Adolpho Lutz and controversies over leprosy

transmitting the leprosy bacillus.” 31

In a report written at the peak of Rio de Janeiro's sanitation campaign, Oswaldo Cruz brought leprosy to the limelight: twenty-three cases had been reported in 1904, and the disease was raging through the city. The chronic nature of the illness made it unfeasible to intern victims at the isolation hospitals intended for people with acute infectious diseases. Therefore, the ill should be “sequestered" in “'leper colonies’ where sufferers would find, together with essential treatment, the elements needed for continuing with their activities, still quite useful.” Oswaldo Cruz (1905, p.67) considered transforming the pesthouse on Ilha Grande into the first of these settlements, with “all the elements of comfort required in accord with the habits of the various social classes.”

The idea of quarantining victims on an island, as in Molokai – or as

had been the case in Bom Jesus, right in Rio's Guanabara Bay32 – was put forward by three São Paulo physicians: Alberto Seabra and two of Adolpho Lutz’ assistants at the Instituto Bacteriológico, Ulysses Paranhos and Adolpho Lindenberg. At the 6th Brazilian Congress of Medicine and Surgery, held in that state during September 1907, their motion to that effect was approved.

In an interview published in O Imparcial on July 3, 1913, four years after leaving his post as head ofpublic health, Oswaldo Cruz reintroduced the proposal to quarantine the afflicted in a farm settlement, to be built on Ilha Grande. His warnings about the danger of the spread of leprosy, “Death's oldest daughter,” found sympathetic ears in the federal Senate, where São Paulo's representative, Francisco Glicério, sponsored a budget amendment allocating 170:000$000 to the proposed leprosarium (Souza Araújo, 1956, p.117).

In mid-1915, a commission was set up to study the “most terrible of the epidemics that have been developing in frightening fashion in

recent times.” 33 This use of dramatic language is in perfect tune with Obregón's description of the situation in Colombia during the same period. However, the similarity in discourse does not mean that leprosy acquired the same importance here as it did in that country when it came to the professional legitimization of physicians and sanitarians. According to Obregón (1996, p.172-3), when Colombian doctors joined the international movement to set up leprosariums, they exaggerated the magnitude of the disease and spread panic among the public and governmental authorities because they needed to convince them, first, that charitable institutions would be unable to handle the disease and, second, that it constituted a much more serious public health concern than imagined, controllable only by those with the necessary qualifications, that is, by physicians. The “medicalization” of leprosy was therefore a predominant dimension in the professionalization of Colombian medicine. Its leaders sought to forge a “national medicine,” focused on local illnesses – and from then on Colombia was viewed as one of the world's major settings for leprosy.

Although associated with one particular disease, thereafter considered a great threat to urban populations, Brazil's mobilization against leprosy reflected a deeper movement aimed at redirecting the country's sanitation agenda towards so-called rural endemic diseases. Between 1917 and 1920, new legal and institutional policy bases were laid down (see Hochman, 1998). But at the top of Brazil's public health agenda, also dominating the social and professional dynamics of the medical field, were hookworm, Chagas’ disease, malaria, and yellow fever.

Leprosy, tuberculosis, and syphilis entered the arena of public health policies, at the same time remaining causes embraced by philanthropy and organizations of civil society, especially the former, in the name of which large-scale mobilizations would take place in a number of states in Brazil beginning around 1910.

When Oswaldo Cruz passed away on February 11, 1917, the institute christened in his honor was the center of gravity for a combative group of physicians who were calling for the modernization of Brazil's sanitation services. The key leaders were Carlos Chagas, Oswaldo Cruz's successor as head of Manguinhos (from 1918 until his death in 1934), and the indefatigable Belisário Pena, author of vehement articles and of Saneamento do Brasil, a book that was to mark an era in Brazilian public health (Lima and Britto, 1996; Lima, 1999; Britto, 1995).

The Liga Pró-Saneamento (Pro-Sanitation League), inaugurated at the headquarters of Brazil's National Agricultural Society on February 11, 1918 (first anniversary of Oswaldo Cruz's death), rallied a large number of physicians and intellectuals around its banners: eradication of the endemic diseases that hampered the nations development and that demanded a centralized, ‘scientific’ sanitation policy capable of overcoming the roadblocks created by state autonomy and able to safeguard health activities from the patronage politics of local potentates.

The oligarchic bloc in power gave in to some of these demands. On May 1, 1918, President Wenceslau Brás signed into law a decree that created the Rural Prophylaxis Service, and granted its head, Belisário Pena, one thousand contos to establish more health posts in the Federal District.

The arrival of the Spanish flu in Brazil late that year aggravated the already troublesome effects of the disagreements between oligarchies common during times of presidential transfer of power. The winning candidate, Rodrigues Alves, fell victim to the flu before taking office. Epitácio Pessoa was then elected. He was from Paraíba, a state lying outside the region of the so-called "café com leite"(coffee with milk) pact, formed by São Paulo and Minas Gerais. This favored calls for greater power to the national public health sector, to the detriment of the states’ autonomy. On November 22, 1919, Epitácio Pessoa sent the federal legislature a message proposing the reform of health services: “Whether a new ministry is created or the current organization is maintained, what is indispensable is to expand the sphere of our sanitary defense” (cited in Hochman, 1998, p.23). In January 1920, the National Public Health Department was created, still under the auspices of the government's most political ministry, the Ministry of Justice and the Interior. Chagas's appointment as director (a post he held until 1926) reestablished Instituto Oswaldo Cruz's umbilical link with a more autonomous and better-equipped public health service.

Belisário Pena making a speech at Liga Pró-Saneamento do Brasil

(DAD/COC/Fiocruz).

