Adolpho Lutz and controversies over the transmission of leprosy by mosquitoes

During his years of study in Switzerland and Germany, Adolpho Lutz published his first articles on zoology, clinical practice, and therapeutics. In Limeira, São Paulo, he began studies on animal and human diseases caused by germs and parasites. In 1885-86, Lutz traveled to Hamburg to study the morphology of germs related to skin diseases, in conjunction with Paul Gerson Unna, one of Germanys foremost dermatologists. He proposed the inclusion of Hansens and Kochs bacilli in a new genus. In 1889, Unna nominated his student as physician-in-chief of the Leper Settlement on Molokai Island, Hawaii. From then on, Lutz sustained the theory that the disease was transmitted by mosquitoes. He conducted research to prove this theory when he was head of the Instituto Bacteriológico de São Paulo (1893-1908) and, later, after he moved to the Instituto Oswaldo Cruz (1908-1940). Although this research was not successful, on commissions and at congresses in which he participated until his death in October 1940, he still held to his conviction that leprosy was transmitted by mosquitoes.

O ne of the most interesting chapters of Adolpho Lutzs scientific work is the one dealing with leprosy, 1 a topic he investigated until the end of his life.By then one of Brazils 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, it is consensus that two Norwegian physicians, Daniel Cornelius Danielssen (1815-94) and Carl W. Boeck, established the diseases defining characteristics on scientific bases in 1847.While Danielssen and Boeck did not discard a possible association with dissolute and anti-hygienic living conditions or with 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 came to an end, 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 (1841Hansen ( -1912)), 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 on examined skin lesions made him suspect they were the specific cause of the disease.Hansen reported his discovery to the Cristiânia 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 the staining techniques that gained prime importance in the observation of this and other microorganisms.
As Obregón (1996, pp. 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 Asianblooded sufferers.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 then.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.There were those who 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, 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 familys 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 defended , 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 diseases 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., pp. 463-4).Lazarus Hospital had long been and to judge from reports by Lopes successors, would still long be stage to 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.
Lazarus Hospital had been the setting for a famous experiment with tropical rattlesnake venom (Crotalus horridus) that had killed the patient who served as guinea pig (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). 7Among the populations of Brazils 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 (Hydr.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 epidemically reign in this hospital two to three times a year (cited in Souza Araújo, 1946, vol. 1, p. 461).
The hiring of Dr. José Jeronymo de Azevedo Lima to head up Lazarus Hospital in 1879 coincided with a turnabout 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 leprosys 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, vol. 1, p. 484).
There were as yet scant authorities whose names could be cited in defense of contagion.Azevedo Lima drew support from Hansens 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 germination 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, vol. 1, pp. 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 inculpated as disease agents by followers of Pasteur and Koch.Azevedo Lima began treating leprosy patients with chaulmoogra oil extracted from the seeds of plants native to Southeast Asia of the genus Hydnocarpus, family Flacourtiaceae.According to Obregón (1996, pp. 164-5), this substance and its products, administered orally or hypodermically, were the only even minimally efficient treatments available up until the 1942 introduction of Promin, a sulphone derivative developed by Guy H. Faget.
In mid-1886, Azevedo Lima reported to the purveyor of the Irmandade do Santíssimo Sacramento da Candelária on fruitless 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 worlds leading authorities on leprosy.Presupposing that the bacillus is oxygen starved and that it would be possible to destroy it by means of likewise oxygen-starved substances, he had proposed using such reduction agents as pyrogallol, ichthyol, chrysarobin, and resorcin, intus et extra (cited in Souza Araújo, 1946, vol. 1, p. 488).
That same year, Adolpho Lutz released his first paper on the leprosy microbe, which appeared in a Leipzig publication edited by Unna (1886).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 rural São Paulo state.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 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 his orientation, Lutz ventured into the terrain of bacteriology, dedicating himself to the morphology of germs related to different dermatological diseases, mainly leprosy. 8 ADOLPHO LUTZ AND CONTROVERSIES Microbiologists were struggling to obtain pure cultures of Hansens bacillus in vitro.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 microorganisms structure was facilitated by a staining technique developed by Lutz and refined by Unna.Thanks to this process and the method discovered by Ehrlich, Lutz was able to distinguish the leprosy agent from other microorganisms, except for the tuberculosis agent, then recently discovered by Koch.This is quite an interesting fact, Lutz wrote, that two illnesses so similar from the anatomical side are also produced by parasites that only differ.They can be distinguished in all certainty neither by shape nor by dye reactions (Lutz, 1887, cited in Souza Araújo, 1946, p. 492).
