The organizing committee was made up of Werneck Machado, Fernando Terra and Eduardo Rabello. The remaining founding members were: Moncorvo Filho, Alfredo Porto, Eduardo Magalhães, Victor de Teive, Caetano de Menezes, Leal Júnior, Oscar da Silva Araújo, Juliano Moreira, Zopyro Goulart, Miguel Salles, Eduardo Jorge e Franco de Carvalho. A draft of the statutes was drawn up by Terra.

Advertisement of Mycol vaccines published on the front cover of

Revista Medico-Cirurgica do Brasil, (n.9, September 1932),

periodical published in Rio de Janeiro by Fonseca Filho, the head of

Instituto Oswaldo Cruz mycology laboratory, and by the son to

Carlos Pinto Seidl (1867-1929), former contributor to Oswaldo Cruz's

work and Public Health general director for many years.

 

Patient with generalized psoriasis. The other image shows the same

patient after 40 shots of anti-mycosis vaccine. Fonseca Filho (1934,

figs. 11 e 12).

Juliano Moreira, Fernando Terra, Adolpho Lutz, Werneck Machado and Eduardo Rabello presented the final version of the statutes and they were published in the journal of public record, Diario Official da União, the same day (Carneiro, 2002, p.55-6). In 1913, Adolpho Lutz was elected honorary president of the Society.

At the end of its first year of activity, it had 81 full members. 86 "There were almost no specialists at the time," wrote Portugal and Azulay (n.d., p.7). "Most members were clinicians, pediatricians, researchers and microbiologists." They met on the last Wednesday of each month in the amphitheaters of Santa Casa until 1922, when they moved to the auditorium of the Brazilian College of Surgeons in Botafogo. Clinical demonstrations were done in the two infirmaries, one for men and one for women, of the Skin Disease and Syphillis Service (Carneiro, 2002, p.58).

The period in which Adolpho Lutz participated most intensely was the 1910s, especially between the Society's foundation and 1915, when he bet all of his prestige in the defense of the transmission of leprosy by mosquitoes, as one of the Society's delegates to the Leprosy Prevention Commission. As we have shown in Book 2, the Commission was constituted by the federal government to establish policy guidelines on leprosy carriers.

Lutz's constant presence and the increasing participation of other scientists from Manguinhos in the Brazilian Society of Dermatology during that decade has an interesting dimension: the renewed traffic of information between tropical medicine and skin disease clinics. The minutes of the Society's meetings, reproduced in part at the end of this book, clearly reflect the change in perspective on health problems in Brazil, shifting the emphasis from infectious diseases that spread epidemically in urban centers along the coast to scarcely known endemic diseases found in the interior, that frequently manifested themselves in serious cutaneous lesions.

Dedications to Adolpho Lutz by young dermatologists, who held him as one of the highest authorities in the field: 1. dedication by Renato

Ferraz Kehl on his Ph.D. thesis (1915); 2. dedication by Nicolás

Gamarra & Guillermo Schouten, who were physicians in Paraguay at

the time and who wrote a relevant paper on the mycological flora in

pregnant women's vaginas (1937); 3. dedication by Achille Breda

(1909).

This change became more accentuated after Oswaldo Cruz left the post of Director-General of Public Health in 1909. These were troubled times, of the death of Afonso Pena, the interim presidency of vice-president Nilo Peçanha and the presidential campaign polarized between the "civilianist" Rui Barbosa and Marshal Hermes da Fonseca. Though he was beloved all over the country, Cruz had been unable to meet the goals of his second term as head of the Department of Public Health. The campaign against tuberculosis had faded away for lack of funds and political support; implementing regulation of the mandatory vaccination law continued to be postponed in spite of a serious epidemic of smallpox in 1908. Backed up by the federalist constitution, the state-level oligarchies blocked the central government's health work in their territories in spite of widespread yellow fever in many cities of the North and Northeast.

The Hermes da Fonseca government was punctuated by social crises, such as the Navy Revolt, led by sailor João Cândido in Rio de Janeiro, and the War of Contestado, a peasant movement that followed a messianic leader, João Maria, on the border between the states of Paraná and Santa Catarina; the economic crises precipitated by the collapse of rubber and the negotiation of a moratorium of payment of the foreign debt; and a political crisis unleashed by the unseating of several political bosses and handing over of their political machines to oligarchical groups aligned with Pinheiro Machado, a political leader from Rio Grande do Sul, very influential at the time.

Though Oswaldo Cruz's health reform sank, health action intensified outside of the capital under his coordination, as director of Manguinhos, by means of personal contacts with the federal and state governments and large companies involved in large-scale projects in the interior of Brazil.

