Adolpho Lutz and controversies over leprosy

his visit to Hawaii in the 1920's (1929, ill.25).

"Leprosy is a chronic disease, like syphilis and tuberculosis, and therefore requires chronic treatment, just as they do,” he wrote. A study that had been recently done by Hawaiian authorities in collaboration with leprologists from around the world (Hawaii, Dept. of Foreign Affairs, 1886) showed the results obtained up until then to be uninspiring. Nonetheless, Lutz seemed convinced that he would be able to cure the disease, just as a cure had been found for syphilis, which, by the way, also afflicted a large number of his patients. (As for tuberculosis, there was still no effective treatment, just spontaneous recovery facilitated by rest, hygiene, and good nutrition.)

During Lutz’ first three months of work, the supply of drugs he had brought from Germany were nearly used up, since he was unable to find what he needed from the druggists who supplied the Board of Health. The treatment was giving better results in cases of tubercular leprosy, especially in the initial stages of the disease. Lutz observed that the erimatose blotches characteristic of other forms, so similar to psoriasis and so often confused with it, could be eliminated with external treatment. His treatment proved to be less efective when muscular contraction and atrophy were combined with loss of sensation. The results were also unconclusive when there was hypertrophism involving connective tissue similar to elephantiasis. “It is likely that some of these symptoms (especially when they have already persisted for many years) are unable to be cured perfectly, since some anatomical changes do not permit restitutio ad integrum.”

The microorganisms present in the tumors that developed in the bodies of the sick were probably inactive, but it was impossible to rule out the possibility that, with the re-absorption of dead material favored by the use of topical medications, active microorganisms could return into circulation. Because of this, Lutz put a priority on systemic treatment. The earlier the diagnosis, the more effective it would be, so it was important for the doctors of the Hawaiian islands to learn to detect the disease sooner.

Of the substances for internal use, the main one was chaulmoogra oil, an extract made from the seeds of plants native to the Indo-Malayan region, of the genus Hydnocarpus, in the Flacourtiaceae family. Ancient Buddhist texts contained references to the consumption of these plants by lepers. In Japan and India, they had already been in use for centuries when, in the nineteenth century, the British brought information about their use back to the European medical community (Coutinho, 157, p.319-21; Murray, 1910, p.864; Benchimol et al., 2003, p.361-96). According to Obregón (n.d., p.164-5), chaulmoogra oil and its derivatives, administered orally or hypodermically, were the only treatments available and reasonably effective until 1942, when Promin, a sulfone derivative developed by Guy H. Faget, was introduced.

Fighting the side effects, especially nausea, until a dose of at least 2.8 grams three times a day was achieved, Lutz was able to maintain his patients in a good general state of health. He also used gynocardic acid, the active ingredient in chaulmoogra, prepared by Merck, until the supplies he had brought from Germany ran out.

During a yellow fever epidemic in the Brazilian state of Campinas the previous year, Lutz had liberally used salol, a combination of salicylic and carbolic acids. He had also used sodium salicylate, although elevated doses of it could cause disagreeable, even alarming side effects. Believed to be good as antiseptics and for reducing fever, they were administered internally for joint rheumatism and intestinal and urinary infections; externally, in powder form, they were used in treating a variety of wounds. Sodium salicylate, a derivative of salicylic acid (a forerunner of aspirin), was widely utilized against various infectious diseases, including yellow fever (Benchimol, 1999). Lutz had already tested another medication on two lepers treated in São Paulo. With daily doses of 6 to 8 grams, fever was reduced and acute eruptions were halted, and both patients were in good health for the next six months. The use of these acids made it possible to foresee favorable effects on leprosy “due to their anti-fermentation action in the blood.”

Several seeds of chaulmoogra plants (Em. Perrot, Le Chaulmoogra;

in Jeanselme, 1934, ill. 259, p.630).

Vegetal creosote, extracted from beech trees, was highly recommended for the treatment of consumption, and was also used for leprosy. The most active ingredient of this compound, guayacol, was used in the treatment of pulmonary tuberculosis and as a local antiseptic. Lutz began to use the 100 grams of the pure preparation that he had brought, but he still lacked the elements for evaluting its effectiveness.

In the symptomatic treatment of severe neuralgic pain, antipyrine was giving good results.

Carpotroche brasiliensis Endl., known as sapucainha, a Brazilian chaulmoogra species, which was studied as an anti-leprosy plant by

Theodor Peckolt (1861-69). Original plates in Martius, Flora

Brasiliensis (v.13, part 1, ill. 88; 1841-1872), reproduced in Souza

Araújo (1946, v.1, ill. 28).

Since the combination of leprosy and syphilis was very common in Hawaii, Lutz administered iodine and mercury to his patients, although many authors warned of the toxic effects of these substances. He paid particular attention to the effectiveness for leprosy patients of potassium iodate, which was used to treat tertiary symptoms of syphilis. Arsenious acid did not give favorable results and had been discarded.

Two other substances were part of Lutz’ therapeutic arsenal. The first one was goldenseal, an herb of the Ranunculaceae family, especially the species native to North America (Hydrastis canadensis). One of the alkaloids contained in its rhizome, berberine, produced strong contractions in the uterus and for this reason was used against uterine hemorrhages. It also had tonic, fever-reducing, and diuretic properties. The second substance was Veratrum, which was also derived from various herbs of the Ranunculaceae family that contained verathrine combined with other alkaloids. It was often used to induce vomiting and as a purgative; applied externally, it gave good results in a number of cutaneous diseases (Littré & Gilbert, 1908).