Created together with the Rural Prophylaxis Service, on May 1, 1918, the Official Medications Service fortified Manguinhos’ industrial side. The main object of this service (also set up at São Paulo's Instituto Butantã) was to prepare and distribute quinine. In addition to developing this malaria-prevention medicine and also tartar emetic, used in treating leishmaniasis, Instituto Oswaldo Cruz's applied chemistry division developed other “official medications": in 1921, sorosol, for syphilis, and in 1924, sodium salts in gelatin capsules and esters made from chaulmoogra oil to treat leprosy. Analysis of vegetable oils from Brazilian botanical species led to the preparation of the oil of the charpotrochis plant (Carpotroche brasiliensis), used by Souza Araújo to treat the same disease.

Regarding this endemic disease, viewed perhaps as the greatest health threat to urban centers, Oswaldo Cruz's July 3, 1913 interview to O Imparcial ignited a movement that came to encompass all of Rio's medical societies. The Bahian physicians Belmiro Valverde and Juliano Moreira proposed to the Associação Médico-Cirúrgico do Rio de Janeiro [Rio de Janeiro Medical-Surgical Association] that a Comissão de Profilaxia da Lepra [Leprosy Prophylaxis Commission] be organized. The Rio association nominated Paulo da Silva Araújo and Henrique de Beaurepaire Rohan Aragão to be part of it as well. Academia Nacional de Medicina [National Academy of Medicine] nominated Emilio Gomes, Alfredo Porto, and Henrique Autran. Other members of the commission included Eduardo Rabello, Werneck Machado, and Guedes de Mello, from the Society for Medicine and Surgery; Sampaio Vianna, Silva Araújo Filho and Oscar D'Utra e Silva, from Sociedade Médica dos Hospitais [Medical Society of Hospitals]; and Fernando Terra, Juliano Moreira, and Adolpho Lutz, from Sociedade Brasileira de Dermatologia [Brazilian Society of Dermatology]. Carlos Pinto Seidl, director-general of Public Health, was chosen to head the commission, and he appointed moderators for the subgroups that were to analyze specific aspects of leprosy in Brazil.

The commission's work ran from 1915 through 1919 and yielded a number of reports and public statements, compiled and transcribed in whole or part by Souza Araújo (1956). These included Silva Araújo and Valverde's observations on leprosy and marriage; Werneck Machado and Emilio Gomes’ on leprosy and occupation; and Adolpho Lutz and Henrique Aragão's on leprosy and immigration. Eduardo Rabello and Silva Araújo Filho studied the disease's relation to domicile, and Juliano Moreira and Fernando Terra, its relation to isolation.

A survey of epidemiological data was to provide the basis for the prevention offensive. Despite the dramatic adjectives used to describe the spread of this disease, Oswaldo Cruz himself admitted in his 1913 interview that Brazil's public health officials did not really know how many sufferers there were in the federal capital or the rest of the country.

The debates leading up to the formulation of government guidelines in the fight against leprosy, starting in the 1920s, rekindled the old controversy about heredity versus contagion. The inarguable hegemony of the latter proponents was challenged by Adolpho Lutz, leader of a third line of thought which seems to have enjoyed greater visibility in Brazil than elsewhere. Although moderator of one specific topic, Lutz’ prestige as a scientist and leprologist assured him the privilege of espousing his views at a conference given on November 5, 1915. His lecture was attended by many physicians and medical students, and also by the Minister of Justice and the Interior, Dr. Carlos Maximiliano, honorary chairman of Comissão de Profilaxia da Lepra.

The Jornal do Commercio (Nov. 7, 1915) transcribed the conference in its entirety (partially transcribed in Souza Araújo, 1956, p.124-7) and summed up the orator's position in these words:

through exclusion of other blood-sucking insects as possible

carriers of leprosy, the mosquito should be identified as the sole

cause of transmission of this illness (whether Culex fatigans or

Stegomyia fasciata), when it sucks in, and only in this case, the

blood of lepers during febrile stages of bacillemia.

Aware of his authority, Adolpho Lutz attributed the endless disputes on the transmission of leprosy to “preconceived ideas” and to a “flawed knowledge of the literature and of the disease itself, which is the rule and not the exception among the medical classes in all countries.” Brazilian physicians were not familiar with the book that Lutz considered a “veritable bible,” the Handbuch der Historisch-Geographischen Pathologie, written by August Hirsch (181794), with

“German patience.” 34 They were also unfamiliar with studies released during the previous thirty-five years (since he had begun studying leprosy) in the Monatshefte für Praktische Dermatologie and in similar periodicals on skin diseases. These readings would have allowed them to observe leprosy with their “own eyes” – a remark that carries between its lines a criticism of Brazilian physicians’ dependence on Francophone authors.

Lutz believed the dichotomy between heritability and contagion to be a false one. Leprosy was indeed more common in certain families but this did not mean it was hereditary “because if that were the case, descendants could not fall ill before their ancestors, as is extremely common.” The theory did not explain how multiple cases occurred in families where older generations had not acquired the disease, either because they had emigrated from unaffected regions or because leprosy did not yet exist in the place where their children and grandchildren would come to fall ill.

In Lutz’ opinion, the notion that leprosy was contagious had gained ground in Europe during a time when the disease was common and tending to spread. When it had become rare, with a prevalence only of imported cases, the theory of heritability became the most plausible way to account for the victims that were to be found in but a few families.

But it is only under these circumstances that someone could

suggest that the illness endured solely by heritability. In other

countries where the illness is common, and where there is at the

same time much immigration from unaffected countries, this

statement is wholly incomprehensible. I have for certain seen

over one hundred people from unaffected places, already adult,

who caught the illness in Brazil or in another place where it is

endemic, and this also proves that nationality does not indicate

a predisposition, because a great proportion of representatives

of unaffected countries fall ill. (Jorn. Comm., Nov. 7, 1915)

But advocates of the theory of heritability were not Adolpho Lutz’ greatest opponents; rather, it was the proponents of the theory of contagion, understood here as direct transmission of the disease from one person to another. The latter invariably pinned their certainties on a historic argument: the longevity of the disease in Europe and its ebbing or virtual disappearance thanks to the isolation of sufferers in leprosariums. For Lutz, it was a mistake to assume that all of the ill had been isolated. Many cases must have gone unnoticed, given the characteristics of the disease – its slow evolution, sores that were hard to identify with precision – or because of family efforts to hide the ill.

