Insects, people and disease: Adolpho Lutz and tropical medicine

Miguel Couto at the Military Bacteriological Laboratory.63

The similarity between the icteroid bacillus and common bacilli, together with problems encountered in isolating and culturing it, hampered the search for a secure method of differential diagnosis, something vital for clinicians and hygienists, particularly during epidemics. But Sanarelli's work resulted in some useful public health guidelines, which Adolpho Lutz summarized: First, Sanarelli's work had lent legitimacy to the prevailing practices of destroying the bacillus through chemical means and with heat. It was rare to find the bacillus in the blood and secretions of the ailing, which explained the reduced danger of direct contagion and even of indirect transmission during less serious infections and during the first period of the disease, which formed the bulk of cases. On the other hand, one serious or fatal case, especially during the stage of hemorrhaging, would create a “veritable epidemic.” If the disease were recognized in time and if the necessary isolation and disinfection measures could be enforced, it would be possible to keep the homes of the sick from turning into epidemic foci. The germ that escaped with the blood rarely ever became totally desiccated and could therefore remain alive for long periods in clothing, mattresses, or other objects, or mixed with dust and dirt, especially in the cracks of old flooring, waiting for a favorable moment to turn infectious and invade human beings susceptible to the disease. Lutz believed the icteroid bacillus could be transmitted through excrement and vomit, and likewise through air and water.

Contrary to press claims, Sanarelli had categorically denied in Montevideo that he had solved the question of serum therapy, which, in his opinion, presented “major challenges.” His studies took this direction in the second half of 1897. In February 1898, he commenced field work in São Paulo. He had already sent doses of the serum to physicians in South and North America, asking in exchange that they provide him with notes on cases treated. His chief recommendation was that the serum be applied only in the early stages of the disease, since during advanced stages it would neither prevent death nor repair the serious anatomical and functional changes caused by the accumulation of “yellow fever

venom” in the organism. 64 The serums inefficacy during advanced stages of the disease had been verified when Seidl, Fajardo, Miguel Couto, and Paretti de la Roca undertook the first experimental inoculations with human beings at São Sebastião Hospital in December 1897.

A commission headed by Joaquim José da Silva Pinto, director of the São Paulo Sanitation Service, supervised field work in São Carlos do Pinhal. Members included Adolpho Lutz, Vital Brazil, Arthur Mendonça, and Cândido Espinheira (director of the Isolation Hospital in the city of São Paulo), along with the sanitary inspectors Ferreira, Vieira de Mello, Estevão Leão Bourroul, and a Mr. Rodrigues Souza, who was not a physician.

They found the streets of this coffee-growing center deserted and many houses abandoned. Just like in Campinas in 1889, almost all the inhabitants had fled. The isolation hospital was deserted, since most of the ill, “imbued with the traditional foolish prejudice against the pesthouse,” preferred to convalesce or die in their own homes. Small doses of the serum were given to two children, who recovered from the disease, but results from the first series of inoculations, involving another six patients in the first phase of the disease, were not satisfactory (Revista Médica de São Paulo, 15 Mar. 1898, p.22-4). A new series was initiated on 17 February 1898, involving fourteen seriously ill patients, four of whom died. One of these was a Portuguese boy “rebellious against all treatment, violent against staff,” according to medical reports by the doctors. “After much effort and using force, we managed to apply a few subcutaneous injections.” Sanarelli lost a total of six of the twenty-two people

inoculated, yielding a rather discouraging mortality rate of 27.27%. 65

Adolpho Lutz and his aids confirmed the presence of the icteroid bacillus in the blood of the ill, and they used this fact to counter objections still raised by doctors faithful to the old belief that the disease would not abandon the coast to take up residence eight hundred or nine hundred meters above sea level. Lutz thus corroborated the first part of Sanarelli's discovery, but he was categorical in relation to the second: “the treatment of yellow fever does not lie in serum therapy” (Revista Médica de São Paulo, Jun. 1898, p.84-7). The same conclusion was reached by Affonso Ramos, head of the bacteriological laboratory of the General Directorship of Public Health, in Rio de Janeiro (Brazil-Medico, 1 Aug. 1898, p.256, 258).

On other occasions, the icteroid bacillus would provide a path used to dispel doubts about the identity of fevers that could be confused with yellow fever, especially typhoid fever and malaria. On 17 April 1898, three months after the unsuccessful experiments with Sanarelli's serum, Lutz was summoned to present a report on the disease that was sweeping through the Campos Salles immigrant settlement, established the previous year by the state government next to the rail lines linking Campinas to Fazenda Funil, along the banks of the Jaguari River. In order to execute its planned venture, the Companhia Carril Agrícola Funilense had obtained a loan, authorized by the Campinas Municipal Chamber (Law no. 47, of 4 Jan. 1896), which in counterpart required the railroad to purchase land contiguous to the right-of-way and then cede it to the state so European immigrants could settle there. The co-existence of immigrant communities of diverse nationalities in Campos Salles accounts for the name given first to the railroad station (1905), later to the district of Campinas (27 Nov. 1906), and, lastly, to the autonomous municipality of Campinas (30 Nov. 1944): Cosmópolis, or “city of the world.”

In 1898, the town was just beginning its life. Adolpho Laufer, an immigrant in charge of the settlement, rendered accounts to the Inspector of Lands, Settlement, and Immigration for the State of São

Paulo.66 In August, he obtained a permit to establish a German School on one of the settlement's lots. Most of the settlers spoke German, and this was most certainly the language that the director of the Bacteriological Institute used when asking the newly arrived Swiss for news about the land of his genealogical roots. In 1897, the families of José Fumstein, Gothelf Lucker, and José Pfeifer moved to Campos Salles. In 1898, the families of Antonio Blaser, Roberto Maerki, Gustavo Epprecht, Alberto Fertz, and Heinrich Mauer were to arrive, bringing total inhabitants to forty-two. They had been drawn to this colony by information publicized through Swiss newspapers, which informed potential immigrants that they should request help to cover the price of their ticket (the government paid for the immigrant's trip to Brazil). In January 1900, the settlement's population would reach 53 families, or 280 people, and then rise to 132 families (624 people) by 31 December of that same year, with

German-speakers accounting for 68.41% of the total.67 They produced honey, corn, beans, potatoes, manioc, and rice for local consumption and ‘exported’ the first three products, as well as wax and butter. It was only in March 1899 that residents of the Campos Salles settlement had a physician (Dr. João Francisco Pereira) to take care of the fevers that so often afflicted them.

