Adolpho Lutz and controversies over leprosy

Adolpho Lutz and controversies over

leprosy

 

Jaime Benchimol; Magali Romero Sá

One of the most interesting chapters of Adolpho Lutz’ scientific work

is that dealing with leprosy, 1 a topic he investigated until the end of his life. By then one of Brazil's leading experts in this field, he went to his death convinced the disease was transmitted by mosquitoes. He had turned his interest to the illness during an era marked by major theoretical and practical turbulence over conflicting views on its etiology, transmission, and prophylaxis.

Among scholars of leprosy from both past and present there is a consensus that two Norwegian physicians, Daniel Cornelius Danielssen (1815-1894) and Carl Wilhelm Boeck (1808-1875), established the diseases defining characteristics on scientific bases in 1847. While Danielssen and Boeck did not discard a possible association with dissolute, unsanitary living conditions or an unhealthy environment – as upheld under the neo-Hippocratic paradigm in the case of many other diseases – they maintained that

leprosy was essentially a hereditary disease. 2 As this belief spread, the fear long instilled by the disease diminished, at least among doctors. Under the new assumption that leprosy was not contagious, previous concern over the need for strict isolation or segregation of its sufferers waned. Extending to the bubonic plague, cholera, yellow fever, and other diseases (Ackerknecht, 1948), this anticontagionist vogue was of short duration, and by the late 1870s it had already begun to ebb.

Leprosy was one of the first infectious diseases to be restructured in the light of microbiology, once again by a Norwegian, Gerhard Armauer Hansen (1841-1912), a physician at Lazarus Hospital in Bergen. Hansen named the small rod-shaped bodies that he observed in the cells of cutaneous tubercles "Bacillus leprae,” since their constant presence in examined skin lesions made him suspect they were the specific cause of the disease. Hansen reported his discovery to the Cristiania Medical Society in 1874, and his finding

was soon after confirmed by Edwin Klebs.3 Using material provided by Hansen, Albert Neisser offered a more consistent description of the bacillus in 1879, thanks to pioneer use of staining techniques that gained prime importance in the observation of this and other microorganisms.

 

Daniel Cornelius Danielssen (1815-1894).

As Obregón (1996, p.173-4) has shown, a clash then arose between two opposing sets of conceptions and ‘evidence’ on how leprosy is transmitted, giving birth to divergent strategies for dealing with the disease. The physicians and lay public involved in this controversy took as “ideal-types” the prevention models adopted in two different regions of the world: the “democratic” model, which got its start in Norway at a time when nationalism was on the rise and doctors were greatly interested in the study of territory, population, and epidemiological profiles; and the segregationist, colonialist model enforced in Hawaii by metropolitan administrators who were repulsed by leprosy and nourished a strong prejudice against native or Asian-blooded sufferers.

 

Gerhard Armauer Hansen (1841-1912).

In different countries or colonies, physicians then recently converted to bacteriology were unsuccessful in their attempts to replicate Hansen's bacillusin vitro and in anima vili, so as to satisfy Koch's prerequisites as postulated in the early 1880s: isolation of the microorganism in pure cultures, experimental inoculation of animals, and production of a disease whose symptoms and lesions were, if not identical, at least equivalent to those of the disease as “typical” in man. These problems made it hard to unequivocally prove a connection between the bacillus and leprosy. Nevertheless, the 1 st International Leprosy Congress, held in Berlin in October 1897, acclaimed this specific etiology, along with the thesis that the only way to keep the disease from spreading was mandatory reporting, supervision, and quarantine of its victims. Based mainly on epidemiological observations presented by doctors working in India, the Guyanas, and other colonial territories, the congress approved resolutions that affirmed the sovereignty of contagion over heritability in transmitting the disease, although the latter theory still had numerous proponents, foremost among these Rudolf Virchow, Hans von Hebra, and the Turkish physician Demetrius Zambaco Pacha (Obregón, 2000, p.271; 1996, p.165-6).

 

Carl Wilhelm Boeck (1808-1875).

The ‘construction’ of leprosy as a microbial disease spurred a worldwide movement to create leprosariums where the afflicted would be segregated. Because of the problems in obtaining a

vaccine,4 the disease was considered chronic and incurable, reinforcing the belief that its carriers must inevitably be segregated.

Held in Bergen, Norway, in 1909, the 2nd International Congress, chaired by Hansen, ratified the decisions made earlier in Berlin. In 1922, in Rio de Janeiro, with Carlos Chagas acting as chair, the 1st American Leprosy Congress remained firm in this tendency while nevertheless making room for a third stream of thought, led in Brazil by Adolpho Lutz: that leprosy was transmitted by mosquitoes, just as yellow fever and malaria were. Lutz was one of the organizers of the event, which was attended by representatives from thirteen countries. The congress's conclusions stressed the need to foster scientific investigations of the disease and to create specific professorships at medical schools.

 

Leprosy studies from 1860-1890

At the time that Adolpho Lutz took up his interest in leprosy, one of Brazil's main treatment and research centers was Lazarus Hospital in Rio de Janeiro (Smith, 2003), under the auspices of the Irmandade do Santíssimo Sacramento da Candelária. From reports written by Dr. João Pereira Lopes, physician at the hospital during the period leading up to Lutz’ involvement in the field, we can evaluate the state of the art which Lutz was about to help change.

