Adolpho Lutz: notable physician and researcher

Adolpho Lutz: notable physician and

researcher

 

Dermatologists know Lutz for his discovery of a new mycosis, today known as Lutz Mycosis or Paracoccidioidomycosis. I would, however, like to highlight other work of his in this medical specialization.

Although Adolpho Lutz was active in various areas of medicine, he was basically a dermatologist. He helped found the Brazilian Dermatology Society in 1912 and the following year was elected its honorary president. He continued to take part in the Society meetings until his death in 1940.

At a special session held in 1913, Dr. Paulo Horta was invited by Professor Fernando Terra, then president, to speak in the name of the Society. Horta stated that Brazilian advances in studies of cutaneous affections over the previous fifty years had largely been fruit of Adolpho Lutz's endeavors:

Only those who have read his eleven notable monographs

focusing exclusively on skin diseases, in addition to the

countless lessons scattered over a number of other works and

in the minutes of scholarly associations in this country and

abroad, can duly evaluate the peerless merit of this master, as

modest as he is great, whose brilliant vision was already

apparent in his memorable writings of 1886 and 1887.1

When Antonio Cardoso Fontes, director of Manguinhos Institute in the 1930s, published his 1910 study on the structure of Koch bacillus in Memórias do Instituto de Manguinhos, he had this to say about Adolpho Lutz:

The present study had already been written and its proof sheets

readied when we learned from Dr. Adolpho Lutz of an 1886

paper of his, published as an insert to the first issue of Prof. P.

G. Unna's Dermatologishe Studien under the title "Zur

Morphologie des Mikroorganismus der Lepra." From this study,

one sees that Dr. Lutz had already ascertained the

preponderant role played by granulation of the leprosy bacillus

in its reproduction. My verification, 24 years later … shows the

correctness of our observations. And this is even more

noteworthy when one takes into account the technical difficulties

during bacteriology's early days, above all in verifications of this

nature (ibid).

On 7 April 1913, Adolpho Lutz began chairing sessions of the Brazilian Dermatology Association. At its second ordinary session, on 29 May 1914, Dr. Terra gave a conference entitled "Acidentes do 914" [Accidents with 914]. Dr. Lutz had the following remarks to make:

One must distinguish anaphylaxis from accumulation of

medication. Often times it is not the applied dosage that

explains this accumulation. In the case in question, the

unfortunate accidents that occurred could not be explained by

anaphylaxis. As a rule, when an accident occurs and it may be

attributable to the effects of arsenic, as limited as these may be,

treatment should be interrupted immediately to avoid any

possible harm.

From the discussions waged at scientific centers concerning this

momentous problem, it can be concluded that Ehrlich's method

is not as broadly efficacious as previously believed, and we

even see a tendency to restrict use of this treatment in light of

the serious accidents it has at times caused. At the same time,

the claim that it could cure syphilis has proved exaggerated, and

therefore it is not as advantageous as proclaimed (ibid).

At this same session, Dr. Silva Araújo Filho presented a paper entitled "Úlcera fagedênica tropical" [Tropical phagedenic ulcers]. In commenting the study, Dr. Lutz stated:

The cases observed here, deemed tropical phagedenic ulcers,

do not match well with those described by the authors,

especially those observed in Africa. The latter are much more

serious, their course fulminating, and they greatly resemble

hospital gangrene. The facts indicated here are indeed of a

malignant nature, but not as acutely as the former, and there is

a constant fusospirillary symbiosis. It is indeed good to study its

relation to tropical ulcers. We know full well that the fusospirillary

symbiosis is not an attribute solely of the tropical ulcer; it is also

constant in membranous stomatitis and Vincent's angina.

Spirilla are quite often found in the lesions of individuals afflicted

with various types of ulcers, such as leishmaniasis, meaning

their course is so rapid that even aggressive therapeutics will be

in vain. If we consider the treatment method as part of our effort

to understand the nature of the disease, we must recognize that

emetic tartar is really salutary in the treatment of phagedenic

ulcers. Yet this argument is not decisive, for we know this

medication causes scarring on various types of ulcers. More

research must therefore be undertaken. A bacillus similar to

that of diphtheria has been found in many ulcers, yet it was

likewise ascertained that it was leishmaniasis. It is very often

difficult to arrive at a clinical diagnosis because we have seen

that when common ulcers on the legs suffer long-lasting trauma

or are soiled by dirt, they can resemble phagedenic ulcers (ibid).