Lutz did not question whether leprosy could be communicable under certain conditions, which included, necessarily, the pre-existence of other cases, but this did not prove direct contagion. He pointed out several anomalies in the theory, many of which had already been raised by those defending the theory of heritability. Individuals fell ill without having had contact with sufferers. The incubation period was sometimes short, other times lengthy. Europeans returned to their homes with leprosy picked up abroad and were interned in public hospitals, yet they did not produce foci of the disease. Paris, Vienna, and other Old World capitals remained unaffected.

To counter his adversaries, Lutz cited the repeated unsuccessful attempts to transmit Hansen's bacillus to people and to animals and also the problems in obtaining pure cultures of the microorganism.

In conjunction with the infection's erratic character, such anomalies made leprosy very different from contagious diseases like tuberculosis and syphilis, and impugned the analogy with other infectious processes, like yellow fever first and foremost and also exanthemic typhus, malaria, and ancylostomiasis, where the appearance of one case depended upon the earlier appearance of another although the disease could be caught without any direct contact between victims. Studies of the bubonic plague that linked it to the fleas carried by rats had negated the supposition that diseases caused by bacteria could have nothing to do with transmission by blood-sucking species.

The epidemiological characteristics of leprosy, however, made it necessary to exclude such ubiquitous species as fleas and bedbugs, mites, and other insects common in big cities. “Thus we are left with

haematophagous Diptera,” Lutz concluded. 35

His experience in Hawaii and his knowledge of the entomological literature equipped him to close the circle on two groups: Culex and, to a lesser degree, Stegomyia.

At the November 1915 conference, Lutz explained that the first Europeans to set foot on Hawaiian soil were some Spaniards who had been shipwrecked there in 1749. The seamen who rediscovered the archipelago in 1778 brought syphilis and gonorrhea to the native population. The first cases of leprosy appeared only after 1840, at first only in very small numbers, and Lutz supposed the endemic disease had originated from a single case. It spread so much that by 1889 nearly 5% of the native population had been struck and 2.5% had already been isolated. A much smaller proportion of foreigners

had fallen sick, that is, about five out of every thousand. 36

Mosquitoes: Culexpipiens (1); Aedes nemorosus (2); Stegomyia

fasciata (3) and Anopheles maculipennis (4). Séguy (1938, plate X).

In the early 1820s, Lutz stated, there were as yet no mosquitoes in Hawaii. He believed that Culex fatigans had been introduced in 1828, “or earlier, by a ship that ran aground on the beach.” He believed Stegomyia fasciata had arrived later. At the time Lutz was on the islands, only those two species existed, and they had become “extremely abundant,” partly owing to extensive aquatic plantings of taro and rice. Lutz suspected that the main carriers of leprosy were the Culex, that is, both fatigans that existed in Hawaii as well as similar species found in cold-climate countries. The role of Stegomyia was “more uncertain.” Phlebotomous flies (sandflies), maruins and mosquitos-pólvora, and mutuca flies – none of which existed in Hawaii – must play a secondary role in the transmission of leprosy.

"Applauded at length,” Adolpho Lutz’ conference fueled heated debates during at least two more sessions of Comissão de Profilaxia da Lepra, and stories of these circulated in the press. Not a single physician came to the defense of the idea of hereditary transmission. However, reinterpreted in the light of eugenics as “predisposition,” this idea was subsumed into the contagionist platform, as an active factor in specific cases of transmission. Stalwart supporters of Lutz’ ideas included Henrique Aragão, also from Instituto Oswaldo Cruz, and Emílio Gomes, a long-time bacteriologist in Rio's public health sector. Most members of the committee had no difficulty in reconciling certain proposals of those who believed in culicidian transmission with calls for segregation as a preventive measure, based on the idea that leprosy was highly contagious. Although no one failed to sing the praises of Lutz’ wisdom, he also had firm adversaries: Fernando Terra and especially Belmiro Valverde. The former was director of Lazarus Hospital, dermatology professor at the Faculdade de Medicina do Rio de Janeiro [Rio de Janeiro Faculty of Medicine], and president of Sociedade Brasileira de Dermatologia.

Belmiro de Lima Valverde was born in 1884, Alagoinhas, Bahia, and died in the city of Rio de Janeiro in 1963. He became well known as a result of his activism during the 1930s in an organization called Ação Integralista Brasileira. His name began to appear in political news before the beginning of Getúlio Vargas dictatorship, when he fought against Arthur Bernardes government, which resulted in him going into exile in Europe for a time. Graduated in 1906 from Faculdade de Medicina da Bahia [Bahia Faculty of Medicine], Valverde did clinical work in the Upper Amazon region and in 1912 moved to Itápolis, in the interior of the state of São Paulo, where his father-in-law owned a pharmacy, Farmácia Italiana.

In 1913, during a session that took place on June 30, Academia Nacional de Medicina named “Prophylaxis and treatment of leprosy” as one of the issues for a research competition during the coming year. Valverde entered a paper with this title and received honorable mention on June 4, 1914.

In February of the following year, he moved to Rio. For many years he worked as the head of the Urology Department of Policlínica do Rio de Janeiro. In 1916, as part of the requirements for becoming a docent in the area of hygiene at Faculdade de Medicina do Rio de Janeiro, he defended a thesis on leprosy prevention (published by

Casa Mayença Cruzeiro). 37

On December 3, a debate that took place among the Committee for Leprosy Prevention became heated when Lutz presented an addendum to his paper from the previous meeting, and Belmiro

Valverde gave a talk on leprosy transmission. 38

Contagionists, with the Bahian physician as principal spokesman, hurled against Lutz the plentiful case histories used earlier against hereditarians by Hildebrand, Kalindero, Taché, and others. They had no hesitations about retelling stories set in far-off places, veritable myths like the tale of the European lad who was playing with a small leper in Borneo and, when he saw him prick his anaesthetized skin with a knife, without feeling anything, mimicked the gesture and fell ill. Or the story of the leprous mother, with lesions on her breast, who had transmitted the disease to her son (on his face) while nursing him. Or the story of the porter who had caught leprosy when he injured his shoulder blade while carrying a leper's cadaver. The renowned bacteriologist Victor Babes, one of the experts whose name was invoked by Valverde, attributed the paucity of cases among doctors and nurses, unquestionable even though less blatant than in the case of other diseases, to the measures they took to avoid contagion.