In his report on the year of 1869, 5 Lopes discussed several hypotheses concerning the etiology of leprosy; while emphasizing syphilitic, nutritional, and climatic origins, he also did not abandon the eclectic or multicausal tendency prevalent among doctors working with this disease, often called ‘Greek’ elephantiasis (Elephantiasis Graecorum) or morphea in Brazil at that time. One vital aspect of the problem was the idiosyncrasies displayed by certain individuals – that is, the particular state of the organism (imprecisely defined) that determined a tendency to develop the disease. Some believed that certain professions, such as blacksmithing or mining, contributed to a predisposition. Another assumption was that climate had a notable influence on the appearance of leprosy. Many stressed the role of food, while not necessarily failing to endorse the widely-held belief that this disease was similar in nature to syphilis, caused by a “virus” (understood to mean ‘poison') that acted on the blood, disorganizing the ‘crasis’ of this humor. A related theory posited that syphilis was nothing more than a degenerate form of leprosy.

Lopes was an anticontagionist, and this seems to have been the predominant position among doctors of his day, shared as well by many members of the lay public. At least this is what his 1869 report suggests: Lazarus Hospital was “constantly visited by people from all classes and ranks, both Brazilian and foreign, most especially by physicians … drawn by curiosity or the news of a cure, announced in daily papers.” Many families were not afraid to pay a visit to the beautiful building constructed in São Cristovão, near the imperial family's residence, or to attend religious ceremonies there. “Long gone are the times,” wrote Lopes,

when Christian charity fled in terror … thanks to the progress of

science, which has so clearly shown us that the idea of

contagion, once so prevalent … has wholly disappeared in view

of the numerous observations of noteworthy practitioners in

Africa, North America, Norway, Brazil, and, lastly, France, as

made by Alibert and Biett. (cited in Souza Araújo, 1946, p.469)

Despite this optimism, which warranted bringing the disease's victims somewhat back into the society from which they had for so long been removed, the treatment of leprosy was characterized by the “obscurity of darkness, [by] tremendous chaos” (ibid., p.463-4). Lazarus Hospital had long been – and to judge from reports by Lopes’ successors, would still long be – a stage for endless experimentation. What is curious is that both lay people and experts seem to have wielded almost equal influence over the medicines tried out during the 1860s and 1870s, medicines which might equally well include preparations from local apothecaries, chemotherapeutics produced at European laboratories, or substances extracted from either local or foreign flora and fauna.

Hospital dos Lázaros.

Lazarus Hospital had been the setting for a famous experiment with tropical rattlesnake venom (Crotalus horridus) that had killed the patient who served as experimental subject (Ferreira, 1996). Lopes had already tested a variety of plants supplied by physicians or lay people: roots of the mochocho plant; cabeça-de-frade (Melocactus bahiensis); and the milky juices of the Barbados nut (Jatropha curcas), figueira-brava (Ficus sp.), and a type of manioc (Manihot

utilissima). 6 Among the populations of Brazil's sertão region, the “irritating, corrosive” juice of the latter tuber was known to help cure elephantiasis. Another plant extolled by them “as astonishingly efficient” was the yam, eaten or used in bathing.

Four experiments were underway at Lazarus Hospital at the close of 1868. One involved “warm baths with spiderwort (Tradescantia sp) and mamono branco, a kind of papaya (Carica sp.); a cooked mixture of barley, sarsaparilla (japecanga), and whey,” where the tubercles would be rubbed with “large gastropods, which should be kept in grasses or the garden.” The diet consisted of plants like “amaranth (caruru miúdo), chicory, beet, sowthistle, and, lastly, yam (inhame branco); the sick person [could] eat some eggs, drink barley coffee, and even eat some very ripe oranges. Once in a while, the person should take some purgatives of trimeza (Trimezia sp.)” (Lopes, p.34, as cited in Souza Araújo, 1956, p.461).

Since leprosy was likened to syphilis, this led to experimentation with Hydrocotyle asiatica, a product that doctors Paupeau, Boileau, and Hunter supposedly employed most successfully in the treatment of scrofulas as well. It could also be used to treat the chronic rheumatism that afflicted so many of those interned at Lazarus Hospital.

Preparations of arsenic – which “Hindu physicians and those from Bengal, and also English and Anglo-American doctors” touted in the treatment of leprosy and syphilis – yielded almost no positive results. In 1869, Lopes also experimented with bromine and bromine compounds, in combination with baths of “sulphurous hepatic waters” prepared by a pharmacist from Rio de Janeiro for those who suffered from “rheumatism of the joints, paralyses, chronic syphilitic ulcers, and, lastly, scabies, which run rampant in this hospital two to three times a year” (cited in Souza Araújo, 1946, v.1, p.461).

The hiring of Dr. José Jeronymo de Azevedo Lima to head up Lazarus Hospital in 1879 coincided with a reversal at the level both of discourse and of curative and preventive practices. The physician began his first report (Lima, Aug. 5, 1880) by attempting to restore belief in leprosy's contagiousness. Although this idea had held sway in the past, it had become so “outside reason” since the studies of Danielssen and Boeck, von Hebra, Virchow, and others that, for Azevedo Lima, questioning these authors meant “risking an accusation of incompetence” (cited in Souza Araújo, 1946, v.1, p.484).

There were as yet scant authorities whose names could be cited in defense of contagion. Azevedo Lima drew support from Hansen's newest studies but he admitted that these were not “certain and proven.” Contemporaneous etiological theories did a better job of explaining the numerous examples of immunity observed “in relations of the greatest intimacy.”

Studies on the morphology and culture of Bacillus leprae were still incomplete. Its presence in blood had not yet been proven, “but,” Azevedo Lima wrote, “this notwithstanding, the classic doctrine on the illness has still been … deeply shaken, which will undoubtedly prove fruitful for practical deductions and, perhaps, come to place it among the cast of virulent affections” (ibid., p.485).