In January 1912, Congress belatedly approved the Defense Plan for Rubber and created an agency, the Superintendency of Defense of Rubber, subordinated to the Ministry of Agriculture, Industry and Trade. Besides counseling the modernization of extraction, processing and sale, the Plan intended to make the work process more "rational" by improving organization and medical assistance,which should keep "within normal limits the absurdly high mortality coefficient" (Albuquerque et al., 1991). On 17 August 1912, the Superintendency signed a contract with Oswaldo Cruz to study health conditions in the great Amazon tributary valleys.

At the same time that Carlos Chagas, Pacheco Leão and João Pedro de Albuquerque made that study (October 1912 to March 1913), other Instituto Oswaldo Cruz expeditions traveled around central and northeastern Brazil. Between September 1911 and February 1912, Astrogildo Machado and Antônio Martins visited the São Francisco and Tocantins valleys with the Central do Brasil Railway Company survey team that was tracing the route of the line that would have linked Pirapora to Belém.

Three teams were active in the Drought Prevention Works Inspectorate, which was created in 1909 as part of the Ministry of Transports and Public Works. One of the Instituto Oswaldo Cruz expeditions, in which João Pedro de Albuquerque and Gomes de Faria participated, crossed the states of Ceará and Piaui from March to July 1912. Belisário Pena and Artur Neiva traveled about 7,000 kilometers through Bahia, Pernambuco, Piaui and Goiás, from March to October 1912.

Adolpho Lutz and Astrogildo Machado (1915) kept a detailed medical and zoological inventory of the São Francisco Valley, which they journeyed down from Pirapora to Juazeiro, from April to June

1912, visiting some tributaries and most riverside settlements. 87

The reports that these doctors wrote on the public health, bioecology, sociology and ethnography of the regions they visited were a first modern inventory of rural health conditions in Brazil. They had considerable impact on intellectuals in large cities – Jeca Tatu, the fictional character created by the author of children's books, Monteiro Lobato, is an example of this – by providing information in debates about the national question, which began to be seen in terms of the dualistic terms that have persisted in Brazilian social thought (Lima, 1999). The triumphalist touting of Brazilian civilization, instigated by the remodeling of its capital, was hard hit by revelations about the "other", poor and sick, part of the country.

The debacle of Amazonian rubber was irreversible and the Old Republic of political bosses did not want to confront the age-old tragedy of drought in the Northeast. In that sense, the medical-sanitarian commissions were not productive. But the laboratories of Instituto Oswaldo Cruz and other medical institutions in the country and abroad provided very valuable observations and materials about Brazilian fauna, flora and pathologies. These inputs fed into many applied health studies and encouraged greater autonomy for specialties in zoology, botany and clinical medicine.

Advertisement of Talcoform inside Boletim da Academia Nacional de

Medicina, year 109, n.6, April 1938.

 

Epilogue

According to Salomon-Bayet (1986), the Pasteurian revolution ran its course during these years. During the First World War, the devastation of infectious disease was reduced and armies were only exposed to the slaughter of arms, but was finally disarmed by the Spanish flu pandemic, costing at least 21 million lives in 1918-1919 (Crosby, 1989; Brito, 1997). The tragic death count showed up medicine's difficulties in dealing with viruses, still invisible to microbiologists, and in Brazil showed up the precarious situation of health services, increasing the dissatisfaction with the oligarchies that had so badly neglected collective health. The most immediate result of the crisis was the creation of the National Department of Public Health (1920-1922), whose scope of action went beyond a few coastal cities for the first time. More lasting action was taken to cure and prevent endemic diseases in rural and suburban zones (Hochman, 1998; Castro Santos, 1987). The Lieutentants' Insurrections, movements for reform of other spheres of public life and internal schisms of the oligarchies that led to the Revolution of 1930 and the foundation of a Ministry of Education and Public Health finally made health the object of national policy, with the help of Rockefeller Foundation, a powerful enclave with a mandate and prerogatives that rivalled the State in this field.