The authors cited by Lutz’ adversaries laid heavy stress on cases transmitted arm to arm, by smallpox vaccination. This was in fact the hypothesis underlying Arning's experiment with the prisoner Keanu. In the opinion of Scheube, a German physician praised by Lutz earlier in these pages, the small-pox vaccine had played a considerable role in spreading leprosy on the Hawaiian archipelago. According to Babes, it did not attack the inhabitants of the British Indies who refused the vaccine.

A third set of evidence had to do with transmission by fomites, especially infected clothing. Valverde told of cases he had observed himself in Amazonas, as well as those by Ross in India, and also by Manson, Babes, Scheube, Hansen, Lorand and Looft, which made it evident that washerwomen were especially susceptible to leprosy.

All these case histories, which Lutz called “of little value,” brought into the open disagreements about diagnostics and, above all, about the role of lesions in spreading the disease. For contagionists, the prime way in which infectious bacilli spread was via secretions from ulcers and nasal mucous, with the nose being the site of the first leprous lesions – and this gave new life to terrifying old ideas about contagion via the air.

For Lutz, most bacilli eliminated through the mucous membranes and ulcerated skin lost their strength once in contact with the environment. “If they were all alive and capable of direct infection, the causes of contagion would be most numerous, which is not the case. They should also be observed all over.” Calling into question his adversaries’ clinical experience, he stated that leprosy generally began:

with a hyperemic spot, more or less infiltrated … I have seen a

regular number of such cases, which are completely unknown to

most doctors … on the back of the foot or the hand or on the

face, usually on the forehead, which is a very common place. In

such cases, the nasal mucous is usually not affected yet, nor is

anything else in the mucous glands affected, which would be the

case if the illness spread like syphilis. On the other hand, these

places match entirely with what would be expected in the case

of transmission by mosquitoes, something that has always

struck me, right from the beginning of my studies on the topic.

(Jorn. Comm., Dec. 6, 1915)

According to Lutz’ principal champion in this controversy, Henrique Aragão (cited in Souza Araújo, 1956, p.137-41), it had been shown through some one hundred experimental inoculations that the germs in the nodules, ulcerations, and other spots on the body had no ability to infect. On the other hand, a number of authors, not necessarily identified with transmission by insects, had recognized that bouts of fever somehow played a role in spreading the disease. The microorganisms that appeared in the sick person's blood during these periods had been proven to be virulent. Thus, haematophagous insects could readily become infected during such bouts, when bacillemia was easily demonstrable through Beurmann and Gougerot's process. The sufferer was thus in a position akin to a yellow-fever sufferer on the days when he could infect the Stegomyia fasciata, or akin to a victim of the plague, during the septicemic

stage, when the flea could ingest Yersin's bacillus.39

Contagionists rightfully denounced the lack of experimental data to prove the role of the mosquito as a carrier of Hansen's bacillus, a criticism that neither Lutz nor Aragão could refute.

In Aragão's opinion, it was a “widely demonstrated” fact that bacilli could be found in the digestive tubes of haematophagous insects that had bitten lepers. Cardoso Fontes, another researcher at Manguinhos, and Emilio Gomes had found acid-fast bacilli quite like leprosy bacilli in the digestive tubes of mosquitoes caught in Lazarus Hospital rooms (cited in Souza Araújo, p.138). But Adolpho Lutz admitted that this was unusual and that multiplication of these microorganisms within the mosquitoes was not yet a proven fact. Lutz and Aragão blamed the failure of many researchers on their attempts to infect mosquitoes by making them prick leprous nodules and patients when they were not febrile.

"I have, in earlier days, had occasion to verify,” Lutz stated

that generally when mosquitoes bite leprous tubercles, they do

not ingest bacilli but they cannot fail to do so when they bite

febrile individuals, with bacilli in the blood. Usable cases are

quite rare, and experiments with Culex fatigans, which only bites

in freedom, are difficult. Only a small proportion of mosquitoes

are probably infected and of these only a small fraction,

perhaps, ever transmits the bacilli. If this were not the case,

infection would be much more common, and demonstrating it,

easier. (Jorn. Comm., Nov. 7, 1915).

The argumentation presented by Lutz and Aragão – like that of Rochard, fifteen years earlier – was founded above all on epidemiological aspects of leprosy, and they in fact transformed anomalies observed in the laboratory into facts consonant with the spreading of the disease:

transmission via the bite of an infected mosquito cannot be

common. Yet this is precisely one of the necessary conditions,

because if this were not the case, we would have serious

epidemics … It would thus be necessary to examine thousands

of mosquitoes to find the one with the power to infect. (Jorn.

Comm., Dec. 6, 1915, cited in Souza Araújo, 1956, p.130)

To judge from contagionists’ papers, few investigators had obtained experimental evidence contradicting transmission by mosquitoes: their results either were not conclusive or did not exclude the role of other blood-suckers. Valverde made mention of a Danish commission comprising Ehlers, With, Verdier, and Bourret that had studied the transmission of leprosy in the Antilles and that had concluded that Hansen's bacilli were found only rarely in the mosquito's digestive tube. Valverde also cited research by John Lindsay, conducted on the border between Brazil and Paraguay, where leprosy was supposedly more infectious than pulmonary tuberculosis, something the English physician attributed to unhealthy homes. Lindsay had found a large number of bedbugs in beds and on walls there, and he presumed they played just as important a role in transmitting leprosy as crowded, stuffy, dark housing.