In his paper 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 they were found in three different forms in tissue: small spherical or oval corpuscles, isolated rods, and larger shiny masses that contained a large portion of the first two elements.A comparative analysis of this microorganism with that of the tuberculosis microorganism prompted Adolpho Lutz to disagree with their classification in the genus Bacillus and to propose calling the Hansen microorganism Coccothrix leprae.His suggestion found no echo in 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 Mycobacterium. 9 According to his daughter, Bertha Lutz (Lutziana); Arthur Neiva (1941, p. iii); and others of his Brazilian biographers, the scientist had presented enough evidence for Coccothrix to be considered the valid name, in a paper published ten years earlier.In 1936, Lutz himself was still complaining (pp. 373-81): The germ that is judged to cause leprosy is generally called Bacillus leprae or Hansens bacillus.But in fact it is not a true bacillus.In 1886, I proposed that the genus term Coccothrix be applied to this and to the germ of tuberculosis, which takes precedence over the name Mycobacterium, generally used. 10 Lutzs claim about precedence was negated in a decision by the Judicial Commission that originated from the 1 st International Microbiology Congress, held in Paris in 1930.At that time a Bacteriological Nomenclature Committee had been created, and it had in turn drawn up the commission, entrusting it to prepare a nomenclature code for bacteria in order to settle the many disputes pending in this area.The code was approved by the 1947 International Microbiology Congress, in Copenhagen, and revisited by decision of the following congress, held in Rio de Janeiro in 1950.The International Code of Nomenclature of Bacteria and Viruses approved in Rome in 1953 was subject to further revisions in accord with decisions made by the Judicial Commission.In 1958, the commission resolved that the genus Coccothrix Lutz 1886 had not been properly published, in that the author had failed to use the genus name in conjunction with the species he was including within this genus (i.e., leprosy and tuberculosis bacilli) and, further, because he failed to provide descriptions of these species, previously published under other names (Lessel Jr., 1960, p. 117). 11 For Otto Bier (1963, p. 538), the granulations found in the leprosy bacillus should be designated Lutz granulations since the Brazilian had studied them quite thoroughly in 1886.Although Lutz had also underscored similarities between the Koch and Hansen bacilli and postulated the inclusion of both within the same genus, only a scarce few references to his work can be found in the literature on leprosy.One reason may be the likening of these microorganisms and cocci: Coccothrix derives from the Greek kokkos, which means grain or seed, and thrix, which means hair, suggesting a string of cocci.Lutz described the leprosy agent in these words: small, round, coccoid cells that divide without the co-participation of the cellular membrane, in one direction only, being found, consequently, isolated or in strings.Staining of the deeper layers of the membranous-gelatinous outer covering reveals larger cells, in part oval and bearing a double border, sometimes free, sometimes at the ends of the cellular strings (Lutz, 1886, p. 22

of the translation).
Problems in cultivating the microbe and replicating it in animals made contact with sufferers indispensable in order to guarantee an ongoing source of organic matter for the preparations used in microscopic studies both of the microorganisms morphology and biology and of how the microorganism was distributed within lesioned organs and limbs.Because it involved exploring cadavers and the bodies of the ill, internally and externally, this second line of investigation required a hospital, and this is undoubtedly what led Lutz to Rio de Janeiros Lazarus Hospital in 1887. 12 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. 13It was then that the Portuguese translation of his work on ancylostomiasis, originally published in Leipzig (1885), came out in O Brazil-Medico, which was a series of articles published in Bahias Gazeta Médica (1887-89); 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.

Lutzs trip to Hawaii
In a letter dated October 13, 1886 (BRMN Fundo Adolpho Lutz, pasta 255, maço 2), Paul Gerson Unna informed Adolpho Lutz of the arrival in Hamburg of the pathologist and bacteriologist Edward Arning, who had worked with lepers in Hawaii from November 1883 through July 1886.The archipelagos Board of Health had hired Arning to conduct a scientific investigation of the disease.Starting in September 1884 and continuing thereafter for four consecutive weeks, Arning inoculated Keanu a native prisoner sentenced to death with Hansens bacilli, but it was only 25 months later that the prisoner developed nodular leprosy.Because the disease took so long to appear and because it was suspected that members of the prisoners family might also have it, the result of the experiment was a matter of controversy.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.The Board of Health fired the English physician, 14 despite his desire to continue with the experiments.As Obregón (2002, pp. 143-7) has shown, other leprologists were to try to study the disease in Hawaii but their relations with the local sanitary authorities invariably became strained, as a result of the many inconveniences, obstacles, and hardships placed before them.
Let us return to Unnas letter to Lutz.Consul Weber, who represented German interests in Hawaii, had told Unna that the Kingdoms Board of Health no longer intended to support fruitless scientific experiments with leprosy but was most interested in sponsoring practical experiments aimed at finding a cure.Unna believed it possible, with the help of the consul, to arrange for a trip to Hawaii, where his therapeutic method could be tested on victims there.In his letter, Unna asked Lutz if he would be interested in making the trip.
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. 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 largescale experimentation with Unnas treatment.
In September 1888, the Leper Settlement on Molokai Island sheltered 881 afflicted individuals.Emerson calculated that an equal number were to be found in the kingdoms various provinces.Fearing the disease would spread by contagion, the government segregated sufferers and it expected to have all of them confined within a little over a year.The settlement stretched over some 5,000 to 6,000 acres (20,235 to 24,282 km 2 ) on a peninsula on the islands north side, the most exposed to wind.The only edge of the premises not on the oceanfront was blocked by a sharp ridge of mountains some 3,600 feet high, running down the islands back.This wall, or pali, cannot be crossed, save for a path that leads up the mountains to the ranch of Mr. R. W. Meyer, a German who is a Board of Health agent on Molokai Island and interim superintendent of the settlement. 16 In July 1889, Adolpho Lutz traveled to Hamburg to ready everything he would need in Hawaii, with Unnas help.He reached Honolulu on November 15, right when the Brazilian monarchy was being 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 Lutzs supervision.
In his first report to the Board of Health director (Lutz, 1890), dated April 1, 1890, Lutz described the condition of the patients taken to Kalihi and the problems encountered in commencing the new treatment because the station lacked necessary hospital facilities.A nurse had just arrived to help him the Englishwoman Amy Marie Gertrude Fowler, whom he would marry the following year (Benchimol, 2003, pp. 13-83).Lutzs second report, dated June 30, 1890, describes the evolution of patients treated with salol (phenyl salicylate), sodium salicylate, chaulmoogra oil, guaiacol, ointments of chrysarobin, and topical salves of anthrarobin, pyrogallic acid, goldenseal, chrysarobin, and veratrum. 17 There are conflicting versions regarding the circumstances that led Adolpho Lutz and Amy Fowler to resign their positions at the Molokai settlement.According to Corrêa (1992, pp. 150-1), in August 1890, Amy punished a Hansens disease sufferer who was an employee at the Kalihi Station, Charles Hahalehile, because of the malevolent comments he made to other patients about the psychotic states displayed by two of them, which he blamed on the medication used by Lutz.Hahalehile appealed to the Board of Health, who set up an inquiry.Questioned aggressively, Lutz proudly rebuffed the insult and showed that a simple request for information would have cleared matters up.