Of the medications used externally, the main one was chrysarobin, an extract made from Goa powder, a vegetal detritus found in the hollow trunks of angelim-araroba, a Brazilian tree. The substance had begun to be used in Brazil against various skin diseases and soon was adopted by European dermatologists, becoming the unrivalled external medication for treatment of psoriasis. Unna was the first to call his peers’ attention to the fact that chrysarobin could make leprous tubercles disappear, especially old ones. Lutz thought it possible to obtain the same result for maculo-nervous eruptions, especially the blotches similar to psoriasis. Pyrogallic acid (C H O ), obtained by distilling gallic acid, acted in a similar 12 6 6

manner, although more slowly. The external use of iodine and hydroxylamine were still sub judice. Lutz was also unconvinced that strychnine, tannic acid, and ichthyol were of specific value for leprosy as external medications, although the latter was useful for inflammatory symptoms when applied topically.

 

The crisis

Adolpho Lutz’ therapeutic project, which had initially seemed so promising, abruptly ended some months later due to a crisis that proved the end of the idyllic scene painted in February by Amy Fowler. According to Corrêa (1992, p.150-1), the crisis developed in August, 1890, when Charles Kahalehili, who suffered from Hansen's disease and who worked as administrator of Kalihi Station, was reprimanded by Amy because of “malicious comments made in the presence of others about two patients’ psychotic symptoms, attributing the cause of their psychosis to the medication used by Lutz.” Kahalehili went to the Board of Health, which named an investigative commission. Questioned aggressively, Lutz “deplored the offense and showed that a simple request for information would have clarified the matter.” The Brazilian doctor and the English nurse then resigned from their positions at Kalihi.

In Lutziana, Bertha Lutz’ version is different. According to her, her father made the decision to resign, as other doctors had done, because of “interference from lay persons.” A white man who was having a love affair with an indigenous woman was brought in as a leper by his brother, a missionary who Lutz detested, and who had no scruples about resorting to such a measure in order to quell the scandal. Having verified that the indigenous woman's lover did not suffer from the disease, Lutz proposed to the Board of Health that he be released. The missionary pressured some of the board members, and when the Board met and voted on the issue, Lutz’ suggestion was defeated. Indignant, he resigned in protest, as did Amy Fowler.

The unhappy man, brother of a missionary so eager to save his

soul and put an end to his mésalliance, committed suicide. At

this, some of the major newspapers of the United States

appeared, requesting interviews with Dr. Lutz. He did not

consider it ethical for a doctor to discuss hospital affairs with the

press, and refused. Mrs. Amy Fowler, however, gave the

interviews and the case was clarified, as it should have been.

The proud resignation letter written by Adolpho Lutz to the Hawaiian Board of Health, on September 3, 1890, less than a year after he had arrived in the Hawaiian islands, is transcribed in its entirety by Corrêa (1992, p.151). It seems to confirm the first version of the incident. Written in a harsh tone, it gives no room for negotiation.

You will remember that in accepting my position with the Board

of Health, I was careful not to bind myself to any given time. As

my task could only be carried out if I found the necessary

support where I had the right to look for it, I desired to provide

for all emergencies. I am now satisfied by public facts that as a

body, you not only refuse that support, but show yourselves very

slow, if not absolutely reluctant to do even common justice,

sanctioning by your silence the disgraceful conduct of an inferior

employé. After that, I think it unnecessary to enter into the

numerous indiscretions and indelicacies, as well as the system

of spying and reporting which the President and the Agent of the

Board of Health seem to consider necessary to the fulfillment of

their duties; nobody familiar with the circumstances will be

astonished to learn that I refuse to go on exposing my life and

my health meeting with such unfair treatment. If I have not

resigned long ago, it is only because I would not have my

resignation misconstrued; the unanimous vote of sympathy from

all my patients satisfies me that my endeavours have been

recognized where I most cared that they should be. I shall

therefore give up my position as physician of the Kalihi Hospital

at the end of the month at the latest, presuming that this time

will suffice for my further arrangements. I expect retribution for

my expenses for drugs and instruments, brought for and sent for Provoked by the representatives of the Board of Health, Rose Gertrude explained why she had appealed to the legislature: “Mr. Carter and Mr. Waterhouse came out to investigate my complaints … I was told that Mr. Damon went to the Roman Catholic Bishop, and gave him to understand that the Board wished me to resign. That was the only answer we received after this committee was here … I considered it an insult to doubt my word and the doctor's against that of a man like Charlie … In England in any hospital, if a charge was made by a matron or physician against any servant he would be dismissed at once (Hawaii, Legislature, 1890, p.2, 7).”

from Europe, as well as of the sum stipulated as compensation

for my journey home.

It is possible that the two versions – that of the punishment of a problematic subordinate and that of an influential missionary – may be connected by a more complex web of events, including the anti-contagionist opinions that Lutz expressed in an article suggestively entitled Leprophobia, published in Journal of Cutaneous and Genito-Urinary Diseases (1892) and in Revista Médica de São Paulo (1898).

In reality, there were two investigative commissions. The one named by the Board of Health seems to have taken an ambiguous position, deferring the punishment of Charles Kahalehili, who had not merely sabotaged Lutz’ treatment but had also spread malicious rumors about the relationship between the doctor and the nurse. Indignant with the Board, especially when she discovered they wished her to resign, Amy went to the legislature, which named another

commission. 23 The depositions made during three visits by legislators to Kalihi Receiving Hospital (August 15, 16, and 18, 1890) showed that the crisis really had been provoked by a more complicated situation.

