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História, Ciências, Saúde-Manguinhos
Texto (Portuguese)
Dossier Sanitarism and Interpretations of Brazil • Hist. cienc. saude-Manguinhos 16 (suppl 1) • July 2009 • https://doi.org/10.1590/S0104-59702009000500010 copy
Carlos Chagas and the debates and controversies surrounding the disease of Brazil (1909-1923)
Simone Petraglia Kropf
, Rio de Janeiro, , , Fundação Oswaldo Cruz, Casa de Oswaldo Cruz , Brazil, simonek@coc.fiocruz.br
Analisa o debate sobre a doença de Chagas, descoberta em 1909, em sua relação com a campanha pelo saneamento rural do Brasil (1916-1920). Argumenta que as bandeiras desse movimento estiveram diretamente referidas à definição e à legitimação dessa enfermidade como fato científico e problema social. A 'nova moléstia tropical', apresentada como emblema das endemia rurais, foi caracterizada como 'doença do Brasil', símbolo de um 'país doente'. A campanha sanitarista foi, por sua vez, elemento decisivo da polêmica em torno da doença de 1919 a 1923. Trata-se, portanto, de um caso exemplar de como as teorias da medicina tropical europeia foram utilizadas pelos cientistas brasileiros para produzir conhecimentos originais nesse campo, a partir de sentidos específicos ao contexto nacional do período.
medicina tropical; endemias rurais; doença de Chagas; Carlos Chagas; Brasil
The article explores the relation between the debate on Chagas' disease, discovered in 1909, and Brazil's 1916-1920 rural sanitation campaign. It argues that the political planks of the sanitary movement were intimately bound up with the definition and legitimization of this illness as a scientific fact and social issue. Presented as emblematic of rural endemic disease, this 'new tropical ailment' was characterized as 'the disease of Brazil', symbol of a 'sickly country'. The sanitary campaign was in turn a decisive element of the 1919-1923 polemic surrounding the disease. This is an exemplary case of how Brazilian scientists used theories from European tropical medicine to produce original knowledge in the field, basing themselves on meanings specific to the national context of their day.
tropical medicine; rural endemic diseases; Chagas' disease; Carlos Chagas; Brazil
DOSSIER SANITARISM AND INTERPRETATIONS OF BRAZIL
Carlos Chagas and the debates and controversies surrounding the 'disease of Brazil' (1909-1923)* * This text is part of my doctoral dissertation, completed in 2006 at the Department of History, Universidade Federal Fluminense, and published by Editora Fiocruz (Kropf, 2009).
Researcher at Casa de Oswaldo Cruz/Fundação Oswaldo Cruz. Avenida Brasil, 4036/400. 21040-361 - Rio de Janeiro - RJ - Brazil. simonek@coc.fiocruz.br
Keywords: tropical medicine; rural endemic diseases; Chagas' disease; Carlos Chagas; Brazil.
In April 1909, Carlos Chagas (1878-1934), researcher at the Instituto Oswaldo Cruz [Oswaldo Cruz Institute]1 1 A free translation is provided in this article of the quoted titles and others that appear in different languages. , informed the scientific world about the discovery of a 'new morbid entity' in the region of Lassance, northern Minas Gerais. It was caused by a previously unknown protozoan (named Trypanosoma cruzi in honor of Oswaldo Cruz) and transmitted by a hematophagous insect known as barbeiro (barber, kissing, or conenose bug), found in abundance in the wood-and-earth houses typical of rural areas.2 2 Carlos Chagas was born in Oliveira, rural Minas Gerais, and graduated from the Faculdade de Medicina do Rio de Janeiro in 1903, with a thesis on malaria prepared at Manguinhos Institute. After heading two malaria prevention campaigns, in mid-1907 he was appointed to fight an epidemic that was hindering work to extend the Central do Brasil Railroad between Corinto and Pirapora, Minas Gerais. When he learned about the existence of kissing bugs in Lassance, he examined some specimens and found a protozoan that experiments at Manguinhos proved to be a new species of trypanosome. The study of these parasites was on the order of the day in tropical medicine at that time, particularly because of African trypanosomiasis, which worried the Europeans in their colonies (Sá, 2005). Returning to Lassance, Chagas identified T. cruzi in the blood of a feverish child; Berenice was the first case of what would from then on be considered a new tropical disease. On the discovery, see Benchimol, Teixeira, 1993; Coutinho, 1999; Delaporte, 2003; Kropf, 2009; and Kropf, Sá, in this issue. For a biographical review of Chagas, see Kropf, Hochman, 2007. On malaria prevention campaigns and the modernization of Brazil in the earliest decades of the 20th century, see Benchimol, Silva, 2008. Chagas' triple discovery of a vector, pathogen, and human infection was celebrated as a 'great feat' in Brazilian science. This was during the international heyday of tropical medicine, a specialty devoted to the study of the parasitic diseases transmitted by vectors like malaria, which in the context of imperialist expansion were of worry to European physicians and government officials in the colonies (Arnold, 1996; Worboys, 1997). Research into this new disease became the flagship of Oswaldo Cruz' project to transform what was then known as the Manguinhos Institute into a prestigious center of experimental medicine engaged with Brazil's public health concerns (Stepan, 1976; Benchimol, Teixeira, 1993). Right from his earliest studies of the matter, Chagas held that the illness was an endemic disease that dramatically threatened national progress by inflicting broad expanses of Brazil's interior with physical and mental deterioration.3 3 For current data on Chagas disease, see WHO, n.d., and Programa Integrado..., n.d.
This article analyzes the relation between, on the one hand, the research and debate surrounding American trypanosomiasis (Chagas disease), which began in 1910, and, on the other, Brazil's rural sanitation campaign, initiated in 1916 within the nationalist context of World War I. The campaign united physicians, intellectuals, and politicians around the idea that Brazil's backwardness was fruit of the damage wreaked by rural endemic diseases and by government disregard for people in the interior (Labra, 1985; Castro-Santos, 1985, 1987; Lima, Hochman, 1996; Hochman, 1998; Lima, 1999).4 4 Formalized in 1918 with the creation of the Liga Pró-Saneamento do Brasil, led by Belisário Penna, the movement called for the federal government to step up its intervention in the public health field. It led to a broad reform of sanitary services, with the January 1920 creation of the Departamento Nacional de Saúde Pública, with Chagas appointed its first director (Hochman, 1998).