In Lutziana, Bertha Lutz (1971) tells a different story.She claims her father like other physicians before him l eft the Molokai settlement owing to the interference of lay people.There was a white man living with a native woman, and his brother one of the missionaries hated by Lutz had him interned as a leper.The missionary apparently felt no scruples about resorting to this means to cover up the family scandal.Upon ascertaining that the native womans lover did not in fact suffer from the disease, Lutz proposed to the Board of Health that he be released.But the missionary put pressure on certain members of the board, and so when it met to vote, Lutz failed to gain the majority.Indignant, he handed in his resignation, with Amy Fowler following suit.The unfortunate man, brother of the zealous missionary seeking to save his soul and put a stop to his mésalliance, committed suicide.Then some of the major U.S. newspapers showed up on the scene, asking to interview Dr. Lutz.He didnt believe it was proper ethics for a physician to discuss hospital matters with the press, and so he refused to receive them.Mrs. Amy Fowler, however, gave the interviews and the entire matter was cleared up, as it should be.
Adolpho Lutzs proud letter of resignation to the Hawaiian Board of Health, dated September 3, 1890 less than a year after his arrival has been transcribed in its entirety by Corrêa (1992, p. 151).It seems to confirm the first version of the facts.It may be that both episodes punishment of the troublemaking subaltern and the story of the influential missionary were linked by a more complex web of events, including the anticontagionist opinions Lutz expressed in a paper suggestively entitled Leprophobia, published in the Journal of Cutaneous and Genito-Urinary Diseases (1892) and also in the Revista Medica de São Paulo (1898).
Written in a harsh tone, Lutzs letter left no bargaining room: You will remember that in accepting my position with the Board of Health, I was careful not to bind myself to any given time.As my task could only be carried out if I found the necessary support where I had the right to look for it, I desired to provide for all emergencies.I am now satisfied by public facts that as a body, you not only refuse that support, but show yourselves very slow, if not absolutely reluctant, to do even common justice, sanctioning by your silence the disgraceful conduct of an inferior employé.After that, I think it unnecessary to enter into the numerous indiscretions and indelicacies, as well as the system of spying and reporting which the President and the Agent of the Board of Health seem to consider necessary to the fulfillment of their duties; nobody familiar with the circumstances will be astonished to learn that I refuse to go on exposing my life and my health meeting with such unfair treatment.If I have not resigned long ago, it is only because I would not have my resignation misconstrued; the unanimous vote of sympathy from all my patients satisfies me that my endeavors have been recognized where I most cared that they should be.I shall therefore give up my position as physician of the Kalihi Hospital at the end of the month at the latest, presuming that this time will suffice for my further arrangements.I expect retribution for my expenses for drugs and instruments, brought for and sent for from Europe, as well as of the sum stipulated as compensation for my journey home.Adolpho Lutz, M.D.
Through mid-1892, the Brazilian physician maintained his private practice in Honolulu, where he treated mostly European residents on the island, among which, many Portuguese (Bertha Lutz, 1971), and continued his research on leprosy and other topics related to dermatology.One of his favorite pastimes was to travel about the islands to study their flora and fauna (ibid).He published important papers in epistolary form (Sept. 1891-Aug.1892) in the Monatshefte für Praktische Dermatologie.This correspondence was to continue during the second half of 1892, when he moved to San Francisco, California.In one of his letters, he described nodosity in the joints for the first time, characterizing these as syphilitic lesions.In 1912, they would be studied this way as a new approach, by Jeanselme (Neiva, 1941, p. iv;Portugal, 1944).
Lutz remained interested in helminthes and used his stay in Hawaii to advance in his research on worms in humans and domesticated animals.According to a text by the Lutz Centennial Commission (1956, p. 9), it was there that he began the entomological observations that were to ground his later work as a sanitarian.He had already formulated his hypothesis that leprosy is transmitted by the mosquito.According to Albuquerque (1950, pp. 13-4), this conviction was to grow stronger over the years, but based on the following observations made in Hawaii: 18   Although he had never avoided direct contact with the lepers, he had not caught the disease, nor had the young nurse in whose tender arms many of them crossed the doorways of life into death.However, among the sick who entered the settlement, many had never before seen another leper.There had been a time, and not so long before, when neither leprosy nor mosquitoes had existed in Hawaii.The native language had no terms designating either leprosy or mosquito, and it dubbed morphea the Chinese disease since it had only appeared with the arrival of the Chinese and their rice-growing.This crop was, as customary, grown in ditches irrigated constantly with water, where mosquitoes, also coming from abroad, found an excellent microhabitat.

Lutz and the theory of transmission of leprosy by mosquitoes
Lutzs first speculation on the role of blood-sucking insects is found in Estudos sobre lepra (Studies on leprosy), written in Limeira in 1885-86 and published at the time of his first stay at Unnas clinic in Hamburg.The paper came out in a journal then edited by Unna, Von Hebra, and Lassar, called the Monatshefte für Praktische Dermatologie (1887), now Dermatologische Wochenschrift.This publication was then the most important international forum for clinical and laboratory experiments on skin diseases.In describing the primary lesions of nerve leprosy, which could be an entryway to infection, Lutz deemed it remarkable that the first location of nerve leprosy occurs almost always in those parts of the body kept uncovered and exposed to insect bites and other traumatisms (Lutz, 1887, p. 24).
As to transmission of the disease, Lutz analyzed the inconsistencies in the theory of heritability and although he was already fascinated by Hansens bacillus, his stance differed from that taken up by proponents of the new microbial paradigm: From my observation of the disease, I have no hesitation in stating that leprosy is less contagious than tuberculosis and in labeling the brusque expulsion of lepers from the heart of society as not only inhuman but also hardly efficient and, moreover, incoherent: and this because leprosy offers no greater danger to anothers life than does tuberculosis, nor are its perspectives for a cure any darker.