During the first session, besides the legislators and the witnesses, those present included Mr. Carter, of the Board of Health, C. B. Reynolds, the Board's representative in Kalihi, with authority over Charles Kahalehili, and Kahalehili himself, the de facto manager, or luna as the native patients called him. The stenographer for the sessions was the reporter D. Logan.

In the beginning, one by one, the three complaints made by Sister Rose Gertrude against Kahalehili were read, as were the Board's responses and the statements made by the accused, but the stenographer only registered occasional comments by the English nurse, which confirm that there were complaints but do not permit us to know their exact content. Only a reading of the depositions in their entirety reveals what the conflicts were.

"This is not England,” Carter protested. “We are bound to conside the rights of this Hawaiian. Why did you not complain about these things before? These things were going on for some time?”

Amy responded that she had done so, to Reynolds, who took the side of Kahalehili, saying only, “You cannot expect much from a native.” She had also spoken with the British commissary, but unofficially (ibid., p.7-8).

Relations between Amy and the president of the Board, Dr. Kimball, had also been strained for some time. The English nurse had told him that the patients felt humiliated when he exhibited them to the visitors that he frequently brought to Kalihi. Kimball responded that he knew Hawaiians better than she did, whereupon Amy retorted that this might be true but she knew her job. “'Very well, since you have taken that line with me,’ Kimball replied, ‘I shall treat you as you deserve: when I come out here I will ignore you', and he has; when he has brought visitors out he has not spoken to me.” During the depositions, one of the patients, Reverend Pahio, confirmed, “It is very disgraceful; we do not like to be brought up and exposed to everybody” (p.22).

The professional conflicts at Kalihi had become impossible to negotiate, and even Carter made a point at declaring that “the Sister and the Doctor both said to me the other day that their positions were not sufficiently defined, and I reported to the Board, and regulations are now being drawn up to allot each officer's place” (p.8).

The most important complaints have to do with Kahalehili sabotaging Lutz’ treatment and the doctor's and nurse's authority. This sabotage, done with the complicity of members of the Board, brought to the surface other condemnable aspects of the hospital administration. The patients lived in constant fear of being sent to Molokai, and the administrators – the luna and Reynolds – manipulated this fear in order to obtain personal favors and free labor, even with patients whose health was poor and whom Lutz and Amy felt needed to rest.

John Francisco, one of the patients called to testify, stated that Charlie Kahalehili “treats us kind of rough … He says, ‘If you do not go to work you must go to Molokai.’ … I worked for four weeks. I told him, if the Government wants me to work it must give me clothes.” The legislators asked if the Board had not provided all that he needed. “I got a blanket and a mattress, that's all,” John Francisco responded. He confirmed Amy's complaint that Mahiai, a patient who was extremely ill, had been forced to paint fences when he had a fever, and when Lutz had ordered him to remain in bed (p.10, 12).

Another of the Brazilian doctor's patients, a young woman of delicate health named Luaka, said that Charlie required her to wash clothes “without pay and he has at times told me that if I didn't wash his clothes he would send me to Molokai.” Once, she confessed, he said angrily that “he wanted to wash out the stains of the doctor's medicines that had been rubbed on his body” (p.12-3, 40).

The patient Dreizehner gave eloquent testimony on this subject: Kahalehili “was a boss here, and if he told anybody to go to work they were all afraid.” He cited the example of Puniae, a kanaka carpenter who was made responsible for finishing the church.

I am sure they worked from six o'clock in the morning till seven

at night. One evening I came along and Puniae was working

very slow on the church, and I asked him why he didn't lay off,

and he said, ‘We cannot because Charlie will send us to

Molokai.’ And he told me that the doctor told him not to work,

and when he told Charlie, he said: ‘It is no use, the church must

be built’ … . The man is nearly all the time sick, the doctor has

to be patching his hands and his feet … There is another man in

there sick and I will say something for him. When he came here

first he was very sick and the Sister did a good deal for him. He

had to go out, when he was a little better, with the dumping cart

digging sand and dirt, and would be getting up and lying down

again … I think when a man is sick, working out in the sun and

then going into the cold water, it is not good for him. He had not

been seen for sometime and I found he was sick. He was lying

there for fourteen days … on a mattress not thicker than that

(shows) nor longer than that (shows), for a man six feet in length

… I do not speak for myself but for these other people. I go into

that yard and ask where they got this or that, and it is the Sister

everything – bits of tobacco, money, etc. I have nothing against

Mr. Reynolds . but when people are taken from their homes

something should be done for them. What would the place be

without the Sister … Sister complained to me that she must do

something, that she could not stand it much longer, and I said,

what is the use, this country has no more mercy for a leper than

for a dog. (p.27-9)

These accusations made it evident that there was a serious problem in terms of the standards of care for quarantined patients, both those who were out of the hospital as well as those within (who should have been separated into those who were already sick and those who were suspected cases). Charlie was a leper, but spent most of his time on the side reserved for the suspected cases, among whom were included the young woman who he made wash clothes. A number of those who testified accused him of eating with these patients, and one of the complaints made by Sister Rose Gertrude even referred to his frequent forays out into the city (p.8).

The neurologic issue was the opposition made to Adolpho Lutz’ treatment, which, in the opinion of a number of those who testified, was similar to that of a kahuna, a faith-healer. Amy accused Charlie of speaking “against the doctor and against me… that the doctor did not know how to treat the patients and … that a patient was made crazy by the medicines, which I administered” (p.3).