I argue that the genesis and significations of the movement's watchwords had much to do with the process of defining and legitimizing Chagas disease as a scientific fact and a social issue. The 'new tropical illness' identified in rural Minas Gerais took shape as the 'endemic disease of the sertões' (hinterlands) and came to be characterized as the 'disease of Brazil', which expressed national identity in a number of senses, not merely geog-raphically. It became the symbol of a 'diseased nation' that could not achieve 'civilization' because endemic diseases lowered the productivity of its rural laborers; it also became emblematic of the science that was then revealing this unknown Brazil and indicating ways in which it could become part of the march towards national progress. This case shows to what extent Brazilian scientists used the theoretical frameworks of European tropical medicine to produce knowledge in the form of original contributions to the field, with meanings specific to the national context of the day.5 5 For case studies on how certain illnesses were treated as 'national diseases', expressing relations between medical science and nation-building debates/projects, see Cueto, 1987; Obregón, 2002; and Snowden, 2006. I apply the formulations of US historian of medicine Charles Rosenberg (1992), who holds that diseases are socially and historically framed as specific entities through certain cognitive and social procedures. At the same time, diseases serve as a frame of reference for society, imbuing it with meanings, values, and significations. From this perspective, Chagas disease constitutes a fertile object of study for reflecting on the sociocognitive nature of the production of scientific knowledge, from the perspective of contemporary approaches in the history and the sociology of science.
In the first section of the text, I examine the earliest statements about trypanosomiasis, along with Chagas' efforts to convince the medical and political communities of the disease's social import as a scourge of rural Brazil. In the second section, I indicate how Chagas disease stood at the center of the substance and circumstances that led to physician Miguel Pereira's declaration labeling Brazil an "enormous hospital", an event underscored by historiography as the sanitation movement's point of origin. Next, examining the weight assigned this disease within the realm of the movement, I argue that the nationalist tenor of the campaign maximized the political visibility of Chagas' conceptions as defended since 1910 and reinforced the symbolic weight of the 'disease of Brazil', both for those who agreed with this idea and for those who did not. In the final section, I focus on questions raised about Chagas disease between 1919 and 1923, when, in conjunction with a scientific controversy over the illness's clinical definition and epidemiological dimension, some physicians began criticizing what they saw as an unpatriotic or exaggerated view of the nation's problems.
In identifying the shaping of the notion of a 'diseased Brazil/sertão' in Chagas' texts and statements, I point out how the significations shaping this idée-force were in large part produced during a process that indivisibly joined science, health, politics, and national identity during the first decades of the 20th century.
Encountering the disease of the sertão
On October 26, 1910, during the ceremony in which he was installed as a full member of the Academia Nacional de Medicina [National Academy of Medicine], Chagas presented the first clinical characterization of the disease that would bear his name. According to Chagas, the main symptoms of the acute stage of the infection were fever; enlarged liver, spleen, and lymph nodes; and facial swelling (myxedema), indicative of a compromised thyroid gland. Chagas (1910b) divided this initial phase into two forms: cases entailing serious brain disorders (usually involving children under the age of one, who almost never survived) and more common cases, devoid of any such manifestations, which evolved to the chronic stage in ten to thirty days.
The chronic form, into which most cases fell, was defined as encompassing endo-crinological, cardiac, and neurological changes. According to Chagas, the most common clinical indicator of the first group was thyroid hypertrophy (goiter). Convinced that T. cruzi caused lesions to this gland, he formulated the hypothesis that endemic goiter was of parasitic etiology. This thyroid dysfunction had been known since ancient times and described especially in the mountainous regions of the European Alps. Some blamed it on a lack of iodine, while others believed it was caused by the action of microorganisms (Sawin, 1999). Endemic goiter was widespread throughout Minas Gerais and, since the 18th century, naturalists, travelers, and physicians had considered it as one of the possible culprits behind the 'backwardness' of Minas Gerais peasants (Marques, Mittre, 2004). Chagas' hypothesis (1910a) was that in Minas Gerais and other regions where infection by T. cruzi occurred, endemic goiter was not the same as in Europe but was instead a clinical manifestation of trypanosomiasis.
Chagas' definition of chronic infection also comprised the 'nervous form', which was attributed to the parasite's location in the central nervous system and caused motor dysfunctions and speech and intelligence problems like idiocy and dementia, especially among children. Together with compromise of the thyroid gland, Chagas underlined these neurological dysfunctions in his characterization of the disease's medical and social role as an "important factor in human degeneracy" (Chagas, 1910a, p.163), responsible for a veritable "population of monsters" (Chagas, 1912a, p.10).
Further according to Chagas' characterization, T. cruzi also caused lesions to the myocardium, which in turn triggered irregularities in cardiac rhythm. Unlike the other forms, the 'cardiac form' manifested in young adults at the height of their productive lives. The prognosis was generally serious, leading to congestive heart failure and in some cases sudden death (Chagas, 1910b).
The first clinical outline of the disease consequently highlighted the following features: it was essentially a chronic infection that evolved progressively and was contracted early in life by almost everyone who lived in housing infested with kissing bugs. Further, since it struck during the prime of a person's physical and mental development, it caused permanent damage to vitality and to organic development. The main clinical presentations involved endocrinological (especially thyroidal, like goiter), neurological, and cardiac dysfunctions. While Chagas assigned importance to all three aspects of the clinical profile, he placed clear-cut emphasis on the first, as indicated by his frequent use in his texts of the designation "parasitic thyroiditis", proposed in 1910 by Miguel Pereira, then president of the Academia Nacional de Medicina. Goiter constituted the "stamp of the disease" (cited in Chagas, 1910b, p.445), in the words of Miguel Couto, chair in clinical medicine at Faculdade de Medicina do Rio de Janeiro [Rio de Janeiro's Faculty of Medicine], and was considered the chief sign in arriving at a clinical diagnosis of the new trypanosomiasis and thus for framing it as a specific nosological entity.
The discovery and first studies of Chagas disease were presented to the medical community as the 'glory' of Brazilian science, a strategy initiated by Oswaldo Cruz himself, who saw in his young disciple's accomplishment a matchless opportunity to strengthen the Instituto Oswaldo Cruz's project as an institution committed to the interests of Brazilian society (by combating urgent sanitary problems through the production of sera and vaccines and through prevention campaigns, concomitant with identification of the problems that needed to be addressed) and to the advancement of science (by producing knowledge in crucial areas of international science) (Stepan, 1976; Benchimol, Teixeira, 1993).
In addition to personally announcing this discovery before the Academia Nacional de Medicina, it was at Oswaldo Cruz' suggestion that the association sent a commission comprising Miguel Pereira, Miguel Couto, Antonio Austregésilo, Juliano Moreira, and Antonio Fernandes Figueira to Lassance in 1910 to witness and validate Chagas' research. Upon his return to Minas Gerais, Pereira, impressed by what he had seen, remarked on the disease's "complex, rich, and opulent" clinical profile, underscoring: "Hardly any of the ill fail to present goiter ... . This is the dominant form" (Academia Nacional de Medicina, 1910a, p.193). The disease's neurological features also caught the attention of these physicians, which included leading names in psychiatry. Studies into endocrine problems, viewed as possible factors behind certain neurological disorders, had drawn interest in this field since the late 19th century (Delaporte, 2003).