 

Campos Salles Settlement: rice processing machine. Campinas,

(SP), c.1900 (Coleção Secretaria da Agricultura Comércio e Obras

Públicas do Estado de São Paulo, Centro de Memória, Unicamp).

Lutz and Arthur Mendonça first examined two ailing people from Campos Salles who were hospitalized in the capital, one at the Isolation Hospital and the other at Santa Casa. They suspected the latter had yellow fever. On the afternoon of 18 April 1898, they headed to Campinas with all the equipment needed for microscopic examinations. They spent the next day visiting patients who lived in houses located far from each other. They examined an Italian man displaying symptoms of yellow fever in its final stages: jaundice, hemorrhaging from nose and mouth, black vomit, a comatose state. A young Swiss boy had also fallen ill with the disease; some days earlier, he had been on a ranch inhabited by Portuguese settlers, among whom two cases of fever had occurred, one fatal.

Campos Salles Settlement: settler's house with cattle. Campinas

(SP), c.1900. The environment is very similar to that considered

typical for sylvatic yellow fever, starting in the 1930s (Coleção

Secretaria da Agricultura Comércio e Obras Públicas do Estado de

São Paulo, Centro de Memória, Unicamp).

Campos Salles Settlement: settler's house. Campinas (SP), c.1900

 

(Coleção Secretaria da Agricultura Comércio e Obras Públicas do

Estado de São Paulo, Centro de Memória, Unicamp)..

The blood from these sufferers was inoculated into tubes containing agar and lactose broth; it displayed a clear “clumping power on the Sanarelli bacillus cultures” isolated in São Carlos do Pinhal. In all the cases that they examined from Campos Salles, Lutz and Mendonça were careful to confirm that the blood was free of the Laveran haematozoon and thus to exclude a diagnosis of malaria.

 

Public health in the 1890s

In his report on his assignment in Montevideo (1897a), Lutz pointed out two characteristics of the Sanarelli bacillus that helped differentiate it from other, similar ones. The first was the form taken by the colonies in agar culture; these resembled wax seals, a form not yet observed in other microbes. A second unique characteristic was that the colonies only developed in the gel when a mold was growing in it. “One can say,” the Italian bacteriologist wrote, “that it exercises a kind of radius of influence and only within its orbit is the development of icteroid colonies possible.” He went on to affirm that this peculiar parasitism was “the main cause of yellow fever aboard ships” (Sanarelli, 1897, t.63, p.190-1). Lutz imagined that this symbiosis derived from a modification of the nutritional medium occasioned by the mold, which favored the bacillus.

Upon his return from Montevideo, João Batista de Lacerda began exploring the symbiotic life of Sanarelli's microbe and the mold he classified as Aspergillus icteroide. He verified that its spores would detach from the mycelial filaments and float along in the air, acting as “crutches” that allowed the bacillus to leave confined environments and spread far and wide (Lacerda, 1900, p.16-30; Brazil-Medico, 8 Jun. 1899, p.212-4). Holding in his hands the “key to Rio de Janeiros public health problem,” he left the laboratory and went to look for the mold and the bacillus in homes recently occupied by the sick. In the neighborhood of Laranjeiras, he found them living in symbiosis but always on fly excrement. “This, gentlemen, is the terrible and frightening perspective to which these observations have led us,” he declared to the Academy of Medicine on 27 July 1899. Rio's housing provided the germ with a vast seedbed. Since it was also carried by flies, this encompassed not just the city's “filthy”

tenements but equally its “clean, aristocratic” homes.”68 Draining the soil, fixing the sewers, constructing a broad dock along the city's shoreline, paving and planting trees along streets and parks, opening new thoroughfares – in short, all the plans laid out under the federal capital's urban renewal project proposed in the 1870s and repeated in 1896 (Abreu, 1998; Benchimol, 1992) would certainly beautify the city but would not rid it of yellow fever.

Instead of fixing our sewers, let us thoroughly fix our houses.

We do not need to go as far as the Americans went in Cuba,

burning them down. Such a procedure … could only be used in

a conquered nation. Experience has already shown us where

and how the germ of this disease harbors itself inside homes; let

us go inside to search them out and destroy them. (ibid., p.53)

This was the guiding principle behind public health initiatives in Rio de Janeiro and the cities of São Paulo at the close of the 19 th century. A good example of this was the epidemic that swept through Campinas in 1897, the fifth and final of the 1800s.

Everything had been tried in the effort to rid the city of the disease. The installation of water and sewer lines in 1891 and 1892 did not keep yellow fever from erupting in 1892 and remaining endemic in the following years. The municipal authorities then adopted new public hygiene measures, starting by filling in some 3,000 ditches and wells that were no longer needed since the new lines had been laid (Santos Filho and Novaes, p.251).

The city was divided into three sanitation districts, each under the responsibility of a municipal hygiene delegate. Streams were drained, trees were planted along streets, tenements were closed down. A domiciliary inspection service began requiring that houses be whitewashed twice a year, and it disinfected those where yellow fever victims had died. Nevertheless, a new epidemic broke out in 1896, with 1,700 cases reported. The state government then took

over sanitation in this and other towns hit by the disease. 69

On 23 July 1896, during the post-epidemic period, Dr. Emilio Marcondes Ribas came to Campinas as head of a Sanitation Commission made up of Drs. Theodoro Bayma, E. C. de Souza Brito, Eduardo Lopes da Silva, and Las Casas dos Santos. On 4 August, superintendent Dr. Manuel de Assis Vieira Bueno formally handed the direction of sanitation services over to him. The Lazareto do Fundão was made into an isolation hospital, and the spacious building that housed the central market was adapted to serve as the

Central Disinfecting Station.70

Campinas's central disinfection station, between 1896 and 1906 (Coleção Geraldo Sesso Júnior, Centro de Memória, Unicamp).