But that is another story and goes beyond the scope of this text, a story that Adolpho Lutz experienced with increasing alienation because of fatigue and increasing age. He no longer had the energy to embrace great medical causes and increasing blindness kept him form observing mosquitoes, miniscule worms and fungus that demand hours of patient observation at the microscope. In his last years, spent in the laboratory, Lutz dedicated himself to amphibians, large animals that he could probe with the help of his faithful assistant Joaquim Venâncio. "I witnessed that," scientist Hugo de Souza Lopes said. "He held an amphibian, already fixed, held its feet and checked whether it had blisters in its nails, or a parotid crest or glands and asked, 'What color is this animal, Joaquim?' And he

defined the animals like that, by palpation."88 Another recent arrival to Manguinhos, entomologist Sebastião José de Oliveira, remembers a scene that he saw every morning when he went up the imposing staircase of the Moorish castle: sitting on the top step, already blind, Adolpho Lutz listened to his daughter Bertha read him the words of that fading group of peers, from which he finally departed on 6 October 1940, when he died as a result of pneumonia. The obituaries exalted the monumental work he left to coming generations, part of which the reader will find in the pages that follow.

 

Bibliograph

AINSWORTH, G. "Historical Introduction to Mycology". In: AINSWORTH, G. (Ed.). The Fungi, an Advanced Treatise. New Yrok: New York Academic Press, 4v., p.3-20, 1965-1973.

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_________.Über eine Rhabdonemaart des Schweines, so wie über den Befund der Rhabdonema strongyloides (Anguillula intestinalis und stercoralis) beim Menschen in Brasilien. Centralblatt für klinische Medicin, v.6, n.23, p.385-90, 6.jun.1885a. [Trad. em português: Sobre uma espécie do Rhabdonema do porco bem como sobre o diagnóstico do Rhabdonema strongyloides (Anguillula intestinalis und stercoralis) no ser humano, no Brasil.]

_________.Über Ankylostoma duodenale und Ankylostomiasis. em Richard von Volkmann, Sammlung Klinischer Vorträge in Verbindung mit deutschen Klinikern Innere Medicin, Leipzig, Druck und Verlag von Breitkopft und Härtel, n.62-92, 1885, p.255-6; n.88, p.2295-2350, 1885; n.92, p.2467-2506,1885b. [Trad. em português: Sobre o Ankylostoma duodenale e a anquilostomíase.]

_________.Üeber in Brasilien beobachtete Darmparasiten des Schweines und anderer Hausthiere, sowie über das Vorkommen derselben Arten beim Menschen. Deutsche Zeitschrift für Thiermedizin, Leipzig, v.12, n.1-2, p.61-2, 1885-1886. [Trad. em português: Sobre os parasitas intestinais do porco e de outros animais domésticos observados no Brasil, como também sobre a ocorrência das mesmas espécies no homem.]

_________.58 Versammlung deutscher Naturforscher und Ärtze in Strafsburg (1885). Über eine neue, in Brasilien beobachtete Krankheit. Monastsheffe für Praktische Dermatologie, Hamburg: Leopold Voss, v.5, n.1, p.32-33, 1886a. [Trad. em português: 58a Reunião de Naturalistas e Médicos Alemães em Estrasburgo (1885). Sobre uma nova doença observada no Brasil.]

_________.Zur Morphologie des Mikroorganismus der Lepra. Dermatologische Studien. Herausg. von dr. P. G. Unna, v.1, Hamburg/Leipizig: Verlag von Leopold Voss, p.1-24, 1886b. (Publicado originalmente em Monatshefte für Praktische Dermatologie, p.77-100, 1886.) [Trad. em português: Sobre a morfologia do microrganismo da lepra.]

_________.Üeber die Beziehungen zwischen Stäbchen und Coccen. Fortschritte der Medicin Unter Mitwirkung Hervorragender Fachmänner herausgegeben von dr. Carl Friedländer Privatdocent der Pathol. Anatomie. Berlim: Fischer´s medicinischer Bachhandlung, v.4, n.10, p.327-31,1886c. [Trad. em português: Sobre as relações entre bastonetes e cocos.]

_________.Über einen sprosspilzartigen Epiphyten der menschlichen Haut (Mikrosporon anomoeon Vidal). Monatshefte für Praktische Dermatologie, Hamburg, v.5, n.2, p.72-3, 1886d. [Trad. em português: Sobre um epífito esquizomiceto da pele humana (Mikrosporon anomoeon Vidal).]

LUTZ, A. Über die Ätiologie der Pityriasis. Monatshefte für Praktische Dermatologie, Hamburg, v.2, p.84, 1886e. [Trad. em português: Sobre a etiologia da pitiríase.]

_________.Referate. I bacilli dell'ulcera molle, del Prof. Primo Ferrari. Communicazione ventiva all'Accademia Gioenia, selecta 26 Luglio 1885 (Atti dell' Accademia Gioenia di Scienze Naturali in Catania, serie III, vol. XVIII). Monatshefte für Praktische Dermatologie, Hamburg, p.439-40, 1886f.