Earning the rubber stamp of the luminaries of Brazilian medicine, these formulations on parasitic thyroiditis began circulating among major players, engendering an object both medical and social. Starting in 1910, Chagas systematically affirmed that knowledge of this new nosological entity had brought Brazilian science and society face to face not only with a disease that in itself had serious social implications but also with a disease that revealed some of the country's realities and structural problems. The Academy's journey to Lassance was the first step towards this 'encounter'. Austregésilo's report tells how a disease identified 'in the' sertão was transformed into the disease 'of the' sertão, emblematic of a physical and social environment characterized by neglect, wretchedness, and non-productivity.
The sertão of Minas Gerais through which we passed looks desolate, with scattered small houses and gnarled, twisted vegetation with meager foliage. In Lassance ... we saw more than thirty with the new trypanosomiasis. ... It is so very sad to watch those wretched-looking, slothful beings, among whom invalids and idiots abound. If their organisms are so degenerate, even more wretched are the things around them - housing, lands, etc. Suffice it to say we did not find one single fruit of this country! (Entrevista..., Oct. 6, 1910).
The October 26, 1910 solemn session of the Academia Nacional de Medicina was the new stage for the encounter Chagas had in mind. During his conference, he defended the notion that Brazil faced a "terrible scourge over a vast zone of the country, thereby rendering a sizeable population incapable of participating in the activities of life and leaving successive generations of inferior men, useless individuals, fatally damned to a chronic morbid state, at such a coefficient of inferiority that they become worthless to the progressive evolution of the Fatherland" (Chagas, 1910b, p.446). A most persuasive strategy served to amplify his words. The electric power inaugurated at the Academy that night as yet another symbol of the progress experienced in the newly renovated capital of the Belle Époque was used by Chagas to project cinematographic images from Lassance, materializing a far-off, backwards Brazil right in the heart of the medical community and of the country (Academia Nacional de Medicina, 1910b).
Laboratory equipment was also used to convince the distinguished audience. Anatomopathological parts were on display and 16 microscopes available for whoever wanted to observe the new parasite. The press later described this 'show', further broadening the circulation and visibility of Chagas' pronouncements. Physician Ismael da Rocha (Oct. 31, 1910) remarked:
All those who attended - and the auditorium was legion - the session of the Academia Nacional de Medicina, in its Silogeu Brasileiro [Brazilian Hall], could not repress a tremendous feeling of sadness, recognizing, from the lighted projections and cinematographic tape that illustrated Dr. Chagas' scientific demonstration, that there is a huge scourge over a vast central zone of Brazil, unmerciful as the paludism of certain Amazon regions, cruel as the yellow fever now felicitously banished from this city. That procession of the misfortunate, which only a cinematograph could allow us to appreciate in their current lives; that bevy of miserable creatures, who live suffering or are born dying, are victims of an endemic disease, whose living cause Carlos Chagas has uncovered.
Presented as the 'disease of the sertão', Chagas disease particularized the idea of so-called tropical disease as national disease, as the 'disease of Brazil'. If, as David Arnold (1996) has argued, Europe's contact with the tropics - not only a physical space but also a conceptual, cultural, and political one - represented the experience of 'otherness', the characterization of the new trypanosomiasis as a disease of a certain region, of a certain population, under certain socio-environmental conditions, likewise revealed an 'other'. From this perspective, Chagas' formulations conjoined the production of knowledge with political grievance: "Will it be possible for public hygiene to find efficacious means for attenuating this malady? We believe so, if this problem, surely a problem of the State and of humanity, becomes the concern of a scientifically well-guided statesman" (Chagas, 1910b, p.447).
Chagas' conference at the Academy made a huge impact. In the nation's House of Representatives, Minas Gerais deputy Camillo Prates demanded that the federal government take measures. The newspaper Correio da Manhã applauded the initiative and criticized those who pointed to the constitution's limits on federal intervention in the public health matters of the states, stressing that it was a question
not of the interest of one State or the other per se, but of the interest of many States. It is not the needs of Minas or of Goiás alone that demand such measures, but of all Brazil. ... Brazil is not just Rio de Janeiro. Let our lawmakers and government leaders not forget that one million Brazilians live here in relative comfort, while some eighteen million drudge away in the sertões (Vidal, Nov. 18, 1910; emphasis added).
In 1910, the watchwords and arguments that years later would shape the rural sanitation movement and its implications for the reform of Brazil's federal public health services emerged, within the context of this debate over Chagas disease.
In 1911, Chagas took his conception of parasitic thyroiditis farther. At the Associação Médico-Cirúrgica de Minas Gerais [Medical-Surgical Association of Minas Gerais], before the president of the state and other public figures, he made the political and social dimensions of this theme the crux of his conference: "If the scientific side merits the attention of researchers, the practical side constitutes the highest matter of State, demanding the attention of the government leaders of our land" (Chagas, 1911a, p.355). This trip to Minas Gerais was another expression of Chagas' strategies for disseminating and validating his statements. He called upon his countrymen not only to endorse his research but also to corroborate his denunciation of a problem that was intimately identified with Minas Gerais, both because the disease had been discovered there and because of the data indicating widespread distribution of kissing bugs and goiter sufferers, in a state which itself evoked the interior of Brazil and the nation's 'agricultural vocation'. At a time when economic stagnation was causing the elite of Minas Gerais growing concern (Dulci, 1999), Chagas came upon fertile ground for finding allies.6 6 The following year, Chagas (1912b) presented the disease in São Paulo as well, another state where economic interests, related to rising coffee production, were considered a reason for the medical community to show special attention to the matter, which would soon become the object of study by local physicians (Silva, 1999).
A few days later, during a second conference at the Academia Nacional de Medicina, before government ministers and Brazilian president Hermes da Fonseca, Chagas drew an even tighter connection between components of the medical scientific framing of the disease and components that shaped the disease as a social object: "slowly undermining the human organism and prompting a progressive decline in its vitality, leaving the individual unable to work and perhaps perpetuating itself, through hereditary transmission, in successive generations of inferior men, parasitic thyroiditis is creating, over vast regions of Minas Gerais and other States of Brazil, a population of degenerates" (Chagas, 1911b, p.373).
Chagas (1911b) asserted that trypanosomiasis not only jeopardized productivity in already occupied rural areas but also hampered the very settlement of the territory, since 'primitive' houses prone to infestation by kissing bugs were built in the settlements opened by expansion of the railways (Lassance being an example), soon turning these places into foci of the disease. The parasite's ease of transmission, long life span, resistance to prolonged fasting, and ability of its larvae to be carried in luggage (p.341) made the kissing bug a powerful "enemy", said Chagas, which could "settle" other regions of the country, in step with economic advances and internal migration.