Various patients confirmed this. “I heard Charlie say it was useless to take medicine, it was better to pray,” Mrs. Johnson declared. Miss Harper also heard from Kahalehili that Lutz’ medicines had made one man go crazy. Reverend Pahio stated:

He had no confidence in the doctor's medicine … what he said

was the cause of preventing people from taking the medicine …

he acted like most Hawaiian kahunas in going and sprinkling

water on this girl Haliimaile (this woman has gone to Molokai).

Charlie came to me and asked me for a Bible … he never did

anything with the Bible except this water business … This girl

appeared to be out of her mind, as though she had a spirit that

had visited her and he was acting as though to drive this spirit

away form her according to the manner of a kahuna. (p.14-5,

19-20)

The man who had gone crazy was from the Fiji Islands. He lived on the side of the suspected cases and ended up dying. According to John Franscico, “he was quiet at night, but if Charlie came in he would become very violent.” The luna had made him go “into the sun although he knew it was against the doctor's orders and he knew he was nearly dying.” John Francisco took care of him on the night that he had one of his episodes and began to scream.

Sister… telephoned to Dr. Lutz … doctor stayed here all night to

keep him quiet — gave him medicine. One night, two nights

after that, I was in the sick man's room. Charlie came up with

two coils of rope and a pair of handcuffs … Sister came along

and asked what he meant by that.

Reynolds intervened and asked the English nurse: “Didn't he (the Fiji Islander) get a pair of scissors and require three or four men to quiet him?” “No,” she replied, “I got him to come out by my own persuasion; didn't I, John?” (p.4, 10).

The incident is related by Bertha Lutz to demonstrate her mother's courage.

One day a patient, made desperate by having been separated

from his family, decided to commit suicide. Taking a long

scissors that Lutz used for cutting paper, he locked himself in his

room. Sister Rose Gertrude went to his door and asked, ‘My

son, did you take my scissors? ‘Yes, I am going to kill myself.’

She replied: ‘But no, you can't do that. Your family will be very

sad. Give me the scissors, I need them to cut paper.’ ‘Then

come in and I will give the scissors to you.'

Everyone insisted that she should not enter the room, but she

calmly opened the door and went in. The patient picked up the

scissors and offered them to the nurse, who thanked him and

left. The incident had ended. (Lutziana)

The depositions collected by the legislative commission indicated that Lutz’ treatment had been popular among the patients at Kalihi. Pahio declared:

I can now show you why I have faith in the doctor's medicine. I

consider that I was one of the worst patients that was in this

yard – my forehead was covered with lumps, and the lobes of

my ears were enlarged, my face all puffed out, my arms in a

horrible condition… you see what condition I am in today.

Therefore I place the most implicit confidence in the doctor's

medicine.

The reverend affirmed that various other patients had also improved. “The doctor … removed them to the suspect yard, so that as soon as they are cured he can release them” (ibid., p.21).

The report made by four of the five members of the legislative

commission24 concluded that the accusations against Charles Kahalehili were true. On their last visit to the hospital, they called all the patients and asked each one, separately, how they were treated by him and if they wanted him to continue as the Boards agent. A unanimous “no” was the answer. They then recommended that Kahalehili no longer be permitted to hold any sort of role in the hospital administration. As he had been acting on instructions from or tacit approval from Reynolds, they also considered that he too was unfit to serve as agent of the Board of Health.

From the evidence it was satisfactorily proved … that

undoubtedly Dr. Lutz is the only suitable person to be in charge

of the medical treatment of the people affected with this disease

… It was represented … that all the Hospital had great

confidence in Dr. Lutz’ treatment of the disease, and your

Committee believe that if there are no obstacles placed in Dr.

Lutz’ way that he may succeed in curing some of the cases …

as many of them already show great improvement.

The commission also observed that the patients had “great confidence in Sister Rose Gertrude who … takes care of them as a parent would a child; and they both love and respect her.” Lutz should have full authority over the patients, and Sister Rose Gertrude, total control over the hospital, under direct supervision by the Board of Health. The commission also recommended that there should be two sets of staff, one to care only for the suspected cases and the other to care for the confirmed cases and those whose illness was advanced.

Kimball left his role as president of the Board of Health and on September 10,1890, his successor, Dr. David Dayton, asked Lutz and Amy to reconsider their decision to leave Kalihi, but they no longer wished to stay.

"Hula Girl,” wearing maile lei, about 1908, by Ray Jerome Baker. In.

HOEFER, Hans Johannes. Hawaii. Ed. Apa Productions. USA,

1985. pp 298.

The events that led to this can be understood as being part of a larger set of tensions involving hygiene agents and the population that was subject to the draconian law of 1865, which resulted in the segregation of thousands of carriers or suspected carriers of Hansen's bacillus. In 1885, the transfer from Molokai to Honolulu would bring a desperate father to kill two policemen and to wound a third. In 1890, in a village called Kailua, Kealoha reacted with gunshots against the police who came to take him away. According to Mouritz, between 1865 and 1895 there were at least a dozen similar episodes. During the period when Lutz and Amy were in the islands, a “cleansing” of the island of Hawaii was conducted, resulting in the reclusion of about 400 people. A sheriff wanted to do the same thing on the island of Kauai, but when he went to hunt down the lepers of the village of Kalalu, armed to the teeth, an indigenous man named Koolai shot him and fled. The government sent 25 soldiers in pursuit of him. Koolai ambushed them in a valley, with a Winchester and a lot of ammunition and the soldiers took off running. He was never caught, but it is known that he died of the disease five years later. The most serious episode occurred in July of 1893, and became known as the “war of the lepers of Kauai.” In a social context of latent civil war that would lead to the deposition in 1894 of Queen Lydia Liliuokalani (2.9.1838 — 11.11.1917) by foreigners who wanted to annex the island to the United States, the Board of Health ordered the destruction of a village of lepers in the Kalalaul valley, where they had been fed and cared for by relatives and friends (Souza Araújo, 1929, p.96-7).