Infection of each new case depended upon the pre-existence of another, within a certain period of time, but the conditions necessary for a new case to appear are so complex and singular that only rarely will they be met within the immediate vicinity of lepers.
Seeing leprosy with the eyes of a parasitologist, Lutz proposed an analogy with ancylostomiasis, topic of a study he published in Leipzig around the same time.Like leprosy, ancylostomiasis presupposed the existence of other cases but someone who lives in a country where hookworm is found can contract the disease from muddy water without ever having come near someone suffering from it, while living in contact with the ill can be totally harmless, as long as rigorous cleanliness is observed regarding drinking water and wastes.
Lutz believed leprosy was a disease that was hard to transmit, in which only very rarely [would] direct transmission be demonstrable and in which for this very reason infection by contact within the family household plays only a lesser role.In his opinion, congenital transmission played a wholly insignificant role and morbidity was maintained chiefly by the sporadic occurrence of new cases within the heart of families spared until that point.
Once it had been learned how to distinguish leprosy from other, similar dermatological diseases, like mycosis, no new cases of infection were transmitted in unaffected countries, even when visited by a sufferer.This fact also argued against the idea of direct contagion: I myself know of some ten lepers who have left for Germany in recent years.
To explain the peculiarities of indirect transmission, Lutz acknowledged hypothetically that the sufferers blood or mucous secretions, containing the infectious agent, might require a period of maturation at a lower temperature in order to develop communicability (for example, by means of spores or forms of resistance, or another stage in its evolutional cycle), or perhaps exposed direct inoculation is also indispensable (for example, through biting insects).
At the end of the paper written in Limeira and published in Germany in 1887, Lutz added the following observation: Given the isolated situation in which I find myself, I have been obliged to completely relinquish any possibility of taking the existing bibliography into thorough account.He had not had access to Leloirs new book, and only by chance [had he] received a review of the same, written by Unna.Lutz stated, I see with satisfaction that many of our observations coincide, and I hope the reader will take as corroboration any involuntary repetitions.
Henry Leloir (1886) seems to have been one of the first to consider transmission of the leprous virus by mosquitoes.Although Edward Arning was author of a crucial experiment favoring the idea of leprosy by contagion, in 1891, he had like Lutz drawn a correlation between the rather concomitant appearance of the disease and of mosquitoes on the Hawaiian Islands.Halloppeau, Chantemesse, Sommer, Leboeuf, Noc, Scott, Joly, Blanchard, and, a little later, the Colombians Juan de Dios Carrasquilla and Guillermo Muños Rivas were other names associated with the hypothesis that leprosy is transmitted by arthropods, particularly acarines and insects, and above all mosquitoes. 19 Of those mentioned above, the name Raphael Blanchard is of special interest here.Physician and parasitologist, Blanchard seems to have been the Manson of French tropical medicine. 20He was a central figure in the network that linked zoologists and parasitologists from around the world, who were increasingly focused on medical topics (in this regards, see Sanjad, 2003, pp. 85-111;Caponi, 2003, pp. 113-49).Blanchard was a founder and secretary-general (1876-1900) of the Société Zoologique de France and, together with Alphonse Milne-Edwards, he organized the international zoology conferences that defined more precise rules for zoological nomenclature, the first, in 1889, and subsequently every three years.Blanchard chaired the Permanent International Commission on Zoological Nomenclature starting in 1898, the year in which the Archives de Parasitologie were created.In 1902, he founded the Institut de Médecine Coloniale, which provided training in parasitology for French and foreign physicians working in the so-called warm countries.
There was great repercussion when Blanchard voiced his opinion in the Bulletin de lAcademie de Médecine (1900) and the Archives de Parasitologie (1901) that leprosy could be transmitted by mosquitoes not only in hot countries, where it was endemic, but even in Paris, which should thus gird itself against these new enemies of public health.In 1905, Blanchard published Les moustiques: Histoire naturelle et médicale, one of the founding treatises of medical entomology.In Lutzs words (1939, p. 477), the work presented an excellent summary of the arguments favoring culicidian transmission of leprosy.In it, the French parasitologist commented on the mosquitos place in zoological classification, its morphology and anatomy, its habits and metamorphoses, and its genera and species.In chapter V, before presenting prevention measures against mosquitoes, he analyzed their proven role as carriers of malaria, yellow fever, and lymphatic filariasis, and its presumed role in transmitting other diseases not just leprosy (pp.543-5) but also scurvy, dengue fever, plague, hot-climate ulcer (caused by Leishmania furunculosa) and Kala-Azar, warts, moles, undulant fever, and an equine epizooty from South Africa.
The 2 nd International Leprosy Congress, held in Bergen in 1909, approved a recommendation by the British delegation that the problem of leprosy transmission by insects should be elucidated (conclusion VI, cited by Souza Araújo, 1952, p. 1).A number of leprologists were already examining mosquitoes that had bitten sufferers of the disease, and in some they had found acid-fast bacilli.Others were undertaking experiments with insect bites but had not come up with any convincing results.According to Adolpho Lutz (1939, p. 476), this was because the experiments were not conducted using rigorous methods.In addition to other errors, the interval needed for the germ to incubate in the mosquitos body was not taken into account.