The idea that the organic deterioration of rural populations was a hindrance to social and economic progress and as such demanded government intervention lent tropical medicine in Brazil its own unique features.7 7 On the 'cultural model' which saw infectious disease (malaria above all) as a barrier to development, see Packard, Brown, 1997. Citing the Europeans who were combating sleeping sickness in Africa for colonialist reasons, Chagas emphasized that in Brazil the study of tropical pathologies should serve the nation itself: "it is the future of a great people that should be safeguarded" (Chagas, 1911b, p.374). Carlos Seidl, then chair of the Academia Nacional de Medicina, declared himself convinced that trypanosomiasis jeopardized key aspects of modernization, like labor power, settlement of the entire territory, and national integration. He made explicit his wish to guarantee the matter national visibility:
What kind of degenerate race will the sertanejos of our immense country become ... ? I requested the presence, here on this occasion, of the Honorable Minister of Agriculture, so that he might look kindly upon these stunted, rachitic, and enfeebled types of human plants ... . His Honor will certainly not fail to perceive the need to strengthen the nation's hands, atrophied by avoidable illness, when so many expenditures are made to obtain the help of foreigners, who will inevitably come to suffer from the same ill, coming to work in a contaminated zone. ... I asked the Honorable Minister of Transportation to come to this Conference, inasmuch as it would be rightful to believe him interested in intimate knowledge of the state of organic deterioration of these men and these women, all of them inhabitants of the zones through which the Brazilian rail lines stretch their nerves of steel, carrying progress as well as Chagas disease (Um palpitante problema..., Aug. 8, 1911).
At this second presentation before the Academy, the hinterland and the new morbid entity were present in the dramatic form of the diseased themselves, brought from Lassance. The 'diseased country' appeared before the chief of State, who, as the press reported, "was sharply struck by what he saw" (Um palpitante problema..., Aug. 8, 1911).
This "theater of proof"8 8 Bruno Latour (1984, p.95) uses this expression to refer to Pasteur's strategy of promoting dramatized, public demonstrations of his scientific experiments. reached its apex in the federal capital and was also staged outside the country, in 1911. At the International Exhibition of Hygiene and Demography, in Dresden, Germany, the disease was the centerpiece at the Brazilian pavilion. In addition to cinematographic projections, four busts representing the ill were on display, commissioned from a French sculptor; goiter was their most salient feature.
In April 1912, the year Hamburg's Institute for Maritime and Tropical Diseases awarded Chagas the Schaudinn prize for protozoology, he presented an argument at the opening of the 7th Brazilian Congress on Medicine and Surgery, in Belo Horizonte (capital of Minas Gerais), which would be synthesized in 1918 by the image of the "damned trinity", an expression coined by Belisário Penna as the stamp of the sanitation movement. According to Chagas, "the three major sanitary problems of the interior of Brazil", responsible for its social and economic backwardness, were malaria, ancylostomiasis, and the illness described in Lassance. Employing an eloquent discursive device, he used the term 'Brazilian trypanosomiasis' to leave clear the national dimension he wanted to lend the disease (Chagas, 1912a, p.12), whose framing was strengthened by its association with the two other illnesses then the focus of international optimism over the new resources available to medical science for 'conquering' tropical diseases.9 9 Starting in 1909, in the US south, the fight against ancylostomiasis - the so-called disease of laziness -eventually gave birth to the Rockefeller Foundation's International Health Commission (which became the International Health Board in 1916), created in 1913 to develop prevention measures against ancylostomiasis, malaria, and other maladies in different countries around the world, including Brazil.
Indicating rural sanitation as the way to ensure continuity to Brazilian medicine's redemptive mission, Chagas stated that if Oswaldo Cruz had "rehabilitated" the country by sanitizing its capital, the challenge now was to combat the sanitary problems of the interior, "where the benefits of well-guided action have not always been able to reach" (Chagas, 1912a, p.8). A proposal was put forward at this congress to create a "central committee to fight tropical illnesses", headquartered in Rio de Janeiro and meant to coordinate the fight against ancylostomiasis, Chagas disease, paludism, and other endemic diseases, under conditions that would extrapolate "the narrow frame of local and regional interests" - in other words, that would cover the entire country. This would form the basis of a "general, official department to fight the endemic diseases that assail us" (Congresso Brasileiro..., 1912, p.66).
Some months after the meeting in the capital of Minas Gerais, the Manguinhos expedition led by Arthur Neiva and Belisário Penna set off for the states of Bahia, Pernam-buco, Piauí, and Goiás. Their report, written in 1915, would have a decisive role in articulating the sanitation movement (Neiva, Penna, 1916). From its earliest years, the Instituto Oswaldo Cruz sent such expeditions around the country to undertake surveys for public agencies and private bodies involved in economic modernization (COC, 1991; Lima, 1999); they became an important way of gathering evidence of the new trypanosomiasis.10 10 See the document "Instruções para o estudo da distribuição geográfica da tireoidite parasitária" [Instructions on the study of the geographic distribution of parasitic thyroiditis], in the COC/Fiocruz Archives, n.d., fundo Carlos Chagas, grupo Pesquisa, subgrupo Doença de Chagas, atividade de formalização de procedimentos técnicos e métodos. In its description of procedures used to gather information on the disease's various clinical forms, the document stresses: "In all clinical cases, look for lesions of the thyroid gland."
During the first years in which knowledge of the disease was produced, the links between the scientific and political-social dimensions of the trypanosomiasis basically found expression in Chagas' texts and conferences, which were communicated within spaces specific to medicine and science - like laboratories, specialized literature, and medical congresses and associations - while also seeking their way into broader spaces of social life. As of 1916, the process by which the disease was framed medically and socially took deeper root, reaching new audiences and, above all, securing a place for itself in the broader political debate about the nation.
Between doubts and glories: the 'disease of Brazil' and the sanitation movement
In 1916 Miguel Pereira11 11 Miguel da Silva Pereira (1871-1918) was born in São Paulo and graduated from Faculdade de Medicina do Rio de Janeiro in 1897, with a thesis on tropical hematology. That same year, with a treatise entitled "Anemia tropical", he became a member of the Academia Nacional de Medicina, over which he would preside in 1910-1911. In 1898, Francisco de Castro invited him to be his assistant in clinical propaedeutics at Rio's faculty. He became a substitute professor of clinical practice at the same school in 1907 and held the chair in internal pathology in 1908 and in clinical practice in 1910. gave the speech that would become famous and ignite a polemic. In it he raised questions about the sanitary picture of Brazil's interior and stated that Brazil was an "enormous hospital". This was also a decisive year in the trajectory of Chagas disease, with its clinical and epidemiological characterization the object of a scientific controversy.