The Calm

Until September of 1890, Amy lived at the hospital and Lutz in the center of the city. Bertha, who was their first child and who would be born a few years later, remembers that her mother told her that

when she would do her shopping in Honolulu, everyone knew

her and the merchants received her very well, but everyone

begged her not to touch the merchandise. They opened their

wares and showed her everything she wished to see, but did not

want her, under any circumstances, to touch the things she

planned to buy until after she had paid for them. (Lutz, Lutziana)

According to Bertha Lutz, what drew Sister Rose Gertrude to the Brazilian doctor was his fearlessness about his risk of contracting the disease, and his consequent affection for and closeness to his patients. Other doctors

did not hide their repugnance for examining the lepers, while he

was completely natural and warm with them, as though they

were ordinary patients or personal friends. She soon followed

his example, and during the time that she was in the ... leper

hospital, she never avoided contact with them and never

contracted the disease. This situation, which both faced with

great courage, could not have failed to bring them together.

(Corrêa, 1992, p.150)

As we have seen, their friendship proved fodder for the malice of Kahalehili and others in the hygiene department, especially the habit they had of taking long rides on horseback during their free time, when Amy used secular clothing instead of the nun’s habit (Law, n.d., p.4). Dreizehner, one of the patients who testified before the legislative commission, made an interesting comment: “Sister complains that she has been insulted, and she has been insulted. Now, there is one man from South America who saw that the Sister needed help, and he has helped her – he has been behind her all the time just like a dog” (Hawaii, Legislature, 1890, p.29).

In his private practice, Lutz had mostly European patients who were residing in Honolulu, “including many Portuguese.” He had very good relations with a German family and with a Chinese man who had great influence over the community of foreigners. The English nurse also began to be part of this circle of people who were not afraid of contact with people who lived among lepers. According to Bertha Lutz, they had good relations with the native elite. As an illustration of this, she cites a note sent by Kapiolani, the Queen of Hawaii, to Lutz when one of the young woman of her court was examined by him. She would have said: “I greatly fear what I already know will be your diagnosis.” And, in fact, the girl did have leprosy. “My mother spoke of the queen’s great courteousness and of how she sometimes gave my mother plants that did not grow in England for her little garden” (Lutziana).

The only people with whom Adolpho Lutz did not get along well were the missionaries

who wanted to convert the natives, the kanakas, but who did

things that seemed to have little honesty, such as trading large

expanses of land for small trinkets and punishing them for minor

infractions. Dr. Lutz used to say that some of the large fortunes

of the archipelago’s well-known families had origins that it was

better not to think too much about... (Lutz, Lutziana)

The crisis we have related here brought the Brazilian physician and the English nurse together, despite differing views of religion. But Lutz’ Germanic formality and the decorousness of the young woman who had been brought up according to strict Victorian manners did not allow the two to permit subside the sentiments that each held for the other, and which certainly they were unable to mask as they carried out their daily responsibilities. At the invitation of Mr. Liu, the Chinese man who was so influential in Honolulu, Amy went to stay at the house where he lived with his family while she waited for her return to England. Days before her voyage, the young Brazilian physician asked for her hand in marriage. In Bertha Lutz’ narrative, (Lutziana), the marriage took place on April 19, 1891, in Honolulu, at the Chinese family's home, with a bucolic altar that had been put up in the garden and decorated with wreaths of flowers. However, according to the documents consulted by Corrêa (1992, p.149-50), Lutz and Amy were married on April 11, at the home of H. M. Schmidt -probably the head of the German family that had opened their home to Lutz – in a simple ceremony celebrated by a pastor of the Church of the Central Union of Honolulu, with Schmidt himself, J. Ena, and G. Woodhouse, the English consul, as witnesses.

 

Note written by the Queen of Hawaii to Adolpho Lutz on April 4th, 1890: “Dear Doctor Lutz. Sir. Will you be king enough to examine

Hahünaib Kaauwai [?] if she has any signs of the Leprosy, and if

anything can be done to the poor child, please let me know by the

bearer. H. M. Queen Kapiolani. Iolani Palace” (BR.MN. Fundo

Adolpho Lutz. Caixa 22, pasta 255).

The couple remained in Honolulu for a little over a year, until the middle of 1892. Lutz maintained his private practice, and continued to treat a few cases of leprosy in Kalihi and Molokai, refusing, however, the insistent invitations from the Board of Health to reassume his post. Amy maintained contact with people she had met at Kalihi after they had been sent to Molokai. In 1891, she used part of the money that had been sent to her from England to build a library in Kalaupapa which was given the name of Beretania Hall (Law, n.d., p.5).

 

Adolpho Lutz and Amy Gertrude Fowler's wedding in Honolulu,

Hawaii, on April 11, 1891. Instituto Adolfo Lutz Collection.