In a letter sent to Lutz in June 1905, Blanchard asked him what studies he had already published on the transmission of leprosy by mosquitoes; he apologized for his inquiry by explaining that unfortunately, papers published in Brazil are not very accessible here.Although Lutzs stay in Hawaii had reinforced his conviction that the culicidian hypothesis was the most appropriate way of explaining the transmission of leprosy, since he was unable to present positive proof he had published nothing on the topic: I merely , upon the occasion of a congress, requested that professor Unna, in my name, call leprologists attention to the matter (cited in Souza Araújo, 1956, p. 130).The Brazilian zoologist and bacteriologist sent mosquitoes for Blanchards entomological collection, which did not include, so to speak, any South American type.He also sent him a brochure on yellow fever. 21 During Adolpho Lutzs time as head of the Instituto Bacteriológico de São Paulo (1893)(1894)(1895)(1896)(1897)(1898)(1899)(1900)(1901)(1902)(1903)(1904)(1905)(1906)(1907)(1908), leprosy was the subject of epidemiological and laboratory studies but it took second stage to other, more burning questions in the realm of state public health, such as diphtheria, typhoid fever, cholera, amoebic and bacillary dysentery, bubonic plague, malaria, and yellow fever.In point of fact, Lutz gathered only scant results on leprosy, according to the reports he wrote during those years.In 1893, still as interim director, he repeated the experiments he had performed earlier at Unnas laboratory in Hamburg and at Lazarus Hospital in Rio; these attempts to cultivate Hansens bacillus proved equally frustrating (see Lutz, 1895, pp. 207-8).
Leprosy was only mentioned again in his report on the year 1898, wherein Lutz highlighted events surrounding the consolidation of tropical medicine in England and other countries.The scientist hailed the inauguration of Londons school of tropical medicine and the forthcoming creation of another one, in Liverpool, as well as the launching of the Journal of Tropical Medicine, published in the British capital by James Coultie and W. L. Simpson.Lutz rejoiced over publication of two excellent treatises, one by Manson on Tropical diseases (1898) and another by Botto Scheube (1853Scheube ( -1923)), entitled Die krankheiten der warmen länder (1898).He also made mention of a session dedicated to tropical diseases, inaugurated at the 66 th meeting of the British Medical Association, held in Edinburgh in July of that year.Of special note among the papers presented there was Mansons work on research by Ronald Ross, tending to prove the theory that mosquitoes play an important role in spreading malaria.Robert Koch had organized an expedition to several countries to investigate transmission of that disease, then being studied both by Lutz and his team in São Paulo and also by Francisco Fajardo, Oswaldo Cruz, and some other bacteriologists in Rio de Janeiro.
The 1 st International Leprosy Congress, held in Berlin in October 1897, was included by Lutz among events surrounding this establishment of tropical medicine and the strengthening of a medicine grounded on precise observations made possible through the natural sciences.Lutz lamented the fact that the São Paulo state government had not sent him or any other delegate to that congress.Disease transmission by haematophagous insects was the overriding idea that served as his touchstone in assessing the papers presented in Berlin, generally of little import.Hansens bacillus had come out strengthened while the theory of hereditary transmission of leprosy lost force, Lutz pointed out.The serum developed by the Colombian Juan de Dios Carrasquilla, already rejected in tests conducted at the Instituto Bacteriológico de São Paulo, 22 found rare supporters, and yet Lutz still lamented that the assembly had not more energetically condemned these absurd syllogisms and observations holding to no criteria (Lutz, 1898, pp. 5-6).In his report, Lutz did not mention the transmission of leprosy by mosquitoes but he certainly had this in mind when he commented that in Berlin the danger of contagion [was] somewhat exaggerated by those who have observed the illness less (ibid, p. 5).
The summary of research conducted at the Instituto Bacteriológico de São Paulo from 1892 through 1906 condenses to a few paragraphs experiments dealing with leprosy.The disease had been the reason behind only three autopsies during that entire period, a number that contrasts with the many dozens performed because of the diseases mentioned above, epidemics then sweeping across the state.Although he was unable to cultivate the leprosy bacillus, Lutz saw no problem with laboratory exams meant to corroborate clinical exams: he performed twenty on soldiers from the Força Pública.Hansens bacillus was easily found in the juice of tubercles and in ulcerations of the nasal mucous, as well as in the lymph glands corresponding to the affected region.Due to its shape and way of reacting to staining, it could only be confused with Kochs bacillus, but such a mix-up would be almost impossible given the two illnesses differing symptomologies and also the grouping characteristic of Hansens bacilli (Lutz, Rev. Med. de SP, 1907, p. 81).
This report is the only one that mentions studies on transmission of this germ by mosquitoes.Lutz had ascertained that the germ did not move into the insects stomach, even when the tubercles themselves were pricked.The opposite must happen during periods of fever, when the bacilli are circulating in the blood, but there has been no opportunity to verify this fact (ibid, p. 81).
In 1901-2, Adolpho Lutz arranged to repeat in São Paulo the experiments that a U. S. mission headed by Walter Reed had just completed in Cuba in an effort to prove Carlos Juan Finlays theory on the transmission of yellow fever by Stegomyia fasciata (currently Aedes aegypti).The goal of both Lutz and Emilio Ribas, director of São Paulos Sanitation Service, was to win over to their new prevention strategy physicians and lay people who believed in the miasmatic etiology and especially in the bacilli and fungi inculpated by Domingos Freire, Giuseppe Sanarelli, and other hunters of the yellow fever microbe.This testing ground arranged by Lutz and Ribas helped clear the way for the campaign against Stegomyia fasciata led by Oswaldo Cruz in the city of Rio de Janeiro in 1903-5, as part of other sanitation and urbanistic measures aimed at regenerating and civilizing what was then Brazils capital (Abreu, 1987;Benchimol, 1992).
After his 1908 move to the Instituto Oswaldo Cruz, Adolpho Lutz, who had been studying carriers of yellow fever and malaria for some time, resumed his research on haematophagous insects that might be able to host the leprosy microorganism.The disease was moving farther up on the agenda of sanitary concerns, and at Manguinhos Lutz found both the time and laboratory facilities needed for his return to a line of research that had been smothered by the burdensome routine of public health in São Paulo.Our study of primary sources has not yet allowed us to precisely chart Lutzs experimental course from 1908 till his death in 1940.All indications are that his results were inconclusive.Nevertheless, for the first time he publicly and with great emphasis upheld the theory of leprosy transmission by mosquitoes, and in this campaign brought to bear both his sparse experimental results and all the weight of his scientific authority.