Concomitantly, a statewide Sanitation Commission, headed by the engineer Francisco Saturnino Rodrigues de Brito (1864-1929), undertook a new water supply project in Campinas, channeling the streams that cut through the city and also proposing that a new

sewer main be built and garbage be incinerated. 71

Such measures failed to avert another epidemic. It began on 5 January 1897, reached its peak in April, and died out in early July. This time 694 cases and 325 deaths were reported (Lapa, 1996, p.259-60). “The population was not expecting it,” Santos Filho and Novaes observe (p.262) — so much so that Carnival celebrations took place as scheduled in early March “in all splendor.” This time, few people fled the city. At the height of the epidemic, the Municipal Chamber considered using Felipe Caldas’ ‘vaccine’, and it was then that Adolpho Lutz began examining it at the Bacteriological Institute.

Emilio Ribas’ initiatives (1896/1897) were aimed primarily at the interior of dwellings, which, in his report of 31 January 1898, he compared more than once to “the old holds of ships … filled with newly arrived foreigners.” Sanarelli's and Lacerda's studies had convinced him that

permanent foci of yellow fever only form inside dwellings, and

that the yellow fever germ's durability and tenacity was due to

the presence of molds, which usually occurs in houses built on

poorly prepared land, which most often lack adequate slope to

allow for the drainage of the waters that seep through the joints

of the wooden floors—houses consisting of a series of alcoves,

with a naturally inadequate supply of air, light, and ventilation.

The “first foci” that had formed in various locales within rural São Paulo had multiplied and spread, generating the repeated epidemics that sanitary authorities could not defeat.

Ribas placed priority on sanitary inspections of homes and on the meticulous disinfection of their interiors, based on his observations of other places, mainly Jaú. When yellow fever struck there in 1896, it had been triggered by the “revival of germs left in 1892, and it had not been imported, as people said.”

Ribas estimated that Campinas had at least 4,200 buildings in 1897, not counting those in outlying neighborhoods. The city center and environs were re-divided into five districts in such a way that each sanitary inspector could systematically visit the entire district once a month, ‘policing’ some 900 houses.

From nine in the morning till six in the evening, sanitation commission physicians saw to their districts; at night, one of them would remain on duty, with two teams of disinfectors plus the personnel needed to transfer the ill and to handle burials. As the sanitary inspectors visited homes, disinfection crews would spray the interiors with corrosive sublimate at 2 parts per 1000; they used phenol solution (2%) on metallic objects; in latrines, sewer drains, and the like, the antiseptic was a solution of copper sulphate (3%) or limewater. In stables, carriage barns, and parks, they sprayed solutions of cresyl or of phenol acid (4%). Between July 1896 and January 1898, no less than 12,089 articles of clothing passed through the large sterilizer installed at Fundão Hospital and, later, at the Central Disinfection Station (by the German company Geneste & Herscher).

 

Desinfection agent at work inside an infected house (Algumas

Instalações do Serviço Sanitário de São Paulo. São Paulo:

Vanorden, 1905. Museu Emílio Ribas).

 

From inside houses to under the ground: where

does yellow fever live?

“If any of the ministers of the ex-monarchy … had taken a file to one end of the bronze chain that was shackling and still shackles public health,” Dr. José Lourenço wrote in 1893, “the hex would be broken … and the unpatriotic procrastination of the most pressing social issue would have ceased.” This viewpoint stood in contrast with the generic, far-reaching program that hygienists subscribed to at a moment when they were attempting to target if not all at least many of the links in the chain of urban insalubrity associated with the production of miasmas. In the 1880s and especially 1890s, hygienists and bacteriologists in Rio de Janeiro and São Paulo began to differ ever more radically in their conceptions about how yellow fever epidemics arose and spread and, consequently, of what measures would be appropriate or top priority in sanitizing cities. However, on one point all could agree: the disease was the key to urban unhealthiness, which was nearly synonymous with Brazilian unhealthiness. The line of thought then in greatest evidence advocated the theory proposed by Bavarian hygienist Max von Pettenkofer in regard to cholera and typhoid fever: Rio de Janeiro's soil and Brazil's national epidemic shared the same relationship that connected Munich's soil to these diseases.

As Koch's chief adversary in Europe on the etiology of cholera, Pettenkofer was a renowned representative of that line of thought which Rosen (1994) called “contigent contagionism.” According to the “Boden Theorie” (soil theory), four factors were necessary for an epidemic to occur: in addition to the germ, certain conditions had to be met regarding place, time, and people. In and of itself, the germ did not produce the disease, thereby excluding direct contagion. Individual susceptibility mattered but variables related to climate and to the soil were indispensable in explaining both how some individuals and regions developed the disease and how others displayed immunity. These variables had an effect on the germ, which matured and became infective matter, just as a seed transforms itself into a plant.

Max von Pettenkofer (1818-1901) (Johann & Junker, 1970, fig. 28).

Pettenkofer's theory was very well suited to yellow fever's most notable characteristics: its seasonal nature and its geographic specificity.

The bacteriologists exploring the question were convinced that the germ — whatever it was — completed an important stage of its life cycle in its surrounding environment. An unknown combination of factors would keep it latent during certain periods and make it virulent during others. This supposition was one of the cornerstones of theories formulated during this period. In varying proportions, the equations roughly involved telluric factors (soil, putrefying organic matter, stagnant water, hills, ditches, and so on), climatic factors (atmosphere, humidity, heat, rainfall, ozone, barometric pressure, and so on), and social factors (ships, housing, cemeteries, slaughterhouses, markets, streets, sewer lines, etc.).

For Pettenkofer supporters in Rio de Janeiro, the city's unhealthiness derived from the “smothered swamp” that lay beneath it, overflowing with putrefying organic matter. When summer rains prompted changes in the water table, the germs deposited there would become activated and epidemics would break out (Benchimol, 1999, p.249-98; Hume, 1925, p.350-93).