One of Adolpho Lutz’ favorite pastimes was making excursions around the islands to study their flora and fauna, and it is possible that Amy accompanied him on these trips. He published important papers in Monatshefte für Praktische Dermatologie (Sept.1891-Aug.1892), continuing to contribute during the second half of 1892, when the couple moved to San Francisco, California. In one of these letters he describes, for the first time, juxta-articular nodules, which would be later studied by Jeanselme, “as something new” (Neiva, 1941, iv; Portugal, 1944), and which today are known as Lutz-

Jeanselme nodules. 25

 

In this 1890 photo, a tramcar of The Hawaii Tramways Company

stops in front of Aliiolani Hale on King Street, Honolulu (Hoefer,

1985, p.49).

Residence of Honorable C. R. Bishop, probably the owner of the

bank where Amy Lutz made her deposits (Whitney, 1890).

In Hawaii, Adolpho Lutz continued his studies of parasites in humans and domestic animals. Biographers put an emphasis on his work on hepatic fluke worms and their sources, which led him to study the snails that lived in different parts of the islands where sheep were raised. These studies would prepare him for what Deane considers (1955, pp 80) his major contribution to medical zoology in Brazil: “his masterful works on Schistosoma mansoni and the mollusks responsible for the propagation of eschistossomosis,” studies begun in the first decade of the twentieth century, at the Instituto Oswaldo Cruz.

Albuquerque (1992, p.13) pinpoints Hawaii as the place where the basis was made for another important later discovery by Adolpho Lutz: the realization that plants that retained water served as habitats for small crustaceans. This would later direct his attention to role of this habitat in the transmission of malaria in the wild.

According to a paper by the Centenary Commission on Lutz (1956, p.9), it was also in Hawaii that Lutz began entomological observations that would serve as a basis for his later activity in the area of sanitation. We will see that he already had formulated a hypothesis that leprosy was transmitted by mosquitoes. For Albuquerque (1950, p.13-4), this conviction would become stronger over the years, but was a result of the following observations made

in Hawaii:26

Although he had never avoided direct contact with the lepers, he

had not caught the disease, nor had the young nurse in whose

tender arms many of them crossed the doorways of life into

death. However, among the sick who entered the settlement,

many had never before seen another leper. There had been a

time, and not so long before, when neither leprosy nor

mosquitoes had existed in Hawaii. The native language had no

terms designating either ‘leprosy’ or ‘mosquito', and it dubbed

morphea ‘the Chinese disease’ since it had only appeared with

the arrival of the Chinese and their rice-growing. This crop was,

as customary, grown in ditches irrigated constantly with water,

where mosquitoes, also coming from abroad, found an excellent

microhabitat.

 

Lutz’ theory of the transmission of leprosy by

mosquitoes

Lutz’ first speculation on the role of blood-sucking insects is found in “Estudos sobre lepra” (Studies on leprosy), written in Limeira in 1885-86 and published immediately afterwards, during his first stay at Unna's clinic in Hamburg, in Monatshefte für Praktische Dermatologie (1887). In describing the primary lesions of nerve leprosy, which could be an “entryway to infection,” Lutz deemed it “remarkable that the first location of nerve leprosy occurs almost always in those parts of the body kept uncovered and exposed to insect bites and other traumatisms” (p.549).

 

Bay and village of Hilo, Hawaii. Painting by D. Howard Hirchcock,

1889 (Whitney, 1890).

As to transmission of the disease, Lutz analyzed the inconsistencies in the theory of heritability and although he was already fascinated by Hansen's bacillus, his stance differed from that taken up by proponents of the new microbial paradigm:

from my observation of the disease, I have no hesitation in

stating that leprosy is less contagious than tuberculosis and in

labeling the brusque expulsion of lepers from the heart of

society … as not only inhuman but also hardly efficient and,

moreover, incoherent: and this because leprosy offers no

greater danger to life than tuberculosis, nor are its prospects for

a cure any darker.

Infection of each new case depended upon the pre-existence of another, within a certain period of time, but “the conditions necessary for a new case to appear are so complex and singular that only rarely will they be met within the immediate vicinity of lepers.”

Seeing leprosy with the eyes of a parasitologist, Lutz proposed an analogy with ancylostomiasis, the topic of a study he published in Leipzig around the same time. Like leprosy, ancylostomiasis presupposed the existence of other cases but

someone who lives in a country where hookworm is found can

contract the disease from muddy water without ever having

come near someone suffering from it, while living in contact with

the ill can be totally harmless, as long as rigorous cleanliness is

observed regarding drinking water and wastes.

Lutz believed leprosy was “a disease for which only very rarely [would] direct transmission be demonstrable and in which for this very reason infection by contact within the family household plays merely a minor role.” In his opinion, congenital transmission played a “wholly insignificant” role and morbidity was maintained “chiefly by the sporadic occurrence of new cases within the heart of families spared until that point.”

Once it had been learned how to distinguish leprosy from other similar dermatological diseases – such as mycosis, psoriasis, rhinoscleroma, erisipelas, etc. – no new cases of infection were transmitted in unaffected countries, even when visited by victims of Hansen's disease. This fact also argued against the idea of direct contagion: “I myself know of some ten lepers who have left for Germany in recent years.”

To explain the peculiarities of indirect transmission, Lutz acknowledged hypothetically that the sufferer's blood or mucous secretions, containing the infectious agent, might require “a period of maturation at a lower temperature in order to develop communicability (for example, by means of spores or forms of resistance, or another stage in its evolutional cycle), or perhaps … exposed direct inoculation is also indispensable (for example, through biting insects).”

At the end of the paper written in Limeira and published in Germany in 1887, Lutz added the following observation: “Given the isolated situation in which I find myself, I have been obliged to completely relinquish any possibility of taking the existing bibliography into thorough account.” He had not had access to Leloir's new book, “and only by chance [had he] received a review of the same, written by Unna … I see with satisfaction that many of our observations coincide, and I hope the reader will take as corroboration any involuntary repetitions.”