In 1919, Dr. Fernando Terra presented a paper entitled "Nodosidades justarticulares" [Lutz-Jeanselme syndrome]. Adolpho Lutz remembered that he had years before published

the case history of two people suffering from this affection, the

nature of which is as yet obscure. The tumors are highly

consistent, bringing enchondroma to mind. Potassium iodide

reduces them. This can be explained by the fact that these

lesions have an abundant number of cells within a network of

connective granulation tissue. The cells are reabsorbed under

the influence of the iodides, decreasing tumor volume and

consistence (ibid).

About Dr. Mario Magalhães' paper "Sobre o rinoscleroma" [About rhinoscleroma], Lutz said he found it particularly interesting because he had studied the first case in Brazil three decades earlier.

In 1921, Adolpho Lutz wrote a report on the skin diseases he had observed over a forty-year period. He said he found it interesting to see "not only the frequency but also the rarity or absence of certain

maladies." 2

He believed psoriasis to be a rare disease since he had found only two cases among Brazilians. On the other hand, he had seen one case of "fungic mycosis" in Brazil, whereas in New York he had observed two cases of "fungoid mycosis", "with the second case subsequent to the use of a bed next to the first case" (ibid), and he believed either direct or indirect transmission may have taken place. Today we know that the disease he called "fungic mycosis" must have been the same fungoid mycosis, from the group of lymphomas, which are not transmissible.

In a retrospective of 1921, Lutz referred to two cases of lupus vulgaris, and attributed inoculation with bovine tuberculosis to insect bites. We know today that this is impossible.

Only rarely did he find that patients from rural Brazil displayed other diseases "quite common in European dermatological clinics, such as lichen ruber, lupus erythematosus, epitheliomas and rhinoscleroma". This observation would not seem correct to judge from current observations. On the other hand, Lutz categorically affirmed his conviction that "the most prevalent maladies are related to local clinical feautures, fauna, and habits" (ibid).

He also made mention of ulcers known locally as feridas (sores, wounds) or perebas (mange), which could produce acute nephritis or, on other occasions, present complications involving myiasis" (ibid). He called attention to elephantiasis hypertrophy as a consequence of such infections. He alluded to the expression "mossy foot," used by Thomas, who believed its etiology could be traced to leishmaniasis, an idea with which Lutz disagreed, and quite correctly.

The Brazilian physician had been to a hospital in the state of Pernambuco where more than a thousand patients were suffering from ulcers. After examining them, he concluded that no case was due to leishmaniasis and few were due to spirillosis. He believed it necessary to study these cases from the perspective of etiology and therapeutics, a clear demonstration of Lutz's ardent investigative spirit.

He believed that Frambesia tropica had been introduced to Brazil by slaves, under the designation boubas (bubo or yaws), and he felt it was possibly transmitted by insects. He rightfully insisted that certain infections were transmitted by insects, such as exanthematous typhoid fever and dengue fever (the latter appeared some time ago in Rio and more recently in São Paulo; dengue is currently a major problem in Brazil). According to Lutz, in the long term, Fowler liqueur could cure lymphomas, which we now know is not true. He believed leprosy was transmitted by insect bites, likewise not true. Lutz also wrote – this time correctly – that generalized skin rashes (i.e., adverse reactions) could be caused by medications like mercury, mercuric chloride, iodoform, and others.

Noting that he had observed no cases of pellagra, he described a similar disease which he designated "pellagroid." My impression is that these were really cases of pellagra. I call the reader's attention to his comments on "Mal de los pintos" or "Caraté " (ibid).

Lutz spent a few years in Hawaii, where he offered interesting sociological observations on the Chinese, Japanese, Portuguese, and immigrants of other nationalities. Moved by his investigative spirit, he tried to study the population's ethnological composition. According to Lutz, "the notable reduction in the original population can be attributed mainly to the diseases introduced with exchanges

between peoples". 3 Among acute diseases, he underscored smallpox and measles as the leading causes of death. He reported that gonorrhea was extremely common and said that high doses of copaíba balsam were effective against the disease. He also affirmed that tuberculosis had been introduced by whites. Lutz emphasized another point of interest: the high rate of leprosy among members of the native population, in a proportion of 1:15 (6-7%). Lutz was emphatically against the idea that the disease was congenital. He pointed to the presence of a benign form of leprosy (circumscribed to small areas of the body) and to cases of spontaneous cure, which is in agreement with our current conceptions. Lutz warned that the persistence of leproma always indicated "the persistence of a focus, while loss of pigment and muscular atrophy, as well as contractures, may linger after the causal process has come to an end" (ibid). We now know this observation to be true.