During the transition from monarchy to republic, much was written and said about the dangers inherent to Rio de Janeiro's water table, all in hopes of convincing the public and the authorities that drying out the soil by draining the deep groundwater would kill off yellow fever. This was the first item on the agenda of proposals voted on at the Second Brazilian Congress of Medicine and Surgery, in 1889, seeking a response to the following question: How could the epidemics that develop during summer months in Rio de Janeiro and other cities around the country be prevented or lessened (Gomes, 1957, p.234-6)?

The intensity of the controversies depended upon how serious the epidemics were and also upon the power games involving high-stake investments in the urban soil. Pettenkofer enjoyed his greatest popularity in Brazil around the time of the Encilhamento, a term describing a period when the country's commercial and financial capital, and the companies and liberal professionals involved in civil engineering, were madly running after opportunities for investment or speculation in the city of Rio.

In 1892, Floriano Peixoto, head of the provisional republican government, tried to hire Pettenkofer to wrench yellow fever from the

city's soil.72 He likewise contacted Émille Duclaux, Pasteur's successor as head of the Paris institute; Rubner, director of Berlin's Institute of Hygiene; Friedrich LÖffler, discoverer of the diphtheria bacillus; and the sanitary engineer Edmund Alexander Parkes, author of a well-known Manual of Practical Hygiene (1864), in which he systematized experience gained in the sanitation of English and Indian cities.

The 1892-93 epidemic and the quarantines that Argentina and Uruguay imposed on passengers and merchandise from Brazil refueled discussions of the old epidemiological question: was yellow fever an endemic disease, “residing” in the city, or an imported disease that could be combated through the triad quarantine-

disinfection-isolation? 73

The economic debacle that followed the euphoria of the Encilhamento, together with the civil war that engulfed the country after the September 1893 rebellion of the Armada, killed any projects for draining groundwater or for “hermetic sealing” of the urban soil. The results of Floriano's inquiries were only made public in February 1897, when the Brazilian economy was beginning to recover and the question of transforming Rio de Janeiro and other ports into healthy cities was back on the order of the day.

The main threat to the city's health was yellow fever, but lingering doubts about its etiology and transmission hampered those who wanted to fight it. Public opinion had already assimilated the notion that the disease was caused by one of the microbes on the agenda of scientific debate or, perhaps, by one not yet discovered. But the relative consensus about what should be done to make these urban centers healthy, grounded in the miasmic theory, gave way to heated controversy over the links that needed to be broken in the chain of insalubrity, with options varying according to the habitats and

peculiarities of each incriminated germ. 74

The new crop of germs that erupted in 1897 exasperated the social and professional groups pressing hard for the much-awaited sanitation of Rio de Janeiro. Doctors were unable to decide (intramural and inter-peer) who had hit upon the way to untie the Gordian knot of Brazil's public health dilemma, and so Congress and the press proposed that tribunals be set up and the issue settled there. In May of that year, on the eve of Sanarelli's conference, deputy Inocêncio Serzedelo Corrêa, a leader of the Sociedade Auxiliadora da Indústria Nacional (Society for the Assistance of Brazilian Industry), proposed that a Pasteur Award be granted to the bacteriologist who received a favorable, unanimous endorsement from the Rio de Janeiro School of Medicine, the Koch Institute in Berlin, and the Pasteur Institute in Paris. In June, deputy Alcindo Guanabara, one of the most influential journalists in the republican movement, presented an alternative project, nationalist in nature and

favoring Freire. 75

The latter commission was formed, but it was not academic validation procedures that put an end to the controversy surrounding the etiology and prevention of yellow fever. As we will see ahead, it was a radical shift in the approach to the disease that would lead a new generation of bacteriologists to the public health stage, under the leadership of one of its more discrete members, Oswaldo Cruz.

 

Focus on malaria

In the summer of 1891-92, some months before creation of the Bacteriological Institute of São Paulo, the Rio de Janeiro and São Paulo state governments requested that the Domingos Freire Bacteriological Institute once again immunize the residents of a number of rural towns against yellow fever and that it clarify the nature of fevers whose diagnoses were unclear. While a commission was busy vaccinating in Niterói, Paraíba do Sul, Resende, and Barra Mansa, Freire visited Limeira, Rio Claro, Cordeiros, Piraçununga, Belém, Jaú, Campinas, Santos, and the state capital as well. Soon after, he published Sur l'origine bactérienne de la fièvre bilieuse des pays chauds (1892), which set off yet another controversy that garnered much press in Rio de Janeiro and involved a complex interpenetration of actors, microbes, and diseases. The purpose of this book was to differentiate yellow fever from the bilious fever of “hot countries,” which resembled each other and sometimes spread together. According to Freire, bilious fever was “one of the manifestations of malaria,” produced by a bacillus that had nothing to do with the plasmodium discovered by the French military doctor Charles Louis Alphonse Laveran (1845-1922). Freire then clashed with Adolpho Lutz and some younger bacteriologists from Rio de Janeiro who shared his interest in this haematozoon. Francisco Fajardo collaborated most closely with Lutz. They were drawn together not only by their joint involvement in the struggles surrounding yellow fever, cholera, and typhoid fever, but also by their interest in issues brought to the fore by British tropical medicine in the late 19 th century: malaria and, hence, the hematophagous insects that could serve as the hosts of microorganisms and disease transmitters. According to Arthur Neiva (1941, p.viii), Fajardo “ardently collected” blood-sucking animals of interest to Lutz in the Federal District and its surrounds. “I recall very clearly that Fajardo's portrait was one of the few to be found in the room in Manguinhos where Lutz lived, in recognition of the collaboration offered by his unselfish friend.”