Henry Leloir (1886) seems to have been one of the first to consider transmission of the leprous “virus” by mosquitoes. Although Edward Arning was author of a crucial experiment favoring the idea of leprosy by contagion, in 1891, he had, like Lutz, made a correlation between the rather concomitant appearance of the disease and of mosquitoes on the Hawaiian Islands. The most important contribution here may be that of Mouritz: in February of 1885, he examined 178 kokuas who lived among lepers in Molokai, finding no evidence of the disease; a year later, seventeen showed symptoms of leprosy. Mouritz developed the hypothesis that it could enter the body by means of skin fissures and external mucous membranes, possibly via insect bites or the presence of ectoparasites, such as scabies (Souza Araújo, 1929, p.65).

Halloppeau, Chantemesse, Sommer, Leboeuf, Noc, Scott, Joly, Blanchard, and, a little later, the Colombians Juan de Dios Carrasquilla and Guillermo Muños Rivas were other names associated with the theory that leprosy is transmitted “by arthropods,

particularly acarines and insects, and above all mosquitoes.” 27

Of those mentioned above, the name Raphael Blanchard is of special interest here. A physician and parasitologist, Blanchard

seems to have been the ‘Manson’ of French tropical medicine. 28 He was a central figure in the network that linked zoologists and parasitologists from around the world, who were increasingly focused on medical topics (in this regard, see Sanjad, 2003, p.85-111; Caponi, 2003, p.113-49). Blanchard was a founder and secretary-general (1876-1900) of the Société Zoologique de France and, together with Alphonse Milne-Edwards, he organized the international zoology conferences that defined more precise rules for zoological nomenclature, the first, in 1889, and subsequently every three years. Blanchard chaired the Permanent International Commission on Zoological Nomenclature starting in 1898, the year in which the Archives de Parasitologie were created. In 1902, he founded the Institut de Médecine Coloniale, which provided training in parasitology for French and foreign physicians working in the so-called warm countries.

 

Raphael Blanchard (1857-1919) (Olpp, 1932, S44).

There was great repercussion when Blanchard voiced his opinion in the Bulletin de lAcademie de Médecine (1900) and the Archives de Parasitologie (1901) that leprosy could be transmitted by mosquitoes not only in hot countries, where it was endemic, but even in Paris, which should thus gird itself against these new enemies of public health. In 1905, Blanchard published Les moustiques: Histoire naturelle et médicale, one of the founding treatises of medical entomology. In Lutz’ words (1939, p.477), the work presented an “excellent summary of the arguments favoring culicidian transmission of leprosy.” In it, the French parasitologist commented on the mosquito's place in zoological classification, its morphology and anatomy, its habits and metamorphoses, and its genera and species. In chapter V, before presenting prevention measures against mosquitoes, he analyzed their proven role as carriers of malaria, yellow fever, and lymphatic filariasis, and their “presumed” role in transmitting other diseases – not just leprosy (p.543-5) but also scurvy, dengue fever, plague, hot-climate ulcer, warts, moles, undulant fever, and an equine epizote from South Africa.

The 2nd International Leprosy Congress, held in the Norwegian city of Bergen in 1909, approved a recommendation by the British delegation that the problem of leprosy transmission by insects should be elucidated (conclusion VI, cited by Souza Araújo, 1952, p.1). A number of leprologists were already examining mosquitoes that had bitten sufferers of the disease, and in some they had found acid-fast bacilli. Others were undertaking experiments with insect bites but had not come up with any convincing results. According to Adolpho Lutz (1939, p.476), this was because the experiments were not “conducted using rigorous methods … In addition to other errors, the interval needed for the germ to incubate in the mosquito's body was not taken into account.”

In a letter sent to Lutz in June 1905, Blanchard asked him what studies he had already published on the transmission of leprosy by mosquitoes; he apologized for his inquiry by explaining that “unfortunately, papers published in Brazil are not very accessible here.” Although Lutz’ stay in Hawaii had reinforced his conviction that the culicidian hypothesis was the most appropriate way of explaining the transmission of leprosy, since he was “unable to present positive proof” he had published nothing on the topic: “I merely . upon the occasion of a congress, requested that professor Unna, in my name, call leprologists’ attention to the matter” (cited in Souza Araújo, 1956, p.130). The Brazilian zoologist and bacteriologist sent mosquitoes for Blanchard's entomological collection, “which did not include, so to speak, any South American

type.” He also sent him a brochure on yellow fever. 29

During Adolpho Lutz’ time as head of the Instituto Bacteriológico de São Paulo [Bacteriological Institute of São Paulo] (1893-1908), leprosy was the subject of epidemiological and laboratory studies but it took second stage to other, more burning questions in the realm of state public health, such as diphtheria, typhoid fever, cholera, amoebic and bacillary dysentery, bubonic plague, malaria, and yellow fever. In point of fact, Lutz gathered only scant results on leprosy, according to the reports he wrote during those years. In 1893, still as interim director, he repeated the experiments he had performed earlier at Unna's laboratory in Hamburg and at Lazarus Hospital in Rio; these attempts to cultivate Hansen's bacillus proved equally frustrating (see Lutz, 1895, p.207-8).