In addressing the question of syphilis, Lutz disagreed with the then-prevalent idea that the disease could evolve into leprosy, and visa versa. He insisted that leprosy and tuberculosis were not found together as often as believed. Still, he referred to the existence of leprosy in ganglia, simulating scrofula.

In Hawaii he encountered and described Lutz-Jeanselme syndrome for the first time, attributing it to syphilis and leprosy.

In regards to dermatophytoses, Lutz stated that he had never seen any favus or any other ringworm of the scalp on that archipelago. However, he did observe pityriasis versicolor, erythema marginatum, and tokelau ringworm (Tinea imbricata). He achieved successful results in the treatment of pityriasis versicolor with iodine tincture, sulfur ointment 20%, and also with salicylic acid 10%. Lutz detected the occurrence of scabies in 20% of the Hawaiian population. He observed chigoes, due to the presence of Tunga penetrans and Pediculus capitis in many people. The number of mosquitoes was high, forcing the population to use netting.

In his research on tumors, Lutz underscored the presence of fibromas and lipomas. He also studied xanthoma. He noted the presence of Molluscum contagiosum on one patient. As to cancroids, he observed these in whites but not among the indigenous population.

He recorded the occurrence of urticaria, Duhring's disease, and even adverse reactions (as mentioned earlier), reporting on a case caused by aspirin.

He showed that intense heat fostered the occurrence of certain diseases, like intertrigo, dysidrosis, and others.

With great wisdom, Lutz declared:

My personal conviction, fruit of prolonged observation, is that

the high morbidity rates in tropical places are a function of

sanitary conditions, usually quite precarious; by improving the

state of hygiene, morbidity … would eventually be lower than in

temperate zones, for it would fall given the absence or rarity of

scarlet fever, diphtheria, lobar pneumonia, typhoid fever, as well

as rickets, scrofula, and chlorosis (ibid).

Lutz did not fail to include among these precarious sanitary conditions the abuse of disease-causing substances such as alcohol.

From São Paulo he came to Rio de Janeiro in 1908, where he worked at the place created by Oswaldo Cruz – Manguinhos Institute. There he conducted interesting studies on tropical diseases.

His greatest contribution to dermatology was to individualize a new mycosis in Brazil, produced by Coccidioides immitis and distinct from that described by Posadas and Wernicke in Argentina. This was the appearance of Lutz Mycosis, later designated Paracoccidioidomycosis, as mentioned earlier. In my dissertation entitled "Contribuição ao estudo da Micose de Lutz" [Contribution to the study of the Lutz Mycosis], I highlighted the fact that Lutz, when studying the parasite in tissues, demonstrated his fine spirit of observation when he declared, quite precisely, that: "there is usually a larger [parasite] in the center, and other, small ones around it, which has always given me the impression of having resulted from a process of gemmation". Lutz went even further when he affirmed: "I

have never seen endogenous sporulation". 4

He held countless honorary posts: honorary member of Brazil's National Academy of Medicine, honorary president of the Brazilian Society of Dermatology, honorary president of the American Leprosy Conference, South America's honorary representative to the American Philosophical Society's Bicentennial, to mention just a few. He published 281 papers, mostly in foreign journals. Lutz was a simple man who loved to study and do research. When he became blind, this did not hinder his quest for new knowledge, and his daughter Bertha read to him daily on the steps of Oswaldo Cruz Institute.

The great scientist passed away on 6 October 1940, at the age of 85.

Rubem David Azulay

Professor Emeritus, Universidade Federal do Rio de Janeiro – UFRJ

and Universidade Federal Fluminense – UFF. Full Professor at the

Souza Marques Technical Educational Foundation and Gama Filho

University. Head of the Dermatology Institute at Rio de Janeiro's

Hospital da Santa Casa de Misericórdia.

1 Annexed to this volume, see "Atas das sessões. Sociedade Brasileira de Dermatologia. Intervenções de Adolpho Lutz."

2 See the paper published in this volume under the title "Contribuições à história da medicina no Brasil. Reminiscências dermatológicas pelo Prof. Adolpho Lutz (1921)."

3 See ahead articles published under the titled "Korrespondenz aus Honolulu".

4 See ahead article published under the title "Uma micose pseudococcídica localizada na boca e observada no Brasil. Contribuição ao conhecimento das hifoblastomicoses americanas."