At that time, the medical press in Rio referred to Fajardo as the

“discoverer” of the Laveran haematozoon in Brazil.76 For Freire, the French physician had explored an agent of “classic form.” “Let him come to Brazil and he will find a new world beneath his eyes. Remember that each of us is studying at a very different latitude.” The biological law postulated by the discoverer of the vaccine against yellow fever was drawn from the same theoretical pot from which Lacerda derived his arguments in favor of polymorphous fungi and from which Pettenkofer had derived the time and space coordinates that rendered the cholera and typhoid fever microbes either pathogenic or innocuous: “climatic diversity implies a diversity of infectious species and consequently a diversity of living pathogenic microelements” (Jornal do Commercio, 15 Jul. 1894; O Paiz, 20 Jul. 1894).

In a work published in 1892 (p.12), Freire raised the possibility that the bacillus he described was the one discovered by Klebs and Tomassi Crudelli, Laveran's two chief adversaries.

As we saw in book two of The Complete Works of Adolpho Lutz, Theodor Albrecht Edwin Klebs (1834-1913) was the first to verify discovery of the leprosy bacillus by Hansen in 1874 (Bulloch, 1938, p.9, 376). In 1883, he discovered the diphtheria bacillus, cultured the following year by Friedrich Lõffler, a member of Koch's team; it was named the Klebs-Lõffler bacillus (now known as Corynebacterium diphtheriae). In 1878, Klebs, together with Corrado Tommasi Crudelli, began researching the malaria germ, which was endemic in the Roman Campagna. J.H. Salisbury, from the United States; Lanzi and Terrigi, both from Italy; and Pietro Balestra, another Italian, had all incriminated microscopic algae that vegetated in swamplands (Busvine, 1993, p.18). Klebs and Crudelli found the Bacillus malariae in the blood of feverish patients; this was a microscopic plant believed to bear a resemblance to the anthrax bacillus, whose spores Koch had just located in the ground where animals were buried; malaria spores were likewise believed to reside in the soil and float through the air. The discovery was confirmed by a number of Italian and French investigators, and it enjoyed great success at the International Medical Congress of 1884 (“Do bacillus malariae,” União Medica, 1881, p.82-6). Adolpho Lutz himself gave his tacit endorsement in an article he published in 1886 on the differences between algae, cocci, and bacilli (p.327-31). The paper was a by-product of his efforts at Paul Gerson Unna's laboratory in Hamburg to demonstrate that the genus Cocotrix was a better fit for the bacilli of leprosy, tuberculosis, various putrefactive bacteria, and for Bacillus malariae as well.

 

Francisco de Paula Fajardo Júnior (1864-1906). Photograph from

1897, given to Lutz as a token of friendship. Companhia Fotográfica

J. Gutierrez (BR. MN. Fundo Adolpho Lutz).

Lutz so far had made no mention of the haematozoon discovered by

Laveran six years earlier. 77 Oscillaria malariae (later renamed Plasmodium) was a protozoan, and although both dysentery and surra had already been associated with these unicellular animals, there was no conclusive evidence they caused any important human disease. The complexity of the life cycles of animals within this subkingdom, the lack of a precise classification system, and the problems encountered in finding artificial means for culturing them all made it more difficult to demonstrate an etiology of this nature. This helped keep Laveran's microorganism in the shadow of Klebs and Crudelli's for some years.

 

Charles Louis Alphonse Laveran (1845-1922). Source:

perso.wanadoo.fr/santards.trad/laveran.jpg, retrieved 22 June 2005.

Studies by E. Richard, Camilo Golgi (1844-1926), and Ettore Marchiafava (1847-1935), which linked the microorganism's life cycle to the clinical syndrome, were crucial in shifting support from Bacillus malariae to Oscillaria malariae in the late 1880s. Dr. Richard, stationed at Philippeville, a French Mediterranean military base, found it in 90% of clinically diagnosed cases and demonstrated that quinine destroyed it. He also proved that the main lesion produced by the parasite was destruction of red blood cells; he believed this was responsible for the characteristic anemia suffered by those with the disease and for the sharp pigmentation of the spleen and liver, verified during autopsies. It fell to Marchiafava and Golgi to clarify part of the haematozoon's life cycle; they related it to the periodicity of fevers. Golgi showed that the release of the parasite's progeny occurred in synchronized pulsations that corresponded to paroxysms of fever. He then raised the hypothesis that different species could be responsible for distinct clinical forms of malaria — tertian,

quartan, and quotidian (or irregular) fevers.78

 

Insects subvert microbial theories

During these same years, there was rising interest in the means by which diseases of proven or suspected microbial etiology were transmitted. Pasteur's and Lister's emphasis on the ubiquity of airborne germs receded as research moved to other vehicles or carriers: on the one hand, water, sewage, food, body wastes; on the other, dogs, cats, birds, and insects. One idea was mechanical transmission of the ‘viruses’ found in stagnant waters and putrefied material, as was the case with flies and the Eberth bacillus (Lutz, 1895, p.12-3). To a lesser extent, scientists considered the idea that diseases were disseminated by blood-sucking animals either directly when they bit human beings or via water contaminated with dead infected insects, which is what Patrick Manson believed to happen with the Culex, transmitter of Filaria.

Camillo Golgi (1843-1926) (Olpp, 1932, S145).

 

Ettore Marchiafava (1847-1935) (Olpp, 1932, S272).