The 1915 controversy and its outcomes
Leprosy stood among the diseases that had to be reported to authorities, along with such others as yellow fever, bubonic plague, cholera, small pox, and diphtheria, according to the Regulamento Sanitário (Sanitation Code) drawn up by Oswaldo Cruz after his 1903 appointment as director-general of Public Health.Despite the contagionist assumptions underlying this code, and perhaps thanks to Lutzs influence, the specific instructions regarding each one of the illnesses that must be reported considered that mosquitoes and other human parasitic insects (fleas, bedbugs, etc.) were to be suspected of carrying and transmitting the leprosy bacillus. 23 In a report written at the peak of Rio de Janeiros 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 indispensable 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 Rios Guanabara Bay 24 was put forward by three São Paulo physicians: Alberto Seabra and two of Adolpho Lutzs assistants at the Instituto Bacteriológico, Ulysses Paranhos and Adolpho Lindenberg.At the 4 th 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 of public health, Oswaldo Cruz reintroduced the project to quarantine the afflicted in a farm settlement to be built on Ilha Grande, an island in Sepetiba Bay.His warnings about the danger of the spread of leprosy, Deaths oldest daughter, found echo in the federal Senate, where São Paulos 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. 25This use of dramatic language is in perfect tune with Obregóns 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, pp. 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 worlds major settings for leprosy.
Although associated with one particular disease, thereafter considered a great threat to urban populations, Brazils mobilization against leprosy reflected a deeper movement aimed at redirecting the countrys 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 what topped the list on Brazils public health agenda, and within the social and professional dynamics of the medical field, were hookworm, Chagas disease, malaria, and yellow fever.
Like leprosy, tuberculosis and syphilis left the orbit of philanthropy and of spontaneously born organizations of civil society, moving into the arena of public health policy.
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 Brazils sanitation services.The key leaders were Carlos Chagas, Oswaldo Cruzs 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 Brazils National Agricultural Society on February 11, 1918 (first anniversary of Oswaldo Cruzs 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 clientelistic influence of local potentates.
The oligarchic bloc in power gave in to some of these demands.On May 1, 1918, lame-duck 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.
When the Spanish flu invaded Brazil late that year, it 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, from Paraíba, a state lying outside the region of the so-called café com leite (coffee with milk) pact, formed by São Paulo, Rio de Janeiro, 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 governments most political ministry, the Ministry of Justice and the Interior.Chagass appointment as director (a post he held until 1926) reestablished the Instituto Oswaldo Cruzs umbilical link with a more autonomous and better-equipped public health service.
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 Paulos Instituto Butantã) was to prepare and distribute quinine.In addition to developing this malaria-prevention medicine and also tartar emetic, used in treating leishmaniasis, the Instituto Oswaldo Cruzs 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 oil of the charpotcochis plant (Carpotroche brasiliensis), used by Souza Araújo to treat the same disease.
Regarding this rural endemic disease, viewed perhaps as the greatest health threat to urban centers, Oswaldo Cruzs July 3, 1913, interview to the O Imparcial ignited a movement that came to encompass all of Rios medical societies.The Bahian physicians Belmiro Valverde and Juliano Moreira proposed to the Rio de Janeiro Medical-Surgical Association that a 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.The 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 DUtra e Silva, from the Medical Society of Hospitals; and Fernando Terra, Juliano Moreira, and Adolpho Lutz, from the 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 commissions 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 Valverdes observations on leprosy and marriage; Werneck Machado and Emilio Gomes on leprosy and occupation; and Adolpho Lutz and Henrique Aragãos on leprosy and immigration.Eduardo Rabello and Silva Araújo Filho studied the diseases 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 Brazils public health officials did not really know how many sufferers there were in the federal capital and 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 between heredity and 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, Lutzs 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 the Leprosy Prophylaxis Commission.
The Jornal do Commercio (Nov.7,1915) transcribed the conference in its entirety (partially transcribed in Souza Araújo, 1956, pp. 124-7) and summed up the orators 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 (1817-94), with German patience. 26They were also unfamiliar with studies released during the previous 35 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 was false.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 Lutzs 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 number of representatives of unaffected countries fall ill (Jorn.Comm., Nov. 11, 1915).
But advocates of the theory of heritability were not Adolpho Lutzs 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 the fact that 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 Hansens bacillus to people and to animals and also the problems in obtaining pure cultures of the microorganism.In conjunction with the infections 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-suckers.
The epidemiological characteristics of leprosy, however, made it necessary to exclude such ubiquitous species as fleas and bedbugs, mange-causing acarines, and other insects common in big cities.Thus we are left with haematophagous Diptera, Lutz concluded. 27His 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, led by English navigator James Cook, christened it the Sandwich Islands, and introduced the natives to syphilis and gonorrhea.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. 28 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.When Lutz was on the archipelago as head of the Molokai Settlements medical service, 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 the fatigans that existed in Hawaii as well as similar species found in coldclimate countries.The role of the Stegomyia was more uncertain.Phlebotomous flies (sandflies), maruins and mosquitos-pólvora (both members of the genus Culicoides), and mutuca flies of which there were none in Hawaii must play a secondary role in the transmission of leprosy.
Applauded at length, Adolpho Lutzs conference fueled heated debates during at least two more sessions of the Leprosy Prophylaxis Commission, and stories of these circulated in the press.Among his stalwart supporters were Henrique Aragão, also from the Instituto Oswaldo Cruz, and Emilio Gomes, a long-time bacteriologist in Rios public health sector.Although no one failed to sing the praises of Lutzs wisdom, he also had firm adversaries, especially Belmiro Valverde and the director of Rios Lazarus Hospital, Fernando Terra.The other members of the commission had no trouble reconciling certain of Lutzs proposals with the strongly segregationist prevention recommendations inspired by a belief in leprosys nearly unlimited contagion.