In 1915, research in Argentina spearheaded by Austrian microbiologist Rudolf Kraus came into conflict with Chagas' formulations on the chronic forms of trypanosomiasis, especially the parasitic etiology of endemic goiter. Although infected kissing bugs and sufferers of goiter could be found in Argentina, researchers were bothered by the fact that no human case of the disease had ever been diagnosed there (Kraus, Maggio, Rosenbuch, 1915). It should be noted that Chagas' method for demonstrating the presence of the parasite in chronic cases had been refuted in 1913.12 12 Chagas believed that certain parasitic forms identified in the lungs of laboratory animals experimentally infected with T. cruzi represented stages in the evolutionary cycle of this protozoan. However, studies conducted in 1912 by Instituto Oswaldo Cruz researcher Henrique Aragão showed that these forms belonged to a different parasite, Pneumocystis carinii, a statement that Chagas recognized in 1913. That same year, Cesar Guerreiro and Astrogildo Machado developed a serological method for diagnosing chronic cases but its low specificity made its use quite restricted at the time. Once the acute stage is over, T. cruzi is no longer found in the blood and is very hard to identify in tissues through autopsy. In the absence of any demonstration of the causative agent (a fundamental precept of microbiology), doubts rose about the clinical criteria for diagnosis, such as its association with goiter.
Kraus and collaborators argued then that the neurological and thyroidal manifestations attributed to the chronic stage of American trypanosomiasis in fact corresponded to the endemic goiter and cretinism already described in Europe - in other words, it was a matter of overlapping yet distinct endemic diseases. According to these researchers, the new trypanosomiasis was essentially an acute disease, restricted to the locations where it was the object of study in Brazil. They alluded to the possibility that the climate in Argentina attenuated the virulence of T. cruzi, thus accounting for the absence of cases there (Kraus, Rosenbuch, 1916).13 13 On the resistance of Argentinean doctors to tropical medicine, see Caponi, 2002. The first record of acute cases of Chagas disease in this country came in 1924. On the history of this illness in Argentina, see Kreimer, Zabala, 2006; Zabala, 2007 and an article in this issue. In September 1916, Chagas rebutted these allegations at the 1st National Medical Congress in Buenos Aires, where an international conference on bacteriology and hygiene was held in parallel. At that time he stated that even if he should come to reconsider some ideas, none of these objections posed a threat to his overall concept of the disease, which, he underscored, was limited neither to acute cases nor to Brazil (Chagas, 1916a). Nevertheless, even while reiterating his convictions, he initiated an important process of reframing the clinical profile of trypanosomiasis, downplaying the primacy of thyroidal signs and reinforcing the weight of cardiac components.14 14 In his proposed new classification of chronic forms, Chagas placed less weight on endocrine elements and presented the parasitic etiology of endemic goiter as a "related problem" open to review (Chagas, 1916b, p.20). In a significant sign that he would no longer characterize the disease as a fundamentally endocrinological malady, he stopped using the expression 'parasitic thyroiditis', replacing it with American trypanosomiasis.
It was at the ceremony honoring Aloysio de Castro, director of Faculdade de Medicina do Rio de Janeiro, for his participation in the Argentinean congress, that Miguel Pereira gave the speech that was to launch the sanitation campaign. His words had tremendous repercussions in the medical field as well as in the broader political and intellectual debate on national identity. It was a time of nationalist fervor, and themes like the race issue, immigration, and, especially, military recruitment all intersected in the endeavor to identify the country's ills as well as its chances for 'regeneration'.15 15 On the relations between the debate over military service and the role of the Army as a force for 'national salvation', on the one hand, and the 1910s sanitation campaign on the other, see Beattie, 2001. Pereira reacted with indignation to those who exhorted Brazilians to engage in the defense of civic, patriotic values without taking into account the true living and health conditions in the country's interior. In a reference to a speech by Minas Gerais legislative representative Carlos Peixoto, who had stated he was ready to draft residents from the interior of his state to serve in the Brazilian Army, Pereira said in ironic tones:
It is well and fine to organize militias, arm legions, rally round the flag, but it would be even better, in this outburst of enthusiasm, if we were not to forget that outside of Rio or São Paulo - capitals that have been fairly well sanitized - and of a few other cities where Providence oversees hygiene, Brazil is still an enormous hospital. ... While reaching such extreme patriotic zeal, this generous, noble initiative may encounter grave disappointment. Part - and a considerable part - of this valiant people would not rise up; invalids, debilitated, done in by ancylostomiasis and malaria; maimed and massacred by Chagas disease; worn away by syphilis and leprosy. ... I am not overstating the colors of the picture. This, without any exaggeration, is our population in the interior. A legion of the sick and useless (A manifestação..., Oct. 11, 1916; emphasis added).
Days later, in another speech at a banquet in Chagas' honor, a still indignant Pereira sought to redress what he saw as an attack on the discoverer of one of the most serious causes of this "hecatomb". In an allusion to Kraus' criticism of Chagas, he referred to those who "in the name of German science, in an abrupt onslaught, [began] gnawing and ripping away at your pyramid, until flattening it with their blows, leaving untouched only a small set of acute forms, produced by a parasite of minor virulence". In response to those who questioned the morbid entity - whose most well-known name (parasitic thyroiditis) Pereira himself had coined - he extolled the social mission of the "men of science" who, like Chagas, ventured into the hinterland and uncovered the reality of a Brazil that could respond to this patriotic hue and cry with nothing but a "an army of shadows". Pereira himself had witnessed this desolate picture, when he had encountered sertanejos suffering from trypanosomiasis in Lassance, in 1910. And so he warned: "No, my esteemed colleagues, it is not through the windows of a hospital that all of us, physicians and patriots, shudder for the future of the Fatherland". This indictment, which had made its repercussions felt since Pereira's first speech, recognized Chagas and the disease he was studying as a fundamental source of inspiration and of fundamentals. Borrowing lines he had penned for Pasteur, Pereira summed it up: "On n'aurait rien compris avant qu'il n'eut parlé" [We would have understood nothing had he not spoken] (Banquete..., Oct. 22, 1916).
In thanking Pereira for the tribute, Chagas emphatically reiterated his colleague's statements, calling them a "splendid panorama of sad truths." Defending Pereira from those who thought it pessimistic or exaggerated to paint Brazil as an 'enormous hospital', he gave his own testimony: "I have seen up close the grievous aspects of life in the fields, photographed in the words of the professor" (Chagas, 1935, p.7-8).