In 1877-78, this physician had uncovered almost the entire life cycle of the parasite that produced filariasis, also known as elephantiasis, thereby putting together the parts of an enigma whose deciphering had begun in Brazil. In 1866, in Bahia, Otto Wücherer had attributed the disease to a microscopic nematode found in the urine of chyluric patients; Timothy Richards Lewis (1873) had then demonstrated the presence of an embryonic form of the nematode in the blood of sick people (Filaria sanguinis hominis); Joseph Bancroft (1876) later revealed the adult form of the embryo in a lymphatic abscess. The helminthologist T.S. Cobbold (1878) named it Filaria bancrofti. It was then known that the nematodes found in blood and urine were offspring of an adult worm that lodged in lymphatic vessels. Manson verified that a dog's vessels could contain millions of embryos. If they reached adult form there, their aggregate weight would exceed that of the host itself. With the host's death, the parasites would perish before a second generation could be born, and the species would therefore die out. This incongruity could only be explained by postulating that the embryos abandoned their host and developed outside it (Delaporte, 1989, p.37-40; Busvine, 1993, p.11-5). Their presence in the circulatory system and the fact that they had no Sir Patrick Manson (1844-1922) way of leaving it led Manson to deduce that a bloodsucking animal was playing a role. He narrowed it down to the Culex, the most common mosquito species in regions afflicted by filariasis. In 1879, he proved that microfilaria were adapted to the mosquito's nocturnal habits; obeying a law of periodicity, they invaded the peripheral circulation as night fell and retreated during the day. By dissecting Culex during successive periods, the English physician duplicated the embryos metamorphism into a larva and then into the adult form of Filaria sanguinis hominis, ready to abandon its host and lead an independent life. At the time, he assumed that after ingesting blood the female mosquito traveled to areas near waters, where she digested the blood, laid her eggs, and died. The Filaria would begin their independent life in the water and through it infect humans.

Sir Patrick Manson (1844-1922) (Manson-Bahr, 1940).

Manson's work opened the way for other discoveries involving arthropods as intermediary hosts for microorganisms pathogenic to humans and animals. In 1893, Theobald Smith and F.L. Kilborne discovered that the protozoan which produced the cattle disease known as Texas fever was transmitted by ticks (Foster, 1965, p.149-57). In 1895-96, David Bruce demonstrated that trypanosomes were transmitted by flies of the genus Glossina.

Much was yet to be defined about malaria and yellow fever, in part because of failures to confirm the identity of its alleged microbial agents and to locate its spores outside the human body (Worboys, 1996). Laveran's haematozoon was found in the organisms of the ill, but no one had been able to culture it in vitro or to produce the disease experimentally.

Advertisement for Banocide, a medicine for treating filariasis,

especially Wucheria bancroft and Onchocerca volvulus, produced by

Burroughs Wellcome & Co. (Transactions of the Royal Society of Tropical Medicine and Hygiene, London, v.46, n.4, July 1952, 464p.,

p. xi).

The polemic between Freire (spokesperson for Klebs and Crudelli's bacillus in Brazil) and Francisco Fajardos and Adolpho Lutz's teams (advocates of Laveran's haematozoon) transpired halfway between the time that Manson formulated his hypothesis that a mosquito played host to this haematozoon before it infected humans (as with filariasis) and the time that this hypothesis was substantiated. Confirmation came thanks both to Ronald Ross, who uncovered the cycle of the bird malaria parasite in the Culex in 1898, and also to Giovanni Grassi, Amico Bignami, and Giuseppe Bastianelli, who the following year clarified the cycle of the human malaria parasite in mosquitoes of the genus Anopheles.

During this interval, the medical press in Brazil and abroad was filled with information and speculation about the role of insects in the transmission of other diseases. The spotlight was on flies, who entered the collective imagination of urban populations as an omnipresent source of danger in the midst — or in substitution — of intangible miasmas. In 1898, it was declared that flies disseminated the microbes of carbuncles, Egyptian ophthalmia, Biskara boils, pian (yaws), and glanders. In his laboratory, Yersin had verified that dead flies contained the plague bacillus and could infect drinking water. Joly (1899, 1898) confirmed that they deposited the bacilli of tuberculosis on foodstuffs and beverages, and carried them even when desiccated.

As we saw earlier, the final theory regarding the etiology of yellow fever was quite unpredictably lit upon right before Finlay's theory was enthroned by the Brazilian public health field. When João Batista de Lacerda went into homes recently occupied by sick people in order to search for Sanarelli's bacillus and its associated mold, he always found them on fly excrement.

Many of the articles written back then leave us with this impression: it was as if the component parts of Pasteurian-based theories on malaria, yellow fever, and other diseases were ‘magnetized’ by the force field of another type of medicine, one which soon would be called “tropical.” New living pieces were fit into constructs built under the aegis of bacteriology, re-arranging them. Soil, water, air, food, houses, and people had been woven into webs traversed by alleged pathogenic microbes (mainly algae, fungi, and bacilli), and it was hard to accommodate the new players inside these nets. Connections were rebuilt, new components added, but the insects very often remained strangers in the nest. In the case of malaria and yellow fever, the logic governing state-of-the-art research in tropical medicine seemed incompatible with the microbial theories then in the process of perishing.

 

Malaria and typhoid fever Adolpho Lutz's research on malaria tied into another polemic question that kept the press busy in the 1890s, especially in São Paulo. This was typhoid fever, a disease with intestinal manifestations that Lutz himself had contracted while on vacation in 1878, when he was studying in Leipzig, Germany. In Reminiscencias da febre typhoide, published in 1936, Lutz would classify it as “one of the Bacteriological Institute's prime concerns.”

The disease had long remained undifferentiated, assigned to the realm of septic diseases, fevers, and diseases associated with the

generic name “typhus.” 79 The Englishman William Budd (1811-80) was the first to correlate typhoid fever with a living “virus” (which at the time meant living “poison”) — transmitted by indirect or direct contagion. In 1880, the pathologist Carl Joseph Eberth (1835-1926) described a microorganism first known as “Eberth's bacillus” and later called Salmonella typhi; it was present in the mesenteric ganglia and spleen of bodies he had autopsied. The discovery was confirmed by Koch, who presented a more precise description of the bacillus. In 1884, Georg Gaffky (1850-1918), Koch's assistant and successor, managed to isolate that microorganism and obtain pure cultures.

At that time, physicians in São Paulo were mistakenly diagnosing as “typhoid-malaria fever,” “remittent fever,” or “São Paulo fever” certain clinical cases that Adolpho Lutz would soon recognize as typhoid fever. The expression ‘São Paulo fever’ had been coined by “masters of indigenous medicine” to designate a disease that during the last decade of the Empire had laid waste to the capital of São Paulo, rivaling the havoc wreaked by yellow fever in Rio de Janeiro and Santos (Pestana, 1915, p.11).