Although an unwavering contagionist, Valverde allowed that insects could be involved, particularly flies, which were proven carriers of the tubercle bacillus, quite similar to Hansen's. He even cited experiments by Marchoux, who had infected rats by exposing them to flies that had fed on the soft mass of leprous tubercles.

Adolpho Lutz, who had at first discarded the possibility of a role by ubiquitous insects, altered his position at the second conference: “There is no objection to including other haematophagous Diptera among possible carriers of leprosy, but there is reason to suspect

mosquitoes.” 40

As we have seen, Culex fatigans and pipiens were the principal mosquitoes inculpated by Lutz, but Stegomyia and other domestic species were not excluded. “As to Simuliidae, Phlebotomous flies, mosquitos-pólvora, it can only be said that they cannot be the only carriers” (ibid.). During the debates, Lutz acknowledged that Simuliidae could account for the occurrence of leprosy in places where there were supposedly no Culicidae, like the Alps, Norway, and Ireland – often the settings of contagionist case histories – but he warned that these blood-suckers, “very common in mountainous regions but unknown in most large cities … can only be of local

import.” 41

The geographic distribution of mosquitoes was the hottest topic of this controversy with contagionists. Lutz and his allies argued that the “capricious” way in which leprosy spread and the absence of epidemics or endemicity in regions visited by victims made the involvement of mosquitoes undeniable. For contagionists, an analogous rhetorical role was played by the argument that the mosquitoes indicated by Adolpho Lutz did not exist in regions where leprosy was endemic.

In this area, Lutz was at an advantage. He was an entomologist of renowned skill, highly respected even by the few foreign experts that contagionists relied on. But since medical entomology was still a young discipline (it had been around for barely two decades), the comparative study of the distribution of leprosy and of mosquitoes yielded inexact results. As competent as Lutz may have been, there would never be a perfect overlapping of the two geographic maps. Beyond this, or perhaps because of this, the multiplicity of hypothetical hosts for Hansen's bacillus in different regions of the globe was another discomfiting factor in Lutz’ theory.

To uphold his theory, Adolpho Lutz, unwavering defender of the hard and fast facts obtained in a laboratory, the man who peppered his speech with “precisely,” had no choice but to use authoritative arguments in order to decide the dispute in his favor.

Valverde (cited in Souza Araújo, 1956, p.132-4) admitted he was wholly unfamiliar with medical entomology and “leafed through the masters” to see if they supported Lutz’ theory. He consulted Giles and especially Frederick Vincent Theobald's monograph on Culicidea, or mosquitoes, and verified that there were no Culex fatigans in Europe but only certain Culex from cold countries and Stegomyia fasciata.

Regarding North Africa, Valverde found only the description of Culex pipiens and maculiventris in Algeria and Culex pusillus in Egypt. “Not a single word about Stegomyia fasciata! So how then does one explain the transmission of leprosy in these countries? … Is this yet another peculiarity of leprosy … that it is the only disease spread by an enormous variety of mosquitoes?”

It was even harder to fit Asia into Lutz’ theory. In the central part of the continent, “there is not a single variety of Culex, nor of Stegomyia, and Theobald questioned … the existence of Culex cuspiusl" In New Zealand, there were Culex albirostris, pervigilans, aussoralis, and iracundus but no fatigans or Stegomyia fasciata. On Madeira Island, a long-time focus of leprosy, only Culex longiareolatus had been found.

The physician from Bahia pointed to certain facts that contradicted Lutz’ theory in Brazil as well. Amazonas was the state with the greatest infestation of mosquitoes but it was also among the states with a low rate of leprosy, and “in no way was it possible to make comparisons [with] São Paulo and Minas, Brazil's two main foci, where there were infinitely fewer mosquitoes.”

In this arena, the polemic with the contagionists was championed mainly by Aragão, who criticized both Valverde's scant knowledge of the authors he had cited and the fact that he had not turned to other, equally valuable sources:

When Theobald does not cite the existence of a given mosquito

in a certain locale, it does not mean it did not exist there, and

from this one can deduce no more than that they have not yet

been collected in these places or they are cited in other works,

unknown to Theobald at the time he drew up his work …

Moreover, in Theobald himself … one finds references to the

existence of Stegomyia and Culex fatigans in spots where its

presence was denied … as, for instance, in Northern Africa,

Egypt, in various parts of China, etc. Denying that Stegomyia

exists in Africa is absurd, inasmuch as this continent is the

cradle of this species that later became cosmopolitan … What is

also found in Theobald, and should be commented here, is that

this notable, highly skilled specialist in mosquitoes has such

great regard and esteem for Dr. Lutz that in his book he adopted

our countryman's classification in its entirety. (cited in Souza

Araújo, 1956, p.140)42

Advocates of the culicidian theory persistently reiterated analogies with yellow fever, not only comparing the means of transmission but also the styles of thinking and conduct displayed by adversaries of Finlay's and Lutz’ theory. The 1915 debate was at first marked by the same adamancy that had characterized the 1903 confrontation between those who contended that yellow fever was transmitted solely by Stegomyia fasciata and those who were “unconvinced,” acknowledging the inclusion of the mosquito in a vaster network of

pathways involving direct contagion by fomites.43 Although he still stuck firmly to his ideas on the transmission of leprosy, Lutz chose not to enter into rivalry with contagionists within the practical realm of prophylaxis. Beyond the fact that he didn't carry the same weight as Oswaldo Cruz at the beginning of the century, the man was now his adversary – a silent yet highly influential one.

In their report on “Lepra e imigração” (cited in Souza Araújo, 1956, p.151-2), Lutz and Aragão proposed an accommodating approach that stood in contrast with the strict prevention measures in force in New York and other U.S. ports, measures that Brazilian sanitarians wanted to see enforced in the case of immigrants arriving in Brazil. The two scientists from Manguinhos believed there was only a minute danger of importing new cases of leprosy; it would be a bit ‘like taking owls to Athens', since Brazil afforded better conditions for spreading the disease than the countries from which most immigrants came; “any irksome measure would of course compel reprisals, in addition to leaving very unfavorable impressions which it would be better to avoid” (ibid., p.151).