For historiography, the motivation and primary basis for Miguel Pereira's statements lie in the report on Arthur Neiva and Belisário Penna's 1912 expedition to the interior of the country. However, although the volume of Memórias do Instituto Oswaldo Cruz in which this report was released gives its publication date as 1916, the issue actually only came out well after Pereira's speech.16 16 Dominichi Miranda de Sá, analyzing the public repercussion of Neiva and Penna's report, indicates that the press first began commenting on the text in August 1917. See her article in this issue. In fact, in a letter to Belisário Penna dated November 7, 1917, Neiva complained about how long it was taking the report to leave the print shop at Manguinhos.17 17 The letter is reproduced by Cassiano Nunes in his introduction to the Neiva and Penna report on their trip, republished by the Federal Senate in 1999. Indeed, when he made his speech, Pereira could already have had information about the report, which was completed in mid-1915. Be all this as it may, it should be emphasized that Pereira was already familiar with the essential lines of Neiva and Penna's diagnosis, which had been circulating in the medical community since 1910, starting with Chagas' declarations about the disease he had discovered and about other rural endemic diseases.
Spurred by the day's heated nationalist debate, the indictment of Brazil as an 'enormous hospital' also derived substantially from the significations constructed around Chagas disease, in itself a critical reference in shaping this metaphor - all part of a process Pereira had accompanied from its very outset. Belisário Penna himself recognized this connection when he said: "Chagas' notable discovery ... was the drop that made the great professor's cup run over with indignation and gave him the courage to manifest it in his famous phrase, because it is profoundly and painfully true" (O Brasil..., Aug. 20, 1920).18 18 Citing excerpts of Chagas' speech before the 1912 Congress of Medicine and Surgery, Penna (1918b) underscored the importance of his words to the mobilization that culminated in creation of the Liga Pró-Saneamento do Brasil. He said: "The government had already received warnings, from knowledgeable people, about the precarious state of the rural population's health" (p.104). The 1916 speech was a landmark not because it launched the notion of a 'diseased Brazil' but because it broadened the notion's scope and, above all, fomented a program of social intervention and reform.
The repercussion of Pereira's words reinforced the process by which Chagas disease was framed as a scientific and social fact and thus became a frame of reference for Brazilian society. In the main documents publicizing the rural sanitation campaign, greater emphasis was placed on the political dimension of the illness. These documents reveal an interesting interplay between the cognitive and social dimensions involved in the construction of this object. If, owing to the scientific controversy, Chagas made shifts in the clinical profile of the disease, relegating to a lower plane the thyroidal features he had formerly accentuated as central, the political movement that was pushing the disease into the national debate would, ironically, reinforce the main element he endeavored to downplay: the association with goiter. In sanitary discourse, this would continue to be the 'stamp of the disease', representing, together with neurological dysfunctions, the dramatic effects of American trypanosomiasis as the emblem of the morbid status of the people perishing in the country's interior.
A decisive vehicle in disseminating this representation was Neiva and Penna's report (1916). With its repercussions extending beyond the medical field (Lima, 2003; Sá, this issue), it played a fundamental role in legitimating the statements and grievances of the Brazilian sanitation campaign. In their effort to show evidence of the presence of Chagas disease, Neiva and Penna located different species of kissing bugs and a significant number of wood-and-earth houses, indicative of epidemiological conditions propitious for trypanosomiasis to spread broadly. Although the authors referred with reservation to the hypothesis that associated Chagas' disease with goiter, they did employ goiter as the primary criterion for defining the presence of the disease during their trip.19 19 It should be pointed out that in 1912, when their journey took place, Chagas' thesis on this matter was widely accepted but by the time the report was concluded, in 1915, questions had been raised about it. It was precisely when they were describing places where the illness had been identified by this sign - as in Goiás, where it "lay waste in proportions the Nation hardly even suspected" (Neiva, Penna, 1916, p.117) - that they drew from thyroiditis all its implications as a symbol of the degradation in which people of the interior lived. Of the 24 photographs of the ill included among the vast, rich set of images produced during the expedition and published in the report, 18 involve Chagas disease. As Nancy Stepan (2001) has pointed out, the most salient feature in practically all of these images was the goiter, a fact that solidified a certain way of seeing and recognizing the disease. When the faces of sufferers from another region of the country were added to those from Lassance, these images configured a powerful persuasive tool in corroborating formulations on the dissemination of American trypanosomiasis in Brazil.20 20 For an analysis of the photographs published along with Neiva and Penna's report, see the article by Mello and Pires-Alves in this issue.
The theme was also publicized through articles by Belisário Penna, collected in the 1918 book Saneamento do Brasil and the basis for that year's founding of the Liga Pró-Saneamento do Brasil [Pro-Sanitation League of Brazil]. Penna claimed that the country's economic trouble lay in the "pressing need to cure rural man, educate him, settle him, and equip him with the means to feed himself properly so he can produce what a normal healthy man produces" (Penna, 1918b, p.51). This alert sounded especially urgent for Minas Gerais, which, according to Penna, despite its tremendous agricultural potential, was the "state of disease", laid waste by rural endemic diseases and above all by the trypanosomiasis discovered there by Chagas (Penna, 1918a).
In his testimony as someone with deep knowledge of the reality of rural Brazil, the leader of the sanitation campaign lent his medical and social representation of Chagas disease great rhetorical force. In 1909, as a physician with the Diretoria Geral de Saúde Pública [General Directorship of Public Health], he had been with Chagas in the fight against malaria in northern Minas and had taken part in important events in the process of discovery of the new trypanosomiasis. Besides collecting the first kissing bugs examined by Chagas and witnessing the moment when Chagas identified T. cruzi in Berenice's blood, Penna helped with the first autopsy in Lassance, in 1910.21 21 Chagas himself gave an account of Penna's participation in these events, in an interview to the Jornal do Commercio (Tripanosomíase americana..., Aug. 23, 1919). In his words, this was the "most appalling of the endemic scourges of the sertão", which "did not limit itself to degrading its victims' physical and moral state, damaging organs vital to health and life; it deforms incredible proportions of them, leaves them completely useless, forming legions of cripples, cretins, idiots, the paralyzed and the goitrous" (Penna, 1918b, p.9-10). Highlighting endocrinological and neurological dysfunctions as the most concrete features of the sickness and guaranteeing that it stretched over an "extremely vast region of Brazil", Penna (p.144-145) estimated that 15% of the population was afflicted by trypanosomiasis, that is, some three million Brazilians.