In his first report as interim director of the Bacteriological Institute (2 Jan. 1894), Lutz argued against the malarial nature of fevers in the city of São Paulo, sustaining that, were this the case, Laveran's

Plasmodium malarie 80 should be found in the victims’ blood. It was not yet clear to him what these fevers represented. Symptoms resembled those of undulant fever, which spread through the Island of Malta (a malady likewise known as brucellosis in honor of David Bruce, who in 1887 had discovered its agent, Micrococcus melitensis). Lutz endeavored without success to locate this microorganism in the blood of São Paulo's ailing. The hypothesis that the disease was “abdominal typhoid” — as the Germans called typhoid fever (Landouzy and Jayle, 1902) — was strengthened by an autopsy performed in 1894 on someone reported to have died of

yellow fever.81

In the war against adversaries of this diagnosis, Lutz called to action Eberth himself, then director of the University of Halle's Anatomical Institute. In a letter dated 1 May 1895, Eberth attested that the Brazilian bacteriologist's cultures were “legitimate cultures of typhoid

fever bacilli.” 82

Most São Paulo physicians insisted that these “São Paulo fevers” were nothing more than a native or local type of malaria. In his 1894-95 report, Lutz argued against this supposition.

As always, when it is a matter of verifying mistakes, we expect

protests. These were not long in coming, but were limited to

articles in political newspapers, some of them anonymous,

others by authors with no authority. There is no attempt to prove

the facts, that is, by thermometric curves, the presentation of

sick people, autopsies, or microscopic preparations. We always

have our observations verified by the most qualified people we

can find, and the Laboratory is open to adversaries, as much as

to friends.83

During the turbulent 1890s, São Paulo fevers were diagnosed either as malaria or typhoid fever, eventually coming to rest on the side of typhoid fever, thanks to Lutz and his aids. Something similar happened with yellow fever. Some physicians reduced it to a unique

manifestation of malaria, of American characteristics.84

To demonstrate that legitimate malaria did not exist in the city of São Paulo, Lutz had to produce evidence that combined clinical descriptions, autopsy reports, and, mainly, laboratory verification of the absence of Plasmodium in the blood. The other side of this venture was the reconnaissance of places where malaria indeed occurred under Lutz's jurisdiction, which meant it was necessary to find sufferers who were carrying Laveran's parasite.

 

In search of protozoans in birds, reptiles, and

amphibians

Adolpho Lutz, his aids at the Bacteriological Institute, and his partners in Rio de Janeiro — Francisco Fajardo first and foremost — were not only in tune with studies being developed by British and Italian scientists in an effort to firmly establish the clinical manifestations and etiology of the disease and discover how it is transmitted. They also offered their collaboration in these studies and pursued a research program that preserved a relative autonomy from the more immediate, controversial issues in public health. The mode of transmission of Plasmodium malariae was the principal enigma then challenging them. Linked to it were other enigmas of not only medical but also zoological interest: what species of this genus, and what other genera of this phylum of the animal kingdom, might be involved with diseases of invertebrates and vertebrates, including humans?

Taxonomic categories were different from today's, and knowledge about protozoans still quite inexact. In his 1895 report, Lutz succinctly described the state-of-the-art in this realm of medical zoology.

Today, Laveran's plasmodia are considered sporozoans, forming

the subdivision Haemosporidia together with the cytozoa of

birds, reptiles, and amphibians. Sporozoans are a group of

protozoans that all lead a parasitic existence and cause a

number of diseases in man and animals, some of which we

have had the opportunity to observe in the laboratory. We shall

first mention rabbit coccidiosis, produced by the invasion of

Coccidium oviforme in the rabbit's liver. This disease has killed

many of our experimental animals and must be largely

responsible for the hardships encountered by those among us

who raise rabbits.

Lutz made mention of some species of myxosporidia that he had found in other animals. He cited a pebrine called Glugea bombycis, which he had observed in a species of Lepidoptera common in São Paulo (Brassolis antyra). He had sometimes found unclassified spores of Myxomycetes in fish.

Adolpho Lutz's first paper on this topic, republished in this volume under the title “On a myxosporidium of the gall bladder of Brazilian Batrachia [in Port.], was conducted when he still lived and practiced medicine in Limeira. It was first released in 1889, in the Centralblatt für Bakterologie und Parasitenkunde (Bulletin on bacteriology and parasitology), a periodical founded two years earlier in Jena by Friedrich LÖffler, Oscar Uhlworm, and Karl Georg Friedrich Rudolf Leuckart (1822-98). The latter parasitologist, who held the chair in zoology and zootomy at the University of Leipzig, was still Lutz's main point of reference. As we saw in volume I of Lutz's Complete Works, Leuckart was spokesperson for the young Swiss-Brazilian's work on the region's cladocera, presented before the Leipzig's Society of Natural Sciences (Lutz, 1878). Among the authors Lutz consulted when he focused on protozoans some years later, Leuckart was the only one who mentioned its presence in amphibians, especially frogs. The article submitted by Lutz to the periodical edited by the German zoologist showed that they too were parasites of the gall bladder of Batrachia. He proposed a new genus and new species of myxosporidium: Cystodiscus immersus. “It is not just its new location that is of interest; this species, which would appear to be unknown, will prove worthy of study from a number of other angles.”

Plate 5 – 11 – Some human malarial parasites. Plasmodium vivax. 1.

 

Normal human erythrocyte 2. Young signet-ring form trophozoite. 3.

Older ring form trophozoite, Schüffner's dots in host cell cytoplasm.

4. Two amoeboid trofozoites with fused cytoplasm. 5. Beginning of

schizont division. 6. Mature schizont. 7. Mature macrogametocyte. 8.

Mature microgametocyte. Plasmodium malariae. 1. Trophozoite in

ring form, with pigments granules. 2. Band form trophozoite with

elongated cytoplasm. 3. Maturing trophozoite. 4. Mature trophozoite.

5. Phase in development of schizont. 6. Mature schizont. 7. Mature

macrogametocyte. 8. Mature microgametocyte (Cheng, 1964,

p.130).