In the case of subsidized immigration, the government was responsible for excluding people with “defective” physical and psychological health backgrounds but without this entailing the adoption of “humiliating measures.” Before granting a free passage, the government could demand that the immigrant produce a certificate issued by a physician or authority from his or her place of origin, or by the physician on board, or even a “formal declaration by the head of household,” but prior to disembarkation, since in normal times the government could not force passengers to submit to a rigorous physical exam.

It would also not be fitting for companies to repatriate cases that

only at the end of the trip are recognized. The leper thus risks

the hazard of becoming a kind of errant Jew, and it would be

well to consider what should be done with the ill under these

circumstances. The simplest would be to allow them to board

certain steamers, where there would be a doctor, but a small

number of passengers, and during the trip they would occupy a

small isolation hospital, protected by a wire screen, and after

their arrival they would be subject to the decisions of the local

sanitation authorities. If some concessions are not made for

such cases, they will always try to hide their illness.

Lutz and Aragão also addressed the question of immigration by land. Brazil's neighboring countries offered no great peril because no country, with the exception of Colombia, was believed to have a greater number of leprosy victims than Brazil. It would be enough for travelers to present a certificate to public health authorities and to customs. The same rule should be applied to those “countrymen who want to move from one place to another, because their number must be many times greater.” This certificate would have “a certain moral effect and make it possible to hold responsible those deliberately making false statements.”

We have already seen that Adolpho Lutz felt it ineffective and cruel to isolate victims of leprosy. During the debates, he asked his adversaries why they didn't call for equally stringent measures for sequestering the victims of tuberculosis or other diseases transmitted by means of the processes erroneously attributed to leprosy (Souza Araújo, 1956, p.130-1). In The Microphysics of Power, Foucault (1984, p.88-9) makes a thought-provoking distinction between the two major organizational models that held sway in Western sanitation through the close of the nineteenth century: one model, inspired by leprosy and extended to embrace madmen and criminals, called for excluding these individuals from common spaces, in the name of purifying them; under the other, applied to the plague and other contagious diseases, individuals should be interned or settled in hospitals or other niches of urban space that could be scrutinized and where the individuals could be effectively watched. The policy that Oswaldo Cruz proposed in 1907 for carriers of the tubercle bacillus – when he felt the campaign against yellow fever had been victorious – was a draconian version of the second model, rejected by the government (see Benchimol, 1990, p.49-50; Nascimento, 1999; Bertolli Filho, 2001).

Although Adolpho Lutz proposed a third organizational model for leprosy, associated with the late-nineteenth-century appearance of intermediary hosts within the web formed by people, things, and microbes, he pragmatically admitted that isolation would hamper the spread of the disease if leprosariums were located well away from other housing, in environments not favorable to mosquitoes.

There is no avoiding the obligation of joining prevention

measures againt mosquitoes with every attempt at isolation,

because individuals’ freedom should not be sacrificed without a

maximum guarantee that this sacrifice will yield practical results

… I leave the dubious satisfaction of combating the new

guideline to that class which endeavors to keep yellow fever

among us, fighting prevention measures against mosquitoes,

and who would like to repeat this opposition in regard to

another, no less important question. (cited in Souza Araújo,

1956, p.130)

Expressing the opinion of most members of the Comissão de Profilaxia da Lepra, Juliano Moreira and Paulo da Silva Araújo proposed that the commission sponsor the experiments needed to confirm Lutz’ affirmations, and that it include protection against mosquitoes among planned prevention measures but not without urgently putting into practice the “universally adopted” ideas of direct contagion, mandatory reporting, disinfection, and isolation or exclusion of the ill (ibid., p.128).

The commission's conclusions, meant to serve as the basis for a

draft law, 44 consisted of eleven items cast in the spirit of the contagionist program approved by the international congresses held in Berlin (1897) and Bergen (1909). The only exception was item IV, which defined the need “to undertake culicidian prophylaxis, that is, a set of efficient measures against mosquitoes able to transmit leprosy, with all due rigor, in cases of individuals confined to their homes or in leper colonies and asylums or isolated in villages and colonies.”

The American Leprosy Conference, which took place in Rio de Janeiro in October, 1922 amid festivities for the hundredth anniversary of Brazil's independence from Portugual, seems to have held to this orientation, but Lutz (1921) no longer found the support he enjoyed in 1915. 35 Still lacking conclusive experimental evidence, he was to come up against a greater number of adversaries, Belmiro Valverde still heading the list. The latter stated:

A number of agents have been inculpated as carriers of leprosy

– mites, bedbugs, fleas, flies, mosquitoes, etc. … Proponents of

direct contagion acknowledge that ectoparasites might

mechanically transport leprosy germs, as occurs with other

diseases and as simple good sense would indicate. However,

those who suppose that leprosy is transmitted by indirect link

are dogmatic . as is the case among us of Dr. Adolpho Lutz,

who, although he has addressed himself to these matters for

forty years, still cannot present the slightest documentation

showing the correctness of his ideas. Even now, in the middle of

the Leprosy Conference, when some paper was to be expected

from Dr. Lutz … in support of his theory, already defeated by

critics, the illustrious sage has limited himself to reaffirming,

without any evidence, without a single fact, without a single new

word, that the mosquito is the carrier of leprosy, although in his

assertions one no longer feels that same primitive enthusiasm

as in 1915, when the great scientist made public, in much detail In order to show that the National Department of Public Health would put into practice the guidelines recommended to other South American nations, Carlos Chagas and the President of Brazil, Epitácio Pessoa, inaugurated the cornerstone of the “Federal Leprosarium” in Jacarepaguá, at that time a rural area belonging to the city of Rio de Janeiro. In the house that would be the offices of Curupaiti Leprosarium, the public health department offered a table of sweets to the conference participants, journalists, and other

and with wide circulation, the ripened fruit of his reasoning.