Monteiro Lobato also brought up the social impact of American trypanosomiasis. In his book Problema vital (Lobato, 1956), first published in 1918, Lobato synthesized sanitary precepts in his character Jeca Tatu and emblazoned the numbers Penna used to illustrate Brazil's sanitary "cataclysm" in the titles of his texts about the endemic diseases of the "damned trinity": "seventeen million hookworm sufferers", "ten million malaria sufferers", "three million idiots and goiter sufferers". Depicted with literary verve, Chagas disease acquired even brighter tones as a metaphor of Brazil. Citing a passage where Penna recounts a scene he witnessed in Lassance, where numerous kissing bugs attacked a child, Lobato remarks: "This child is not 'a' child but the child of the Brazilian sertão" (p.240; emphasis in the original). Blending the tragic and the comic, he manifested his indignation: "Three million - three million! - creatures mired in the most wretched mental and physiological misery on account of a cockroach!" (p.241).
Monteiro Lobato (1956) seconded Penna's acid criticism of the indifference of politicians and men of letters to the economic consequences of this "progressive decline of the population" (p. 242). He advocated the end of the power of bacharéis (members of the lettered elite, most of whom held law degrees) - "triatoma bacalaureatus", he called them, comparing them and their "vampiric" action to the kissing bug itself - and called for scientists to replace them in the nation's highest posts. He had this to say about Manguinhos: "Salvation lies there. From there has come, comes, and will come the truth that saves - this scientific truth that leaves the field of the microscope stripped of any affectation" (p.243-244).
If, since the 19th century, Brazilian physicians and scientists had been attaining legitimacy in the public eye through their commitment to issues of major relevance to society, at this moment they were recognized not just for their ability to identify such problems but also for their aspirations to occupy positions of government, where they could dictate the nation's direction. In October 1919, two years after becoming director of the Instituto Oswaldo Cruz and after leading the fight against Spanish flu in the federal capital in late 1918, Chagas was appointed federal director of public health services, reorganized shortly thereafter under the Departamento Nacional de Saúde Pública [National Department of Public Health], created in early 1920 in response to demands by the sanitation movement.22 22 Chagas headed the Departamento Nacional de Saúde Pública (1920-1926) during his tenure as director of the Instituto Oswaldo Cruz, a post he occupied from 1917 until his death in 1934.
The fact that American trypanosomiasis and its discoverer were on center stage in the political realm both reflected and yielded recognition and legitimacy, but it also left both more vulnerable to criticism and tensions. As the 'disease of Brazil' fueled the sanitarians' outcry, it became the center of a heated controversy, in which the scientific dimension was inseparable from the debate's political content. Those who questioned Chagas disease as a scientific object and social issue stood in contrast with those who classified Brazil as an 'enormous hospital'. This is one more way in which the trajectory of this illness intersected with that of the sanitation movement.
National scourge or 'illness of Lassance'? The 'disease of Brazil' in question
In July 1919, in the heat of Brazil's rural sanitation debate, Henrique Aragão (Jul. 24, 1919, p.8) voiced his uncertainties about the malady discovered by his colleague from the Instituto Oswaldo Cruz, speaking before the Sociedade de Medicina e Cirurgia do Rio de Janeiro [Rio de Janeiro Society of Medicine and Surgery] (SMCRJ). Declaring Chagas' hypothesis about goiter as untenable, he pointed out that the reduced number of parasitologically proven cases, in sharp contrast with the 'millions' decried by Penna, numbered less than forty.23 23 In 1916 Chagas published his observations of 29 acute cases. Although he said chronic cases were numerous, he did not quantify them in his papers. Basing himself on Kraus' arguments, Aragão contended that T. cruzi might present low pathogenicity for the human organism, primarily in adults. Touching on another point that would become controversial, he called Oswaldo Cruz the "discoverer of T. cruzi", in which he was seconded by Henrique Figueiredo de Vasconcellos, also a researcher at Manguinhos.
At another conference of the SMCRJ (Aug. 21, 1919), Vasconcellos stated that because Oswaldo Cruz had been responsible for the experimental infection that had revealed the new parasite, he deserved priority for its discovery, and so the disorder should be called "Cruz' and Chagas' illness".24 24 Chagas sent kissing bugs from Lassance to Oswaldo Cruz at Manguinhos, so marmosets could be experimentally infected and Chagas could ascertain the nature of the protozoan identified in the insects' intestines. He further stated that he could not accept the idea of the widespread dissemination of trypanosomiasis since it was based on the erroneous association with endemic goiter. In a clear allusion to the sanitation movement, he said that "the gloomy colors" many were using to paint the disease and the national sanitary picture would bring discredit to Brazil and frighten off immigrants and foreign investments essential to progress (Vasconcellos, Aug. 23, 1919).
The following year the matter remained on the agenda. The newspaper A Noite (Um exagero..., Aug. 17, 1920) made it apparent how Chagas disease was interwoven with the image of Brazil promoted through Miguel Pereira's speech: "Veiled yet violent, a question of major import for all Brazil is circulating through the medical milieu: that there was great exaggeration in the first conception of the illness of Chagas, and this exaggeration served as the main foundation of the pessimistic concept of Brazil as an enormous hospital". The article asserted that the belief that "the illness of Chagas was a national cataclysm" derived from "a precipitated generalization" born of the coexistence of goiter sufferers in the areas of Minas where cases of the disease had been detected. In a temporizing tone, the paper concluded: "The exclamation by Miguel Pereira, impressed by Chagas' research, did produce something positive. The press, government, and parliament turned their thoughts to improving the country's sanitary conditions. But good sense demands that we modify the tone of this imprecation".
Belisário Penna, who along with Chagas had been rebutting Aragão's and Vasconcellos' allegations, responded with an indignant letter to the newspaper, in which he stated that Pereira's "outcry of alarm" was rooted in the latter's knowledge not only of Chagas disease but also of other endemic diseases ravaging the country. As to those who wanted to "take the tarnish off the glow of Carlos Chagas' discovery", he challenged:
Instead of going around medical societies and newspapers raising doubts, why do not those who contest this notable discovery go to the infected regions to verify the facts, study them, deepen them, observe its extension, see the dozens, better, the hundreds of thousands of wretched people who have been left vegetating like animals by the terrible disease of rural Minas, Goiás, Mato Grosso, and other states? (O Brasil..., Aug. 20, 1920).
The dispute reached its apex in November 1922. Welcoming Vasconcellos as an honorary member of the Academia Nacional de Medicina, Afrânio Peixoto - man of letters and chair in hygiene at Faculdade de Medicina do Rio de Janeiro - lit the fuse on a heated controversy that was to last a year. Commenting on Vasconcellos' services to the Instituto Oswaldo Cruz, he observed ironically: "You could have done more ... . You could have found some mosquitoes, invented a rare, unknown disease, a disease that would be much talked about, but almost no one would know the sick, hidden away in a rural vivarium in your province, [a disease] that you would magnanimously distribute among some millions of your compatriots, accused of being cretins" (ANM, 1922, p.723-724).