Not a single physician came to the defense of hereditary transmission.Nevertheless, reinterpreted from the perspective of eugenics as a predisposition, the notion of heritability was subsumed within the contagionist program as a factor in certain specific cases of transmission.
The contagionists of whom Valverde was principle 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 lepers 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 to the measures they took to avoid contagion, unquestionable even though less blatant than in the case of other diseases.The most famous victim had been Joseph de Veuster, or Father Damien, a member of the Belgian Order of Picpus, who had traveled to Oceania in 1863 to care for the lepers and who had died of the disease in Molokai on April 15, 1889(see Obregón, 2002;Huenermann, 1953).
The authors cited by Lutzs adversaries laid heavy stress on cases transmitted arm to arm, by small-pox vaccination.This was in fact the hypothesis underlying Arnings 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 observed by himself in Amazonas, by Ross in India, and also by Manson, Babes, Scheube, Hansen, Lorand, and Looft, cases that 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, the great number of bacilli that were 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: ADOLPHO LUTZ AND CONTROVERSIES 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 Lutzs principal champion in this controversy, Henrique Aragão (cited in Souza Araújo, 1956, pp. 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 played a role in spreading the disease.The microorganisms that appeared in the sick persons 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 Gougerots 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 Yersins bacillus. 29 Contagionists rightfully denounced the lack of experimental data to prove the role of the mosquito as a carrier of Hansens bacillus, a criticism that neither Lutz nor Aragão could refute.
In Aragãos 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.Lutz stated: case, infection would be much more common, and demonstrating it, easier (Jorn. Comm., Nov. 7, 1915).
The argumentation presented by Lutz and Aragão like Rochards, 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 by the bite of a contaminated 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 the 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 Hansens bacilli were found only rarely in the mosquitos 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 the beds and on the 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 Hansens.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 ubiquitous insects, altered his position at the second conference: There is no reason not to include other haematophagous Diptera among carriers of leprosy, but there are formal indications towards mosquitoes. 30 As we have seen, Culex fatigans and pipiens were the principle mosquitoes inculpated by Lutz, who did not exclude Stegomyia and other domestic species.As to Simuliidae, Phlebotomous flies, mosquitoes-pólvora [genus Culicoides], 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. 31 The geographic distribution of mosquitoes was the hottest topic of this controversy with the 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 the contagionists, an analogic 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 the 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 Hansens bacillus in different regions of the globe was another discomfiting factor in Lutzs 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 preciselys, had no choice but to use arguments of power in order to decide the dispute in his favor.Valverde (cited in Souza Araújo, 1956, pp. 132-4) admitted he was wholly unfamiliar with medical entomology and leafed through the masters to see if they supported Lutzs theory.He consulted Giles and especially Frederick Vincent Theobalds 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 Lutzs 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 cuspius!
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 Lutzs 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, Brazils 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 Valverdes 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 countrymans classification in its entirety (cited in Souza Araújo, 1956, p. 140). 32  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 Finlays and Lutzs theory.The 1915 debate was at first marked by the same adamancy that had characterized the 1903 confrontation between those who contended 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. 33Although he still stuck firmly to his ideas on the transmission of leprosy, Lutz chose not to enter into rivalry with the contagionists within the practical realm of prophylaxis.Beyond the fact that he didnt 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, pp.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.The article states, as far as leprosy, our relations with foreigners offer as much or greater danger to them as to us, and 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 irksome 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.Brazils neighboring countries offered no great peril because, except for Colombia, the number of sufferers was believed not to be greater than in Brazil.It would be enough for the travelers to present a certificate to the 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 (ibid, p. 152).
We have already seen how Adolpho Lutz felt it inefficacious and cruel to isolate victims of leprosy.During the debates, he asked his adversaries why they didnt 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, pp. 130-1).In The Microphysics of Power, Foucault (1984, pp. 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, pp. 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 again 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 Leprosy Prophylaxis Commission, Juliano Moreira and Paulo da Silva Araújo proposed that the commission sponsor the experiments needed to confirm Lutzs 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 commissions conclusions, meant to serve as the basis for a draft law, 34 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 and was chaired by Carlos Chagas, seems to have held to this orientation, but Lutz (1921) no longer found the support he enjoyed in 1915. 35Still 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 ectoparisites might mechanically ADOLPHO LUTZ AND CONTROVERSIES 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 and with wide circulation, the ripened fruit of his reasoning (Jorn.Comm., Oct. 1922).
Lutz is not alone: haematophagous insects as carriers of leprosy  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 2 nd American Congress of Dermatology and Syphilology held in October 1921 in Montevideo Uruguay, at the same time that Brazils newly created National Department of Public Health kicked off its segregationist offensive against leprosys victims through its Inspetoria de Profilaxia da Leprosia e das Doenças Venéreas, an oversight agency devoted to leprosy and venereal disease prophylaxis.
In 1936, Lutz published an overview (in German, Portuguese, and English) of the literature on leprosy transmission, reviewed in French and Italian medical journals. 36Letters 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 anti-mosquito campaign to the International Congress in Cairo (Mar.[21][22][23][24][25][26][27][28]1938).37 The disease was also the topic of the scientists final two papers, dictated to his niece since he was already completely blind. A ransmissão da lepra pelos mosquitos e a sua profilaxia, read at the 7 th 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 (Indispensable rules for anti-culicidian prophylaxis, suggested to the São Paulo State Sanitary Service) remained unpublished.38  Lutzs 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.
In his article published in November 1939, Lutz also described in unprecedented detail the experiments meant to prove his theory: 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 treefilled gardens.
The mosquitoes should be (or were) 39 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 40 and Stefanskys bacillus, which in rats produced an illness bearing similarities to leprosy.