_________.Über Cysticercus in der Haut. Real-Encyclopädie der gesammten Heilkunde (Wie, Urban und Schwarzenberg) einen eingehenden Artikel von Prof. G. Lewin. Monatshefte für Praktische Dermatologie, Hamburg, v.2, p.84-5, 1886g. [Trad. em português: Sobre o cisticercus da pele.]

_________.Die parasitären Krankheiten des Menschen. I. Entwickelungs geschichte der menschlischen cestoden. von S. Th. Stein. Monatshefte für Praktische Dermatologie, Hamburg, v.2, p.85, 1886h. [Trad. em português: As doenças parasitárias do homem. I. Histórico da evolução dos cestóides humanos, de S. Th. Stein.]

_________.Relatório do dr. Lutz comunicado ao dr. Azevedo Lima. Rio de Janeiro. Excerto de: Relatório do Hospital dos Lázaros do Rio de Janeiro, p.24-32, 4.jul.1887a. In: SOUZA ARAÚJO, História da lepra. v.3, 1946, p.491-3.

_________.Report on Leprosy in Trinidad by Beaven Rake, Port of Spain 1886. Monatshefte für Praktische Dermatologie, Hannover, v.6, n.12, p.968-9, 1887b.

_________.An Abstract of Lectures on Lepra by J. L. Bidenkap, London, Williams & Norgate, 1886. Monatshefte für Praktische Dermatologie, Hamburgo, v.6, p.653-61, 1887c.

_________.Mitteilungen über Lepra Nach in Brasilien gemachten Beobachtungen von dr. Adolph Lutz in Limeira, Brasilien. Monatshefte für Praktische Dermatologie, Hamburg, v.6, n.9, p.387-93, 504-20 e 546-60, 1.maio.1887d. [Trad. em português: Estudos sobre lepra. Comunicações sobre a lepra segundo observações realizadas no Brasil pelo dr. Adolpho Lutz de Limeira (Brasil).]

_________.Ein Fall von Lichen ruber obtusus et planus. Monatshefte für Praktsche Dermatologie, Hamburg, n.6, p.592-6, 1887e. [Trad. em português: Um caso de líquen rubro obtuso e plano.]

_________.Zur Frage der Invasion von Taenia elliptica und Ascaris lumbricoides. Centralblatt für Bakteriologie und Parasitenkunde, Jena, ano I, v.2, n.24, p.713-8, 1887f. [Trad. em português: Sobre a questão da invasão da Taenia elliptica e do Ascaris lumbricoides.] _________.Klinisches über Parasiten des Menschen und der Hausthiere. Nach Erfahrungen aus einer ärztlichen Praxis in Brazilien mitgetheilt von dr. Adolf Lutz in São Paulo – I. Ascaris lumbricoides. Centralblatt für Bakterologie und Parasitenkunde, Jena, ano II, v.3, n.18, p.553-7, 1888; n.19, p.585-8, 1888; n.20, p.617-20, 1888a. [Trad. em português: Relatos clínicos sobre parasitas humanos e de animais domésticos a partir de uma práxis médica no Brasil – comunicação do dr. Adolpho Lutz de São Paulo – I. Ascaris lumbricoides.]

_________.Klinisches über Parasiten des Menschen und der Hausthiere Nach Erfahrungen aus einer ärztlichen Praxis in Brazilien mitgetheilt von dr. Adolf Lutz in São Paulo – II. Oxyuris vermicularis. Centralblatt für Bakterologie und Parasitenkunde, Jena, ano II, n.22, p.681-4, 1888; n.23, p.713-6, 1888; n. 24, p.745-6, 1888; n.24, p.746-7, 1888; n.24, p.747-8, 1888; n.25, p.777-8, 1888; n.25, p.778-81, 1888b. [Trad. em português: Relatos clínicos sobre parasitas humanos e de animais domésticos a partir de uma práxis médica no Brasil – comunicação do dr. Adolpho Lutz de São Paulo – II. Oxyuris vermicularis.]

_________.Nachtrag zu menier lezten Mitteilung über die Invasion von Taenia elliptica und Ascaris. Centralblatt für Bakterologie und Parasitenkunde, Jena, ano II, v.3, n.10, p.299-300, 1888c. [Trad. em português: Aditamento à minha última comunicação sobre a invasão de Taenia elliptica e Ascaris.]

_________.Sul modo di trasporto dell'Ascaris lumbricoides. Giornale della R. Accademia di Medicina di Torino, ano 51, v.36, n. 2-3, p.84-6, 1888d.