In the absence of any means for effectively combating the disease, there was no alternative but “a more or less rational empiricism,” and Azevedo Lima experimented with a good number of medicines with different effects and properties. The basis of his treatment was to “boost or maintain organic forces by modifying nutrition, through good-quality food … regular exercise of skin functions, etc.” (cited in Souza Araújo, 1946, v.1, p.485-8). Disinfection of infirmaries became routine, and to the list of medications in use was added phenic acid, a well-known antiseptic employed internally and externally against many other microbes incriminated as disease agents by followers of Pasteur and Koch. As will be discussed later, Azevedo Lima began treating leprosy patients with chaulmoogra oil.

In mid-1886, Azevedo Lima reported to the purveyor of the Irmandade do Santíssimo Sacramento da Candelária on the fruitlessness of experimental attempts to transmit leprosy to humans and animals; he also presented an evaluation of the results obtained with the treatment proposed in 1885 by Paul Gerson Unna, one of

the world's leading authorities on dermatology.7 Basing his approach on the theory that the bacillus is starved for oxygen and that it would be possible to destroy it by means of substances that were similarly oxygenstarved, he had proposed using such reduction agents as pyrogallol, ichthyol, chrysarobin, and resorcin, intus et extra (cited in Souza Araújo, 1946, v.1, p.488).

That same year, Adolpho Lutz released his first paper on the leprosy microbe (1886), which appeared in Monatshefte für Praktische Dermatologie (1887), currently Dermatologische Wochenschrift, a journal edited by Unna, von Hebra and Lassar. This publication was the most important international sounding board for clinical and laboratory experiments related to skin diseases – and, as we will show in the next volume of Adopho Lutz’ Complete Works, dermatologists were at the vanguard of bacteriological, histological, and pathological research on leprosy. Lutz began his studies on this and other dermatological diseases in 1880 when he set up office as a physician in Limeira, a city in the state of São Paulo. By late 1888, he estimated having treated 200 to 250 lepers, “of which 50 would be followed for a long time” (Corrêa, 1992, p.146). He judged that there were then 5,000-10,000 sufferers in Brazil, most of them in São Paulo, which he felt was one of the hardest-hit states.

In March 1885, Lutz left Limeira to work for about a year at the clinic Unna had founded in Hamburg. Under Unna's orientation, Lutz ventured into the terrain of bacteriology, dedicating himself to the morphology of germs related to different dermatological diseases, mainly leprosy.

Microbiologists were struggling to obtain pure cultures of Hansen's bacillus. Lutz tried in Hamburg but failed. Nor was he successful in transplanting it from humans to animals, so that the latter would develop a “typical” disease. Study of the microorganism's structure was facilitated by a staining technique developed by Lutz and Unna. Utilizing this process and the variations on it discovered by Ehrlich, the Brazilian physician was able to differentiate the leprosy agent from other microorganisms, except for the tuberculosis agent, discovered by Koch in 1882. “It is quite an interesting fact,” Lutz wrote, “that two illnesses so similar from an anatomical perspective … are also produced by parasites that barely differ. Neither by shape nor by dye reactions can they be distinguished with certainty” (Lutz, 1887, cited in Souza Araújo, 1946, p.492).

Leprosy tubercle. On the fibroblast, round, epithelial and leprosy

cells background, several clusters of acid-resistant, short and

frequently granular bacilli (Jeanselme, 1934, illustration page 6, ill.

2).

In a paper he published in 1886, Lutz endeavored to show that leprosy “schizomycetes” did not belong to the category of “legitimate bacilli, formed by one or more cylindrical cells,” since their elemental component consisted of a small round cell similar to a coccus, with a membrane that became thick and colloidal. These cells always unfolded in the same direction, in a linear series whose form was rod-like or similar to pearl necklaces, with a gelatinous envelope that increased more and more as they gained new layers. The gelatinous agglomeration could coalesce with neighboring ones to form a single mass. A comparative analysis of this microorganism with that of the tuberculosis microbe prompted Adolpho Lutz to disagree with their classification in the genus Bacillus and to propose calling the Hansen microorganism Coccothrix leprae. His suggestion was not taken up by the scientific community and was supplanted by Karl B. Lehmann and R. O. Neumanns 1896 proposal that the agents of

leprosy and tuberculosis be classified in the genus 8 Mycobacterium.

Problems in cultivating the leprosy microbe and replicating it in animals made contact with those sufferering from the disease indispensable, in order to guarantee an ongoing source of organic matter for the preparations used in microscopic studies on the morphology and biology of the microorganism and of its distribution in affected organs and limbs. Because it involved surface and internal examination of cadavers and the bodies of the ill, this second line of investigation required a hospital, and this is undoubtedly what led Lutz to Rio de Janeiro's Lazarus Hospital in

1887. 9

That same year he moved from Limeira to São Paulo, the state capital, resumed his private practice, and continued to publish numerous articles, mainly in Germany, not only on dermatology but

on helminthology as well. 10 It was then that the Portuguese translation of his work on ancylostomiasis, originally published in Leipzig (1885), came out in O Brazil-Médico, which was a series of articles published in Bahia's Gazeta Médica (1887-1889); soon after, it appeared in book form (1888), making Adolpho Lutz better known among his peers in Brazil. In 1889, in the prestigious Centralblatt für Bakterologie und Parasitenkunde (Jena, Germany), he published his first studies on protozoans, the myxosporidia found in the gall bladder of batrachia, an order of animals to which he would return at the end of his life.

 

Lutz’ trip to Hawaii

The next chapter in the active career of physician-researcher Adolpho Lutz would take place in Hawaii. In a letter to Lutz dated

October 13, 1886. 11 Paul Gerson Unna informed him of the arrival in Hamburg of the pathologist and bacteriologist Edward Arning, who had worked with leprosy victims in Hawaii from November 1883 through July 1886.