(Jorn. Comm., Oct. 1922)

 

Lutz is not alone: haematophagous insects as

carriers of leprosy (1920-1950)

These criticisms were founded. Still, Adolpho Lutz stuck firmly to his theory, bolstering it with arguments not much unlike those used in 1915, at the 2nd American Congress of Dermatology and Syphilology held in October 1921 in Montevideo, at the same time that Brazil's newly created National Department of Public Health kicked off its segregationist offensive against leprosy's victims through its Inspetoria de Profilaxia da Leprosia e das Doenças Venéreas.

During the Montevideo conference, there was a proposal to organize a conference, American Conference on Leprosy. “Problems related to the study of leprosy” (1922) brings together the papers presented by Adolpho Lutz in both events. The conference's opening ceremonies, which took place on October 8, in the pavillion of the National Exposition, were presided over by the Minister of Foreign

Relations. 45 From October 9-14, papers were presented at the Academia Nacional de Medicina, with Lutz speaking in the evening session of October 13. He was one of the members of the organizing committee, which was presided over by Carlos Chagas. Valverde was one of three honorary presidents (Souza Araújo, 1956, p.364-72).

Although Lutz’ position was again defended by Emílio Gomes, the conference's final conclusions were entirely shaped by the concern for a public campaign, in Brazil and throughout the Americas, focusing on “the fight against infection … the decisive element in the struggle against leprosy;” the only concession to Lutz’ ideas lay in the recommendation that the technical measures to be taken should reflect “the diverse schools of thought related to the transmission of the disease.”

guests.46

 

Gustavo Capanema, Ministry of Education and Public Health, and

other authorities at the Curupaiti Lepers Settlement foundation stone

ceremony on December 26, 1935 (FGV CPDOC, Gustavo

Capanema Archive, GC photo 080).

The prize awarded by the Academia Nacional de Medicina in 1921 to Belmiro Valverdes monograph on “Prophylaxis and Treatment of Leprosy,” published the same year as Leprosy in Brazil, represented an endorsement by an important part of the capital city's medical elite of the contagionist ideas that Valverde had supported so fervently since 1915.

Within the Academia, leprosy was one of the most frequently-discussed issues between 1921 and 1930, repeating the controversy between Valverde and Lutz’ faithful spokesman, Emílio Gomes. A number of scholars conciliated the contagion theory with the possible transmission by mosquitoes or other blood-sucking insects. The “eclectics” included Parreiras Horta, Henrique Autran, Alfredo

Augusto da Matta 47 and Eduardo Rabello, who in 1925 succeeded Fernando Terra as professor of dermatology at the Faculdade de Medicina do Rio de Janeiro and as president of the Sociedade Brasileira de Dermatologia. But in 1926, another controversy developed within the Academia, overshadowing the debates over Lutz’ theory, when Belisário Penna, another future advocate of integralism, stubbornly advocated an intransigent policy of quarantining carriers of Hansen's disease in leper colonies and leprosariums. Penna criticized the fact that, in all of the national forums where the problem had been debated, restrictions on the isolation of homes had been weakened.

"Leprosy,” Penna stated,

is not a disease of civilized countries, nor of savage ones.

Among the savages there is no leprosy. Leprosy is characteristic

and symbolic of countries in a semi-civilized state. Now, Brazil

would like to be a civilized country and shouts about it every

day, makes noises in the League of Nations. It needs, however,

to demonstrate that it in fact is one … We do not even need to

leave the capital to find lepers everywhere. I saw a leper …

taking a bath at Post 6 in Copacaba, in the middle of everyone,

and everyone was disturbed. I know a leper who sells

newspapers … And that's how it is all over the place. … It is not

possible to continue on this way; it has become necessary to put

up barricades to stem this avalanche that is dominating the

country. (cited in Souza Araújo, 1956, p.417)

As Monteiro (2003, p.95-121) shows, after the revolution of 1930, the faction that advocated compulsory, unconditional quarantining of victims of Hansen's disease assumed control over health policies in this area, not only in São Paulo but also in other Brazilian states.

Working against this tendency, Lutz continued to preach his conviction that the disease was transmitted by mosquitoes and therefore not contagious. In March, 1932, the Bulletin of an influential association created by ladies from the high society of São Paulo in 1926, the Society for Assistance to Lepers and for Fighting Leprosy, published the text of a lecture Lutz had delivered over Rádio Sociedade of Rio de Janeiro. He later returned to defending the position he had put forth in this lecture, in a conference held in Rio in September-October 1933, for the unification and uniformization of the Brazilian campaign against leprosy. The participants of this conference included government authorities and delegated from leagues and associations from all over Brazil. Lutz’ paper was published in the Sunday edition of two important Rio de Janeiro newspapers, Jornal do Commercio and Jornal do Brasil (Oct. 1, 1933).

Three years later, Lutz published an overview (in German, Portuguese, and English) of the literature on leprosy transmission,

reviewed in French and Italian medical journals. 48 Letters of support for his ideas came from around the world, for instance, from Jesus M. Gomes, physician in Guindolim, a town in Goa, and from Dr. Peskcowsky, director of the Krasnodar Experimental Leprosy Colony and Clinic, in the Soviet Union, who was responsible for epidemiological research into the disease in the area just east of the Azov and Black seas. Lutz sent a paper entitled “No control of leprosy without antimosquito campaign” to the International

Congress in Cairo (Mar. 21-28, 1938).49 The disease was also the topic of the scientist's final two papers, dictated to his niece since he was already completely blind. "A transmissão da lepra pelos mosquitos e a sua profilaxia,” th read at the 7 Congress of the Pan American Medical Association in 1938, was published in Memórias do Instituto Oswaldo Cruz in November of the following year, while ‘Regras indispensáveis de prophylaxia anticulicidiana sugeridas ao

Serviço Sanitário do Estado de S. Paulo" 50 remained unpublished.