Lutz recommended using culture from 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 ADOLPHO LUTZ AND CONTROVERSIES 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. 41  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 Stefanskys 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 out by Heraclides-Cesar de Souza Araújo, head of the Leprology Laboratory at the 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.Based on the results of experiments with Culidae (mosquitoes), Ixodidae (tics), Pediculidae (lice), Cimicidae (bedbugs), Pulicidea (fleas), and Triatominae (sub-family of Hemiptera, which includes the carrier of Chagas disease) conducted by them and by other researchers during the 1940s, Souza Araújo (1953Araújo ( , 1952) ) reached the conclusion that any haematophagous insect could transmit leprosy under certain conditions, and it would therefore be advisable for the public health authorities to extend the fumigation program aimed at the malaria vector to include rural and suburban leprosy foci. 42The leprologist from Manguinhos defended this thesis at the 10 th Brazilian Congress on Hygiene, held in Belo Horizonte in October 1952, and at the 5 th International Congress on Tropical Medicine and Malaria, which took place in Istanbul in August-September of 1953.
Adolpho Lutzs ideas were defended before other audiences by his daughter, Bertha Lutz.During the seventeen months in which she held office as a legislative deputy (Partido Autonomista) for the Federal District, representing the Liga Eleitoral Independente (Independent Voters League), she urged that mosquitoes be combated as part of leprosy prophylaxis.She in fact lodged a petition with the Chamber of Deputies, requesting information on the anti-culicidian measures taken at the leprosariums and isolation hospitals then being created in different places around Brazil (Benchimol and Sá, 2003, pp. 203-50).
World War II was a watershed in treatment of the disease.As of the 1940s, the use of compounds derived from diamino-diphenyl-sulphone (Promin, by Parke Davis; Diazone, by Abbot; Sulphetrone, by Burroughs Wellcome) would bring a cure to thousands of interned patients who began receiving their treatment in dispensaries, until they could be fully released after some years (Coutinho, 1957, p. 321).These pages are not the place for a detailed investigation of all the chemical-pharmaceutical, socioeconomic, and political-cultural factors that made leprosariums and leper colonies obsolete, destined to decay or to be transformed into monuments meant for other purposes, among which preserving our memory of medical practices now fortunately left behind.But should you, the reader, happen to come across rusty screens protecting the doors and windows of one of these ghostly institutions, now you will know they represent prosaic vestiges of the ideas so fiercely defended by Adolpho Lutz.In this case, as in many others, the historian does not find the neat closing chapter always imagined to finalize scientific polemics, separating truth from error like wheat from the chaff.

NOTES
1 Although in Brazil and other nations the term Hansens disease has been adopted to refer to this illness as part of an effort to relieve its sufferers of the stigma associated with leprosy, we have nonetheless chosen to apply the word that was in current use during the historical period examined in these pages.From a historiographic perspective, a politically correct stance would in this case yield an unacceptable anachronism.
2 See Danielssen and Boeck (1848).Heraclides-Cesar de Souza Araújo edited a commemorative centennial edition of the Atlas de la lèpre par C. Danielssen e C. W. Boeck, Bergen en Norvèege, 1847(Rio de Janeiro, 1946). 22The report presented on July 28, 1897, to Emílio Ribas, director of São Paulos Sanitation Service, contains the results of an analysis of the material Lutz had received from Colombia shortly before his trip to Montevideo, where he attended the conference at which Giuseppe Sanarelli announced discovery of the icteroid bacillus, the presumed agent of yellow fever (Benchimol, 1999).The labels of the ten bottles were marked: Instituto Carrasquilla Suero antileproso [antileper serum] Bogota Plaza de los Mártires.With the help of Arthur Mendonça, Lutz ascertained that all contained bacilli similar to coli, a larger bacillus, and cocci.They injected the serum into a dog and noticed no phenomena other than a bit of local tumefaction.Lutz judged it should not be used since it contained several different organisms.As to its therapeutic actions, he wrote, we can say that the little we have found in the literature provides absolutely no scientific basis for justifying any hope in this realm.This appears to be merely a work guided by no criteria, or of commercial speculation (BRMN Fundo Adolpho Lutz, pasta 12, maço 1).Carrasquillas serum was widely accepted in Colombia, and the government of that country gave him an institute so he could continue his research.Prepared from the blood of infected patients, his serum was criticized by the international scientific community, including a number of participants at the Berlin congress, who argued that Hansens bacillus is not found in the blood of patients (Obregón, 2002, pp. 194-6). 23Art.145, title II, Profilaxia geral das moléstia infectuosas, in Barbosa and Rezende (1909, p. 1,000). 24In 1817, Enxadas Island, a storage place for gunpowder, provided temporary shelter to the ill who were transferred from the leprosarium in the neighborhood of São Cristovão.The lepers were moved to Bom Jesus Island, where they stayed until completion of works on Lazarus Hospital in 1850.Another island, Boa Viagem, in Niteroi, was site of a pesthouse for seamen afflicted with contagious diseases.Created in 1810, shortly after the Portuguese Court moved to Brazil, this pesthouse was supported by daily fees paid by merchant marine ships docked in Guanabara Bay (Kushnir, 2002;Sarthou, 1964). 25These words were pronounced by Emilio Gomes at the July 22, 1915 session of Brazils National Academy of Medicine.They were published in the academys annals (vol. 81, p. 161) and reproduced by Souza Araújo (1956, p. 123).
26 Hannaway (1993) names two works as the essential foundations of Germanys medical geography: Leonhard Ludwig Finkes, published in 1792-95, and the two volumes that Hirsch published in the 1860s, on the eve of the Pasteurian revolution.In these pages, the German physician compiled a remarkable amount of data on the distribution and types of diseases during different periods and locales around the world and on the relation between these diseases and the environments in which their victims lived.