The son of a German merchant residing in England, Arning was born in Manchester on June 9, 1855. At the age of twelve he began studying at the Gymnasium Johanneum, in Hamburg, and graduated in medicine from the University of Strassburg in 1879. He began his career in Berlin, as a gynecologist, but soon became interested in dermatology, becoming a member of the Dermatological Institute of Breslau in 1881. Two years later, he was hired by the Board of Health of the kingdom of Hawaii to investigate leprosy there. The Humboldt Institute of the Royal Prussian Academy of Science requested him to collect material for its ethnographic collections. Arning arrived in Honolulu on November 8 and established his laboratory in Kakaako Hospital.

With the goal of proving that leprosy was contagious, for four consecutive weeks starting in September 1884, Arning inoculated Keanu – a native prisoner sentenced to death – with Hansen's bacilli. It took twenty-five months for the prisoner to develop nodular leprosy. Nerves and lymph nodes near the site of injection were also affected. Despite controversies over the possibility of Keanu having family members who suffered from the disease, and doubts that arose because of the length of time that had elapsed between inoculation and the presentation of symptoms, this experiment became paradigmatic in the eyes of contagionists and was always referred to in public discussions on the subject over the next few

decades. 12 In late 1885, Arning reported on his disappointing attempts to cultivate the bacillus in artificial media and to locate it in the air, water, and food. In mid-1887, the Board of Health fired him, due to differences with Walter M. Gibson, Hawaii's Minister of Foreign Relations and president of its Board of Health. The bacteriologist then returned to Hamburg, where he resumed his dermatology practice, also teaching a course on the subject at the university there.

As Obregón (2002, p.143-7) has shown, other researchers were to attempt to study leprosy in Hawaii, but their relations with the local hygiene authorities invariably became strained, as a result of the “many inconveniences, obstacles, and small acts of tyranny” they faced in conducting their work.

In the letter to Lutz mentioned previously, Unna wrote that Consul Weber, who represented German interests in Hawaii, had told Unna that the Hawaiian Board of Health no longer intended to support “fruitless scientific experiments with leprosy” but was quite interested in sponsoring “practical experiments aimed at finding a cure.” Unna believed it possible to arrange for a trip to Hawaii, in order to test his therapeutic method there, and wanted to know if the Brazilian physician would be interested in making this trip.

Located in the middle of the Pacific Ocean, the Hawaiian archipelago includes eight principal islands: Niihau, Kauai, Oahu (where the capital is located), Molokai, Lanai, Kahoolawe, Maui and Hawaii. Hawaii, the largest. In 1778, the navigator James Cook named them the Sandwich Islands. North American Presbyterian missionaries established themselves there in 1820. Seven years later, they were followed by priests of Picpus (Pères et Religieuses des Sacrés-Coeurs), a congregation founded in France in 1800 and dedicated to missionary apostolate. There was a great dispute between the British, French, North Americans, and their religious spearheads over who would control the islands, a dispute which continued after independence in 1842-43. As the result of an 1872 treaty, a native monarchy was made economically dependent on the United States, and in 1887, Pearl Harbor became a North American military base. On July 30, 1889, two months before Adolpho Lutz arrived in Hawaii, an insurrection led by Robert Wilcox attempted to unseat the Reform Party and return lands that had been appropriated by foreigners to Hawaiians and to King Kalakaua. The monarchy was later removed in 1893 by a group that in 1898 would manage to annex the islands to the United States. In 1959, the Hawaiian Islands became that country's 50th state.

Between 1835 and 1848, the first clinical observations on leprosy in Hawaii were published by the physicians Arthur Mouritz and William Hillebrand. The latter attributed the spread of the malady to what the natives called Mai-Paké (Chinese sickness) during an increase in the number of Chinese immigrants after the discovery of gold in

California. 13

In August of 1850, Honolulu was officially designated a city; four months later, King Kamehameha III created a Board of Health, with seven members, all of Anglo-Saxon origin. In a report issued in April, 1863, Hillebrand called on the Board to pay attention to the alarming frequency of new cases of leprosy. Prince Lot, who came to the throne the following year with the title of Kamehameha V, conferred upon the doctors Edward Hoffmann and Hillebrand the task of cataloguing the number of cases and of proposing reasonable preventive measures. In response to the suggestion that the sick be quarantined, the king named a commission to draft a law, which was voted on by the legislature and approved by royal decree on January 3, 1865. This law empowered the Board of Health to quarantine all infectious lepers; and authorized the police and judicial agents, when solicited by the Board, to apprehend any suspected cases and upon examination, should leprosy be confirmed, to quarantine the victims. The law also authorized the Board to found a hospital for treatment of incipient lepers could be treated, who would be freed upon cure or definitively quarantined if found to be incurable or contagious. The law also gave the authorities the power to require the sick to work and also to seize their property in order to cover the expenses of quarantine.

Iolani Palace at Honolulu (Whitney, 1890).

Queen Liliuokalani, in 1893 (Hoefer, 1985, p.50).

Map of Molokai Island. The Leper Settlement used to be on the

slope opposite to where stands today the Molokai General Hospital

(Hoefer, 1985, p.220).

The Board of Health lost little time. In June of 1865, presided over by Godfrey Rhodes, it decided to create two establishments, one in Honolulu, for the confinement of mild cases, and another in Molokai, for the incurable. On November 13, Kalihi Hospital and Detention Station, under the direction of Dr. Hoffman, were opened in Kalihikai, a town neighboring Honolulu. That same year, 141 lepers were admitted to the institution, and on January 6, 1866 the first group of sufferers of the disease disembarked in Molokai, the world's first insular leper colony, which, three decades later, would serve as a model for an international movement favoring reclusion in similar institutions for victims of Hansen's disease (Gussow, 208, 253-4).