Leprosy was only mentioned again in his report on the year 1898, wherein Lutz highlighted events surrounding the consolidation of tropical medicine in England and Germany. The scientist hailed the inauguration of London's school of tropical medicine and the forthcoming creation of another one, in Liverpool, as well as the launching of the Journal of Tropical Medicine, published in the British capital by James Coultie and W.L. Simpson. Lutz rejoiced over publication of two “excellent” treatises, one by Manson on Tropical diseases (1898) and another by Botto Scheube (1853-1923), entitled Die Krankheiten der warmen Lander (1898). He also made mention of a session dedicated to tropical diseases, inaugurated at the 66th meeting of the British Medical Association, held in Edinburgh in July of that year. Of special note among the papers presented there was Manson's work on Ronald Ross’ research, tending “to prove the theory that mosquitoes play an important role in spreading malaria.” Robert Koch had organized an expedition to several countries to investigate transmission of that disease, then being studied both by Lutz and his team in São Paulo and also by Francisco Fajardo, Oswaldo Cruz, and some other bacteriologists in Rio de Janeiro.

The 1st International Leprosy Congress, held in Berlin in October 1897, was included by Lutz among events surrounding this establishment of tropical medicine and the strengthening of a medicine grounded on “precise observations” made possible through the natural sciences. Lutz lamented the fact that the São Paulo state government had not sent him or any other delegate to the congress. Disease transmission by haematophagous insects was the overriding idea that served as his touchstone in assessing the papers presented in Berlin, “generally of little import.” Hansen's bacillus had come out strengthened while the theory of hereditary transmission of leprosy lost force, Lutz pointed out. The serum developed by the Colombian Juan de Dios Carrasquilla, already rejected in tests conducted at the Instituto Bacteriológico de São

Paulo,30 found “rare supporters,” and yet Lutz still lamented that the assembly had “not more energetically condemned these absurd syllogisms and observations holding to no criteria” (Lutz, 1898, p.5-6). In his report, Lutz did not mention the transmission of leprosy by mosquitoes but he certainly had this in mind when he commented that in Berlin “the danger of contagion [was] somewhat exaggerated by those who have observed the illness less” (ibid., p.5).

The summary of research conducted at the Instituto Bacteriológico de São Paulo from 1892 through 1906 condenses experiments dealing with leprosy to a few paragraphs. The disease had been the reason behind only three autopsies during that entire period, a number that contrasts with the many dozens performed because of the other diseases mentioned above, epidemics then sweeping across the state. Although he was unable to cultivate the leprosy bacillus, Lutz saw no problem with laboratory exams meant to corroborate clinical exams: he performed twenty on soldiers from the Força Pública. Hansen's bacillus was easily found in the

liquid of tubercles and in ulcerations of the nasal mucous, as

well as in the lymph glands corresponding to the affected region.

Due to its shape and way of reacting to staining, it could only be

confused with Koch's bacillus, but such a mix-up would be

almost impossible given the two illnesses’ differing

symptomologies and also the grouping characteristic of

Hansen's bacilli. (Lutz, Revista Medica de São Paulo, 1907,

p.81)

This report is the only one that mentions studies on transmission of this germ by mosquitoes. Lutz had ascertained that the germ did not move into the insect's stomach, even when the tubercles themselves were pricked. “The opposite must happen during periods of fever, when the bacilli are circulating in the blood, but there has been no opportunity to verify this fact” (ibid., p.81).

In 1901-1902, Adolpho Lutz arranged to repeat in São Paulo the experiments that a U.S. mission headed by Walter Reed had just completed in Cuba in an effort to prove Carlos Juan Finlay's theory on the transmission of yellow fever by Stegomyia fasciata (currently Aedes aegypti). The goal of both Lutz and Emilio Ribas, director of São Paulo's Sanitation Service, was to win over to their new prevention strategy physicians and lay people who believed in the miasmatic etiology and especially in the bacilli and fungi inculpated by Domingos Freire, Giuseppe Sanarelli, and others in search of the yellow fever microbe. Lutz’ and Ribas’ demonstration helped clear the way for the campaign against Stegomyia fasciata led by Oswaldo Cruz in the city of Rio de Janeiro in 1903-5, as part of other sanitation and urbanistic measures aimed at “regenerating” and “civilizing” the city, which was at that time the capital of Brazil (Abreu, 1987; Benchimol, 1992).

Construction of new buildings in 1908, when Adolpho Lutz was transferred to Instituto Soroterápico Federal, whose name was

 

changed to Instituto Oswaldo Cruz in March that same year

(DAD/Fiocruz).

After his 1908 move to Instituto Oswaldo Cruz, Adolpho Lutz, who had been studying carriers of yellow fever and malaria for some time, resumed his research on haematophagous insects that might be able to host the leprosy microorganism. The disease was moving farther up on the agenda of sanitary concerns, and at Manguinhos Lutz found both the time and laboratory facilities needed for his return to a line of research that had been smothered by the burdensome routine of public health in São Paulo. All indications are that his results were inconclusive. Nevertheless, for the first time he publicly and with great emphasis upheld the theory of leprosy transmission by mosquitoes, and in this campaign brought to bear both his sparse experimental results and all the weight of his scientific authority.

 

The 1915 controversy and its consequences

A sanitation code that was drawn up by Oswaldo Cruz after his 1903 appointment as General Director of Public Health required that certain diseases be reported to the government. Leprosy was among them, as were yellow fever, bubonic plague, cholera, smallpox, and diphtheria. Despite the contagionist assumptions underlying this code, and perhaps thanks to Lutz’ influence, the “specific instructions regarding each one of the illnesses that must be reported” considered that “mosquitoes and other human parasitic insects (fleas, bedbugs, etc.)” were to be suspected of “carrying and