At the Bacteriological Institute of São Paulo, the medical-sanitary approach prevailed, and theoretical and experimental references changed, but Adolpho Lutz did not lose his zoological interest in sporozoans. His observations are found in his annual reports as director of the Institute, most of which never published.

When he went in search of Laveran's plasmodium in 1893, its presence in the blood of malaria victims had already been demonstrated in Rio de Janeiro “by Dr. Fajardo, from whom we received splendid preparations.” But Lutz claimed priority in verifying existence of the parasite in the blood of birds: “This is the first time this fact has been verified in Brazil,” he wrote in that year's report.

He had detected plasmodia “wholly like those found in man” in the blood of a socó bird (Nyticorax) he had purchased at the market and also in the blood of about half the “many birds” from Penha, on the outskirts of São Paulo.

His adversaries pointed out that these findings stood in contradiction with the fact that plasmodia were not found in the blood of alleged malaria victims in the city of São Paulo.

We could have said these birds come from a small farm, near

the Tietê River, where there is a large swampy lake reputed to

be a focus of human malaria. We chose this place for this

precise reason. But … we do not lend great importance to the

fact for two reasons: first, because the identity of the

haematozoa of men and of birds is far from being proven …

and, second, because, as one can know without being a

naturalist, frugiverous birds move around and may have been

infected elsewhere.

In all these cases, no plasmodium has been shown to have

come from a sick person from the city of S. Paulo, where every

month so many dangerous fevers are diagnosed, and we are

still awaiting such evidence before we change our opinion.

In early 1895, 85 Lutz requested a leave of absence and made an excursion to swampy areas around Santos, where he had already identified cases of human malaria. He examined the blood of aquatic birds and other animals, but did not find any plasmodia, which he attributed to the unfavorable season of the year. In May, back in São Paulo, he had better luck: he examined a jabirú (Mycteria americana) “so infected with plasmodia that one often saw up to ten or more pigmented bodies under the microscope … We observed up to four small plasmodia in a single blood globule … There were no flagellated forms. The bird's spleen contained a large quantity of pigment.”

 

Drawings of Brazilian birds, among them the jabiru or wood ibis

(fig.1), Mycteria Americana species (Sick, 1985, v.1).

Lutz searched for haematozoa in amphibians and reptiles as well. Regarding frogs captured in Santos in 1893, he observed that the parasites in the red globules, “although probably belonging to the same family, distinguish themselves from human parasites by the fact that they are not pigmented and do not consume hemoglobin.” He further found Filaria embryos and a trichomonas in the animals’ blood. In another batch, collected from Barra de Santos two years later, there were three species of parasites: trypanosomes, Filaria embryos — “probably Filaria rubella” — and Danilewsky's Pseudovermiculi, which invaded the globules like malaria plasmodia. Lutz once again found these pseudo-worms in frogs and toads from Santos, São Paulo, and Taubaté, thereby verifying that they were “common and disseminated.” He also found flagellates in the blood

of rats, and a different species in the blood of 86 Batrachia.

A trichomonas as well as Filaria embryos were found in a lizard (Enyalius) captured in the woods of the Serra de Santos mountain range.

These investigations of animal parasites reached their peak in the mid-1890s. Thereafter, Lutz concentrated more and more on human malaria, especially the mosquitoes that hosted its protozoans. In his 1896 report, he still included news of a series of observations on cytozoa in amphibians. The species examined were a Boa constrictor from Bahia, presented to him by Von Ihering, director of the Museu Paulista; a rattlesnake (Crotalus horridus); and five specimens of water snakes (Liophis merremii), captured on the outskirts of São Paulo.

 

Snake of the Crotalus horridus species. Source:

www.bio.davidson.edu/people/midorcas/research/Field%20trips/SRE

L03/Crotalus%20horridus%20(17).jpg, retrieved 22 June 2005.

These species represent three different families, which would

seem to indicate that under favorable conditions any species of

snake can be infected. I examined about twenty snakes from six

different places, and found haematozoa in seven specimens

caught in four different places, which indicates that the parasite

is not rare. It was most often found in larger specimens, from

which it can be concluded that the infection is not limited to one

period of these animals’ lives.

The cytozoa in these snakes all seem to be of one species,

quite similar to the Pseudovermiculi of frogs. They are worm-

shaped, with one end rounded and the other pointed. The

nucleus is rich in chromatin, and the protoplasm often contains

some shiny granules. When a preparation of fresh blood is

made, they remain inside the red globules quite some time; after

leaving them, their movements slow. They may likewise curl and

then straighten like the falciform germs of coccidia, to which

they bear some resemblance.

The prime fruit of these studies was the article published in 1901 in Centralblatt für Bakteriologie und Parasitenkunde (v.29, no. 9, p.390-8), under the title “Über die Drepanidien der Schlangen: Ein Beitrag zur Kenntnis der Hämosporidien” — republished in this volume as “On Drepanidae in snakes: a contribution to our knowledge of haemosporidia” [in Port.]. Lutz begins the article with an overview of the previous decade's research on sporozoans that parasitize hot-and cold-blooded beings. In humans and in birds (Fringillidae, Ciconiae, and Columbae), he had found the parasites of benign tertian fever, of quotidian fever, and also the forms Proteosoma and Halteridium. He had quite often observed cytozoa in snakes and frogs, and only sporadically in specimens of Tejus teguixin, Enyalius sp., and Jacare nigra. Tortoises, common limbless lizards (Amphisbaena, commonly known as the two-headed snake), and Batrachia apoda always presented negative results.

Another group of blood parasites, trypanosomes, were found in rats and frogs, while Filaria embryos were found in humans, dogs, birds, frogs, and reptiles (Enyalius sp.).

In his 1896 report, Lutz had classified the existence of haematozoa in the blood of ophidia as “still unknown.” He later verified that this

fact had been observed by Billet, in Tonkin.87 Lutz, however, had examined over 200 individuals from some 20 species in another part of the world. In 1901, he claimed he had only included brief notes, in Portuguese, in Bacteriological Institute reports because he wanted to further explore the study of these parasites which were of such interest to him.