Endowed with a mountainous terrain, the island of Molokai was located to the southeast of Oahu and to the northeast of Maui. The part of the island reserved for the leprosarium was a peninsula of about 150,000 m2, which projected out into the sea along the windy northern coast. From the middle of the peninsula arose an extinct volcano, Kauhako. The peninsula was separated from the rest of the island by a steep range of mountains reaching an altitude of 3,600 feet, which formed the spine of the island. “This wall or ‘pali’ is insurmountable, except by means of a trail over the mountain tops, along which lies a ranch belonging to Mr. R. W. Meyer, a German who is the Board of Health agent of the island of Molokai, and interim

superintendent of the leprosarium.” 14 There were three towns: Kalaupapa, Makanalua and Kalawao. From 1870 to 1900, a total of 4,739 patients were confined to Molokai. The largest number of patients – 1,213 – ocurred in 1890, the year that Adolpho Lutz came to Hawaii as a leprologist.

In 1875, the Kalihi hospital was closed because of the high cost of its maintenance, its imperfect isolation and the ineffectiveness of its treatments. The lepers and those suspected of carrying the disease were taken to police facilities and from there transferred to Molokai. It is possible that the resistance that arose in response to the policy's lack of humanity may have led to the opening of another hospital, on December 12, 1881, this time in the Kakaabo district, near what is referred to as Diamond Head, in Honolulu. In 1884, an amendment to the penal code authorized the Sanitation Services to create similar hospitals in every island of the archipelago. Everything suggests that the decentralization of these ‘vestibules’ in Molokai did not occur, and in 1889, about two miles from Honolulu, the Kalihi hospital was rebuilt. It was in this hospital, with patients transferred from Kakaabo, that Lutz would work. (Souza Araújo, 1929, p.80-2, 95-6; Obregón, 2002, p.139-40)

According to Corrêa (1992, p.146), the president of the Board of Health of the Kingdom of Hawaii, Dr. N. B. Emerson, drew up a formal invitation to the Brazilian physician on March 22, 1888. For the rest of the year, the terms of the contract were discussed via correspondence. Lutz requested two thousand dollars in financial assistance for his preparatory studies in Hamburg. A contract with legal guarantees was signed, giving him a monthly salary of 300

dollars and the right to a private clinical practice. 15 The requirement that Lutz reside on Molokai Island was the subject of lengthy epistolary disagreements, since the Brazilian physician intended to set up a private practice in Honolulu and would not agree to large-scale experimentation with Unna's treatment. In April of 1889, the president of the Board still argued that re-opening the Kalihi hospital would cause much dissatisfaction among the patients, those confined to Molokai as well as those who would be sent there. Adolpho Lutz remained inflexible, and the Board finally agreed to his trip, in the hopes that he would change his mind after arriving (Law, n.d., p.3).

In July 1889, he traveled to Europe in order to prepare for his stay in Hawaii with Unna's help. Both men participated in the First World Conference on Dermatology, held in Paris, from August 5-10 of that

year.16 Unna's disciple reached Honolulu on November 15, the same day that, in Brazil, the monarchy was deposed. In January 1890, he was appointed Government Physician for the Study and Treatment of Leprosy. His work was to be carried out at the Kalihi Receiving Station, future site of the U.S. Leprosy Investigation Station, while broader treatment at the settlement was assigned to the resident

physician, under Lutz’ supervision.17

Two months later, he would have the assistance of an English nurse, whom he would marry the following year.

 

The successor of Father Damien, martyr of

Molokai Rose Gertrude was the name that Amy Marie Gertrude Fowler had adopted upon becoming a lay sister of the Third Order of Saint Dominic (Corrêa, 1992, p.148-9). She had been born on July 14, 1869 in a small village near Bath, an ancient city of Roman origin. Amy was 25 years old, and had two sisters and a brother. With a penchant for mysticism, she had converted to Catholicism, an unexpected decision for the daughter of an Anglican pastor highly regarded in the village. Bertha Lutz (Lutziana) attributes the conversion to a “very enlightened” sister who lived in London, gave poetry recitals, and had wanted to be an actress. In those days, however, it was unthinkable for a young girl of family to have such a profession. Her consequent rebelliousness led to her conversion to Catholicism. Amy went to live with her. She wanted to study, to have a profession. Like other young women of her class, she was profoundly influenced by the example of Florence Nightingale (1820-1910), who cared for the wounded during the Crimean War (1855-1856), organizing emergency hospitals and working to improve conditions of hygiene through innovations that would later be adopted by all countries and by the Red Cross. Amy studied nursing in London, then spent a period in Paris, where she lived in a convent, studied microbiology at the Pasteur Institute, and worked in an office belonging to a family friend.

Upon returning to London,

the young English girl who… was in search of her vocation read

in an English newspaper… that the doctor in charge of the leper

hospital in Honolulu had complained to the local legislature that

there were not enough nurses. … In an impetuous act of

admiration, and, emulating Florence Nightingale, [Amy] wrote to

the British Society for Assistance to Lepers, offering to go to

Honolulu, as a volunteer nurse. (Lutz, Lutziana)

In a letter dated June 18, 1889, addressed to the superintendent of the Molokai Leprosarium, she declared,

I am willing to make any sacrifice in order to serve in some way

these poor creatures. It is indeed with the hope of seeing this

long-cherished desire realized that I have placed myself under

Hospital Training in a Hospital and Workhouse in England, and

for the last eighteen months have been studying and attending

Cours in France more especially of the discoveries of Monsieur

Pasteur and of Microbiology … In my Hospital training I have

been through drudgery and mere everyday commonplace work,

as well as dressing and bandaging, and am willing to fulfil the

humblest duties. I would ask you to be so very good as to send

me an early reply, as should you not be able to allow me to

settle in the Island, I should give myself to an Indian

Establishment for Lepers. (cited in Corrêa, 1992, p.149; and

Law, n.d., p.1)

 

Father Damien, in photo taken a few weeks before he died in 1889

(Hoefer, 1985, p.138)

This letter was written two months after the death of Joseph de Veuster, or Father Damien, a member of the Belgian Picpus congregation. Father Damien had come to Oceania in 1863 to care

for lepers and died from the disease in Molokai, on April 15, 1889. 18 His death had enormous international repercussions, in addition to inspiring Amy to follow his example, and Molokai became a sinister legend in the contagionist literature, taken as a symbol of the dangers leprosy posed to society and of the European fear that this incurable, degenerative disease, which flourished in far-off parts of the world among peoples that God had forsaken, would also take over Europe.