 

Map published in Souza Araújo (1937), showing anti-leprosy

organizations in Brazil in 1936.

Envelope of a letter addressed to “Instituto Adolpho Krutz” by dr.

Peskchowsky, Director of Experimental and Clinical Leprosarium in

Krasnodar, Soviet Union, received by Adolpho Lutz on 6.22.1937

(BR.MN. Fundo Adolpho Lutz. Caixa 22, pasta 255).

Lutz’ prevention recommendations, especially in his first article (1939), were now much more detailed and aimed primarily at “those who do not acknowledge the mosquito as the only means of transmission of leprosy.” The latter category may have included not only less unbending contagionists as well as physicians and researchers who considered that other vectors might be involved, such as the haematophagous fly Musca sorbens Wiedemann (Lamborn, 1937).

He recommended that there should be at least one person in every leprosarium undertaking constant prevention measures against mosquitoes. Furthermore, larger settlements should keep on staff an entomologist or physician qualified to raise the larvae found in infirmaries and lodgings, determine their species, and describe them in periodical reports to the institution. In regions where leprosy was found, a complete study of the local fauna of haematophagous Diptera and insects was indispensable in orienting anti-culicidian prophylaxis, which was “always useful, dispensing the need for justification.”

Patients’ medical histories should include information on their contact with mosquitoes in the places where they probably caught the infection. Those with fever or whose disease was progressing rapidly should be isolated in screened infirmaries. The patients’ lodgings should also have screens, and an effort should be made to eliminate dark corners, dark painting, and other “hiding places” for mosquitoes. Even though domestic species were the most likely suspects, leprosariums should be built where there were no infestations of marshland or wildland species.

 

Logo of Associação Protetora dos Morféticos used in the cover of

Emilio Ribas book with “answers to questions made by the

Association … with the purpose of obtainning data for the

humanitarian solution of the urgent problem of Saint Lazarus

disease”.

In an article published in November 1939, Lutz also described in unprecedented detail the experiments meant to prove his theory:

Letter from Alice de Toledo Ribas Tibiriçá, President of “Lepers’

Assistance Societies and Defense against Leprosy Federation” to Dr.

Adolpho Lutz inviting him to a conference to unify the criteria for the

campaign against the disease. BR.MN. Fundo Adolpho Lutz. Caixa

22, pasta 255.

The common nocturnal mosquito, Culex quinquefasciatus, must

especially be suspected of transmitting leprosy but it does not

lend itself easily to experiments because it only bites in the dark.

It is best not to use Stegomyia for a variety of reasons. It is

better to use species that bite readily … for example, species

from the genera Mansonia, Taeniorhynchus, and Ianthinosoma.

The easiest to obtain is Culex, today Ochlerotatus scapularis,

plentiful in tree-filled gardens.

The mosquitoes “should be” (or were51) infected with a variety of microorganism species, not just “of the genus Coccothrix (1886), a name that has precedence over Mycobacterium" but also of different “strains” of the tubercle bacillus- especially those associated with bovine or avian tuberculosis – and Stefansky's bacillus, which in rats

produced an “illness very similar to leprosy.” 52

Lutz recommended using cultures of these microorganisms, mixed with fresh defibrinated blood or diluted honey, to infect mosquitoes. The insects could also suck the germs directly from people or animals carrying the disease, but this method did not yield good results. In this case it would be better to use people or animals displaying recent and rapidly progressing pathological processes, with fever and the subsequent circulation of bacilli in their blood.

Many years ago I performed some experiments, applying

mosquitoes to leprous tubercles, which are always full of acid-

fast bacilli and usually form masses in zooglea. In my

experiments, acid-fast bacilli were not found in mosquitoes.

However, other observers seem to have been more successful.

Today I attach little importance to these negative results

because I believe that while acid-fast forms are convenient for

diagnostics, they represent later, not very active stages.53

For Lutz, the first question to resolve after infection of the mosquito was how long the bacilli remained alive in its body. Infected specimens should be kept alive for some time, “preferably completely in the dark,” to give the germ time to incubate. If it did not disappear from the internal organs quickly, these mosquitoes could be used in the inoculation of animals and in cultures attempted in succession. In animals, the salivary glands and the body should be inoculated in an effort to produce a lesion: guinea pigs and rabbits were susceptible to various forms of tuberculosis; rats, to Stefansky's bacillus; and monkeys, to human leprosy.

Experiment with bites, which may be repeated, or by means of

inoculations using mosquitoes ground up in a little liquid. They

can be washed in alcohol and lightly singed to disinfect the

external parts. This same process can also be used to inoculate

appropriate nutritive media. It would be good to repeat these

experiments as often as possible in hopes of obtaining one or

two positive results. It will suffice to obtain positive results with

only one of these germs in order to demonstrate the possibility

of mosquito transmission of Coccothrix species.

Adolpho Lutz passed away on October 6, 1940, a few weeks before his 85 th birthday. His research program was carried on by Heraclides Cesar de Souza Araújo, head of the Leprology Laboratory at Instituto Oswaldo Cruz, and by Gustavo M. de Oliveira Castro, an entomologist at the same institute who had already published a number of papers in collaboration with Lutz. In a previous note published in 1945, with José Mariano, Oliveira Castro presented the results of the experiments performed with dozens of human volunteers to determine whether the proboscises of contaminated mosquitoes could infect the tissue they bit. The volunteers were all “negative” for leprosy, or “abacilliferous, with skin that is for the most part healthy and resistant to re-infections.” Based on the results of experiments with Culidae (mosquitoes), Ixodidae (ticks), Pediculidae (lice), Cimicidae (bedbugs), Pulicidea (fleas), and Triatominae (sub-family of Hemiptera, which includes the carrier of Chagas’ disease) conducted by these and by other researchers during the 1940s, Souza Araújo (1953, 1952) reached the conclusion that any haematophagous insect could transmit leprosy under certain conditions, and it would therefore be advisable for public health authorities to extend the fumigation program aimed at the malaria