The Hawaiian Board of Health offered Amy a position in Kalawao, as assistant to Dr. Swift, and promised her room and board, a horse, and a servant, as well as $20 a month, and $300 for her travel

expenses.19 In a letter dated December 19, 1889, she stated that she would arrive in Honolulu in February of the coming year. Her trip was made under the aegis of the Society for Assistance to Lepers, whose patron was the Prince of Wales, later King Edward VII. Queen Victoria then opened a call for donations to be taken with the altruistic nurse.

After everything had been settled, she left for the United States,

her trunks filled with presents for the lepers, including sheets

embroidered with ‘VR,’ for Victoria Regina … she made a

triumphant trip from New York to San Francisco, on a special

train, with a number of cars that were filled with gifts … pianos,

conserves, and everything imaginable.20

On February 27, 1890, the newspapers in San Francisco, California, reported the arrival of the young heroine and her imminent departure for Hawaii. The diary of Sister Leopoldina Burns, cited by Law (n.d., p.2), gives eloquent testimony to the expectations that Amy's trip had awakened among the people of the islands:

trumpets sounded over the vast Atlantic; an English

gentlewoman who had been drawn by the good works of the

saintly Father Damien… after being applauded and encouraged

by the royal family, and the celerity of the Prince of Wales, now Among the documents compiled by Law on the subject of Amy and her trip is a letter that Brother Joseph Dutton sent to Father Hudson, of Notre Dame University before her arrival. Dutton lamented the fate of the poor English girl who was doubtlessly moved by sincere sentiments but unaware of the reality that awaited her.

found herself riding the crests of the waves on her way to

Hawaii where she intended to carry out her life's work … in

Molokai. The sounds of the trumpets had carried over the

Atlantic and had been heard by the wealthy class in the city of

New York, who welcomed her. Trunks filled with valuable objects

were sent from England and from New York, some of which the

Board of Health sent to our mother, for her to distribute among

her children … Miss Fowler received a donation of two splendid

new pianos for her use, one with her name, Sister Rose

Gertrude, engraved in beautiful characters. One day, while I was

cutting cloth to make trousers for the children, Dr. Swift came in

the door. He is always in a hurry. The natives refer to him as

Makani, which means wind.

"Oh, sister, today I received a marvellous letter from Amy

Fowler. I tell you, my sister, that a woman capable of writing a

letter like that would be able to work wonders.”

 

Ship that probably took sister Rose Gertrude, or Amy Marie Gertrude

Fowler, Adolpho Lutz’ future wife, from San Francisco to Hawaii

(Whitney, 1890, attached leaflet).

The things she proposes doing as stated by her interviews are

not the things the Govt. desires nurses for. The remedy she

proposes using has had its day here years ago. Nor is it likely

she would be allowed any discretion in use of Govt. medicines,

and at present no remedy for leprosy is in use here. The people

are being now given a rest from the trouble and pains of

experiments. However useful they may be to science and for

benefits of generations to come, they are a discomfort to the

people experimented on. (Law, n.d., p.2)

Dutton, who knew very well the way of life in Molokai, described to Father Hudson incidents evoking a scenario of barbarism and primitivism, which he felt lay in store for the lady from England. He wrote of the habit that the sick had of picking lice from each other's heads; of their predilection for dog meat; of the flies that swarmed in droves everywhere. “Do you think Miss Fowler will like it here?” (cited in Law, n.d., p.3).

In a letter dated March 18, 1889 – but which in reality is from 1890, a month after her arrival – Sister Rose Gertrude presented, for the thousands of eyes that had accompanied her saga, her impressions of her first visit to Molokai, in the company of J. H. Kimball and

George C. Potter, president and secretary of the Board of Health,21 respectively, Dr. Bradley, doctor of the war ship Mohican, and a reporter who traveled with her from San Francisco to Hawaii and who had been authorized to remain with the group. Also included in the group was someone to whom as of yet Amy had not given much attention, the young Dr. Lutz, “a student of Dr. Unna, of Hamburg.” The goal of the three-day visit was to gather information for an official report to be written for the Hawaiian legislature.

They left at ten o'clock in the morning on a stormy Wednesday and arrived in Kalaupapa around six o'clock in the evening. The town lay at the foot of the majestic Pali, surrounded by incredibly high cliffs covered with lush, emerald-green vegetation – ferns, morning glories, banana and papaya groves, and kukui nut trees. There had been heavy rains in recent weeks, and the visitors counted fourteen waterfalls cascading from Pali's rocky slopes.

The bad weather prevented the ship from reaching the shore, and as they waited offshore, a small boat filled with local residents came to the anchorage, supposing that the ship brought friends and relatives to visit them. When Amy and her companions put their feet on solid ground, they were greeted by cries of “aloha, aloha, aloha nui” (love, love, much love) – amid the strains of music played by a band that had hurriedly been called together to welcome the visiting authorities. “Amongst those drawn up around the landing-place,” wrote Sister Rose Gertrude (1889 [1890?], p.5),

were some with disfigured countenances, bandaged hands or

feet, but all were bright and cheery-looking despite the pouring

rain, and the disappointment at none of their relatives being in

the boat.

Kalaupapa was a small village with three churches – one being Catholic, another Calvinist, and a third, Mormon – and a handful of whitewashed cabins with small gardens where bananas, sweet potatoes, taro root, and many flowers had been planted.

They spent the night at the house of Mr. Evans, the superintendent, and the following morning left early to visit an orphanage where 95 women of all ages were being cared for by six sisters of the Franciscan order of Syracuse. Amy was enchanted by their living quarters:

imagine the prettiest little cottage with green trellis-work and a

verandah, clean and ‘home’ looking, furnished, though simply,

with almost Parisian taste, by Mr. Reynolds, and you have

before you the residence of the Sisters. In front is a smooth

green lawn where the girls play croquet, surrounded by beds of

lovely flowers such as we treasure in our green-houses in the

old country.

The buildings were made of wood and included bathrooms, kitchens, classrooms, and dormitories. Their appearance was comparable to that of the best English hospitals but, there,

we had for the first time le coeur serre. There were girls of all

ages and sizes, some with their faces eaten away by sores,

others with the deep furrows that give them the appearance of

old women of ninety or 100; others with finger-less hands and

toe-less feet, and in spite of the spotlessness of the rooms and

furniture, the cleanliness of their persons, one involuntarily

thanked God for blunting the senses of those forced not only to

bear with them the body of decay, but also to live in constant

and close contact with fellow-sufferers in more or less advanced

stages of the disease. (p.6)

A carriage took the visitors to Kalawao, a village on another part of the peninsula where Father Damien had lived and died. In describing her visit to a young, refined Englishman, Rose Gertrude uses once again a narrative strategy common in her account: the contrast between interior scenes of decadence and human suffering, and the wonders of the natural world surrounding them: around the deathbed, the scent of jasmine, sunlight, and a soft breeze. The scene that the young nurse witnessed in that house led her to comment on the incredible lack of an infirmary for the critically ill:

And these poor creatures, entering the valley of the shadow of

death, are surrounded by careless, unthinking friends, who are

compelled, through no fault of their own, to pursue the noisy

avocations of everyday life in the chamber of death: and the

soul trembling on the brink of eternity, instead of being

comforted by the loving messages of welcome of an infinitely

merciful Saviour, is distressed and harassed by the jaring

discords of common gossip and senseless jokes. (p.11-2)

At the foot of the same page, Sister Rose Gertrude asked for contributions to the project, suggesting that they be sent to Reverend H. Chapman, in London (177, Camden Grove, North Peckham), or to her account in care of the bankers Bishop & Co., in Honolulu.

They later visted the church in which Father Damien celebrated mass; his successor, Father Conrardy, took them to the Boy's Home where there were 105 patients. “Here the same ravages of disease as those which struck us so painfully in the Girls’ Home, met our eyes.” Despite this, she was surprised to see that many of the patients ran and played merrily, “but when we think of the healthy English boy, running, leaping, riding and enjoying life, and building towering castles in the air for the future, can we help wishing to fill the lives of these poor, doomed leper children with bright surprises of toys, pictures, candy and books.” In addition to distributing the things she had brought from England, Rose Gertrude decided to leave the piano donated by Messrs. Broadwood & Sons “to entertain these poor orphans who truly feel an intense love for music” (p.10).

They then went to visit lepers in their own homes. Some were from important families and possessed beautiful, even luxurious houses. Others were poor and had small cottages they had received from the government: “Clean and comfortable they are too, but the people are in many cases too indolent to spend much pains in keeping them as nicely inside as they might do.”

Partial view of Kalawao, the village where Father Damien lived, on

the peninsula where Molokai Leprosarium was built. On the back,

the majestic Pali, which isolated the village from the rest of the

island. Photo taken in the 1920's by 11th Photo Section Air Service

U.S.A. (Souza Araújo, 1929, ill. 36).

Molokai Leper Settlement. Partial view of Kalaupapa in the 1920's.

Photo taken by the 11th Photo Section Air Service U.S.A. (Souza

Araújo, 1929, ill. 37).

Small road connecting Kalaupapa to Kalawao. On the right, the

dramatic Pali. Photo taken in the 1920's by the 11th Photo Section

Air Service U.S.A. (Souza Araújo, 1929, ill. 38).

In the house where Father Damien had lived and where his books still were, the brother who served as their guide showed them the hiding place in the roof where the holy man used to guard his money (p.11, 13).

Upon returning to Kalaupapa, they went around the edge of the extinct volcano, whose slopes were covered with luxurious vegetation. That extensive valley, protected from the winds by Pali, seemed to be quite fertile. Amy was charmed by the scenery along the way: delicate ferns; high, gracious shrubbery; gardens cultivated by natives, with bananas, yams, papayas, figs, and oranges; and children who played hide-and-seek amid the high relief topography. They saw many people on horseback, and the English nurse was informed that there were at least 800 animals for the more than 1,200 sick people who lived in the leprosarium; thus, despite the confinement: “Those who cannot walk may enjoy this most agreeable exercise through the kindness of the Government” (p.14-5).

During that Thursday and for all of the following day, Dr. Swift, who was Molokai's resident physician, and Adolpho Lutz were examining patients, and Amy was especially struck by the plight of Keanu, the condemned man who had traded the death penalty for inoculation with leprosy, which had finally developed and would soon take his life. The two doctors’ activities were mainly focused on children who had been born to parents who were lepers, with an eye towards transferring those who did not show any signs of the disease to Honolulu and other islands. In Dr. Swift's office there was also a group of kokuas, healthy men and women who had obtained authorization from the Board of Health to care for the sick in Molokai.

Often it is a father whose children are lepers, or a wife who

wishes to accompany a leprous husband. The kokuas are most

anxious to be inscribed as lepers, so that they may not be sent

back to Honolulu, but may obtain rations of food and clothing.

(p.13-4, 16)

On Friday morning, in Kalaupapa, Amy's group visited the small church and school for children with leprosy who lived with their parents, both groups under the care of Father Wendolen, an extroverted character who chatted with the residents in their own language: “Here, for the first time, a little leper girl, to whom we spoke, turned away her head as if ashamed to be seen.” Under the direction of a native teacher, the children sang for the visitors and seemed to Amy to be “bright and cheery” (p.15).

Saturday morning they left the leprosarium. As no ships would come into Kalaupapa that day, they crossed the Pali on horseback, by means of a sinuous trail recently blazed by the natives. In the highlands, the trail brought them past the house belonging to Mr. Meyer, superintendent of the leprosarium, “a lovely house in a bower of roses, passion-flowers and lilies.” The descent to the coast took more than two hours, and at ten o'clock that morning a small boat took them to S. S. Likelike, which would bring them back to Honolulu (p.17).

The Board of Health had control not merely over Molokai but also other hospitals within the kingdom of Hawaii, including the Receiving Station in Kalihi and the Kapiolani Home. This institution, named after the queen, was located in Kakaako, near Honolulu. Opened on November 5, 1885, it was intended to serve the daughters of parents who suffered from leprosy. It had fifty beds, but the number of patients was never more than 35. The girls who lived there were cared for by Franciscan sisters. (p.22)

Everyone who was suspected of being a carrier of the disease, Sister Rose Gertrude explains, was examined first by their district doctor. If infection were deemed a possibility, the patient would be sent to Kalihi, where Dr. Lutz would carefully perform another examination. Finally, a Board of Examiners would examine the patient one more time and make the final decision regarding his fate (p.18-9).

The receiving station at Kalihi occupied an area of about eight acres, surrounded by a double wooden fence that was eight feet high. The station was divided into two parts, one for lepers who would receive treatment from the Brazilian doctor, and another for those whose diagnosis was not yet confirmed. The “suspects” would be quarantined for observation, until they either manifested unequivocal signs of the disease, in which case, they would be sent to Molokai; or until they were cured, in which case they would be released. In order to prevent contagion, no contact was permitted between the lepers and the suspected carriers. A Chinese cook who did not have the disease prepared the food for both sections of Kalihi. Right in the middle, a wood-frame construction was being built to serve as chapel and school. It would be divided, with one side reserved for the lepers and the other for the suspected carriers. The second piano donated to Sister Rose Gertrude would remain there to accompany the children's choir and the hymns sung during morning and evening services (p.19-21).

At the beginning of 1890, in the part of Kalihi station where lepers lived, there were 45 patients housed in independent wooden cottages. “[They] are well fed and cared for, there is a native guardian, Mr. Charles Kahalehili, who is endowed with the tact, straightforwardness and activity, so necessary in his position of trust.” Other hospital buildings included a kitchen, a dispensary, doctor's offices, an examining room, and a photography studio that Lutz had ordered prepared. Amy Fowler also refers to the “beautiful wood-frame cottage, surrounded by a verandah,” that the Board of Health had built for the sister who would care for the establishment.

That ingenuous English girl, still filled with a missionary zeal to relieve the sufferings of those at Molokai and the sins of all, by giving all that had been presented to her during her voyage in terms of donations of money and goods, saw Kalihi as a charming, healthful station near the seashore, surrounded by graceful mesquite, ready to be transformed into a “lovely little Garden of Eden,” with the growth of the fruit trees, ferns, and flowers that the North American

president of the Board, John Hancock Kimball,22 intended to plant there. Molokai also seemed to be, for those who were not at advanced, painful stages of the disease, “a dreamy, lazy arcade – a land in which, if not ‘manna, bread, and honey’ at least yams and fresh meat are at one's fingertips” (p.19-20, 16).

Judging from the information gathered by Law (n.d., p.3), until her arrival in Hawaii, the English nurse did not know that Molokai was already a Franciscan territory, and she became extremely disappointed when the Board of Health put her in charge of the Kalihi Receiving Station. There, her dreams were quickly shattered, and the life of Amy Fowler took a turn that most certainly was not part of Sister Rose Gertrude's plan.

 

The therapeutic project of Adolpho Lutz

In a report submitted to the Hawaiian legislature at the beginning of 1890, John Hancock Kimball wrote that in Kalihi everything was working

in a way that was entirely satisfactory to the Board … A limited

number of patients, not to exceed twenty, who are disposed to

obey the rules and regulations necessary for their governance,

has been chosen by Dr. Lutz to be placed under careful

observation and care. (cited in Corrêa, 1992, p.148)

In his first report to Kimball, in April of that year, Lutz described the state of the twenty patients and the first results obtained from his treatment.

 

Map of Oahu Island. On the southern coast, near Honolulu, the

peninsula called Diamond Head, where Kalihi Receiving Station or

Kalihi Hospital used to be (Whitney, 1890).

Partial view of Kalihi Leper Hospital, when it was already a

 

U.S.A.institution. Souza Araújo's photo, from his visit to Hawaii in the

1920's (1929, ill.19).

 

Kalihi Leper Hospital central pavillion. Souza Araújo's photo, from his

visit to Hawaii in the 1920's (1929, ill.23).

Kalihi Leper Hospital. House for ten patients. Souza Araújo's photo,

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

 

Kalihi Boy's Home, which sheltered boys that were segregated at the

time of birth in order to avoid contagion. Souza Araújo's photo, from