Chagas declared that his personal and professional honor had been defamed and he requested that the president of the Academy, Miguel Couto, appoint a commission to evaluate his studies on the clinical and epidemiological characterization of the disease. His future as a member would depend upon the commission's affidavit. The matter was opened to debate at Academy sessions in November 1923.
Peixoto raised the temperature of the discussion even higher when, via letter, he reiterated his doubts about the "nosographical rarity" that he snidely called "Lassance disease" (ANM, 1923a, p.681). Vasconcellos stuck by his thesis that Cruz deserved priority in the discovery of T. cruzi and reiterated the need to review the "exaggeration" surrounding Chagas disease and the diagnosis of Brazil as an 'enormous hospital'. Yet again leaving the political weight of the issue clear, he declared: "I do not want our land to be considered the only country in the world where, from north to south, from east to west, a terrible, horrendous illness rages, unknown in any other part of the world" (p.687-688). Paulo de Figueiredo Parreiras Horta, professor of parasitology at the Escola Superior de Agricultura e Medicina Veterinária [Higher College of Agriculture and Veterinary Medicine], also questioned the disease's medical and social import. He said that, like the Argentineans, he had observed the dissemination of kissing bugs in a number of states during his travels around Brazil, yet had not proven any clinical cases of the disease in parasitological terms. He defended the hypothesis that T. cruzi was a parasite of low virulence or perhaps even inoffensive (ANM, 1923b, p.714). Clementino Fraga, professor at Faculdade de Medicina da Bahia [Bahia's Faculty of Medicine] and a personal friend of Chagas', rose to his colleague's defense. To press home his disagreement with Vasconcellos, he presented a letter in which the son of Oswaldo Cruz, Bento, bore witness that his father himself had always attributed the discovery wholly to Chagas. As to the distribution of the disease, he said he had witnessed "plentiful numbers of the sick" in Lassance (ANM, 1923a, p.683), as had the commission sent by the Academy in 1910, which Vasconcellos had accompanied.
The topic was followed by the press. O Jornal (A doença de Cruz..., Dec. 17, 1922) stated: "This nosological entity, about which there is still much confusion on many points, is on the order of the day". Another report, asserting that the matter boiled down to "jealousies, enmities, and nothing else", voiced concern about the image of Brazilian science abroad (Tripanosoma..., Nov. 18, 1923).
On November 23, 1923, the awaited affidavit was read at the Academy. On the matter of priority for the discovery of T. cruzi, the commission ruled in Chagas' favor. As to the clinical characterization of the disease, it refuted Horta's allegations about the harmlessness of the parasite, but, drawing attention to the challenges of diagnosing chronic forms, it also made clear that it felt unable to settle the matter unequivocally. It thus remained "an open question" (ANM, 1923b, p.744). The affidavit also left open the question of the epidemiological dimension of trypanosomiasis - the political crux of the debate - although it did so in conciliatory terms: "the new disease, whose geographic extension and morbidity coefficient as well lie outside the bounds of the Commission's available means of inquiry ... , represents, no matter how widely spread through the interior of the country, a social issue of the utmost relevance, warranting the attention of the State" (p.745; emphasis added).25 25 Despite Chagas' insistence, the Academy's commission did not travel to Lassance to investigate the disease cases studied there, as he had requested at the start of the controversy.
On the evening of December 6, Chagas gave an address closing out the discussions at the Academy. Before a crowded auditorium, he presented the bases of his "unshakable conviction" and did not hide his hurt: "No one has given due regard to the word of he who, in order to vouchsafe the scientific heritage of a school, now finds himself in the position of the accused, charged with improbity and of demolishing our rural folk's privileges of vigor and stamina" (ANM, 1923c, p.791). He presented what he considered to be the "ineludible signs" (p. 804) of the clinical definition of American trypanosomiasis, like cardiac features, and sharply criticized the "false patriotism" of Peixoto and followers, who endeavored "to divert the State's efforts away from one of the matters of greatest urgency for us as zealous Brazilians" (p.809-810). He challenged the professor of hygiene to travel with him to rural Minas to "personally verify" the veracity of his conclusions (p.792). Addressing his friend Couto, whose authority had been so decisive in the earliest moments of the research now being questioned, Chagas begged the professor to join him on the journey to guarantee a "correct judgment" and "solution to this dispute" (p.797). However, contrary to 1910, this time the Academy did not go to the sertão.
This controversy formed a watershed in Chagas' biography and in the trajectory of American trypanosomiasis. Much as Chagas himself recognized that the clash with Kraus was dominantly scientific in nature26 26 In a 1920 interview to the newspaper A Rua, Chagas stated: "He is a researcher and his observations of course have foundation" (A doença de Chagas..., Aug. 18, 1920). , the idea that he had faced 'detractors' gained steady strength, especially after his death in November 1934 (Magalhães, 1944). For Carlos Chagas Filho (1993), underlying the rivalries at play were not only the envy stirred by his father's recognition but also the disputes over the directorship of Manguinhos and of the National Department of Public Health, positions coveted by Vasconcellos and Peixoto, respectively, along with the tensions between Chagas and the medical establishment at Faculdade de Medicina do Rio de Janeiro.
According to Benchimol and Teixeira (1993), the question of who would succeed Chagas as director of Manguinhos and the problems he encountered while heading both the Institute and the Departamento Nacional de Saúde Pública [National Department of Public Health] (DNSP) formed the core of the disputes feeding this controversy. From the earliest years of his tenure at the Manguinhos Institute (1917-1934), Chagas was the target of much criticism, not only because of internal divisions between researchers but primarily because of the crisis embroiling the institution throughout the troubled 1920s, in the context of the turmoil within Brazilian society that culminated in the so-called Revolution of 1930. According to Benchimol (1990, p.66-68), Manguinhos struggled with a financial crunch triggered by competition from other laboratories that manufactured immuno-biological products, an ever-tighter budget, and inflation that was worsened by World War I; this occasioned the steady deterioration of the Institute's physical and technological infrastructure while also pushing down staff wages, which in turn meant that researchers left or took second jobs.
Furthermore, Chagas suffered political fallout during his tenure at the DNSP, especially during the administration of Arthur Bernardes (1922-1926), who governed the country under a state of siege and was a personal friend of Chagas'. One target of criticism, for instance, was Chagas' association with the Rockefeller Foundation during sanitation campaigns; in the nationalist climate of the 1920s, this tie was censured by physicians who were unhappy about the protagonist role played by foreigners in a domain Oswaldo Cruz had transformed into a showcase for Brazilian public health expertise: the fight against yellow fever. When Chagas left the DNSP in 1926, the press came down hard on him because Rio faced an outbreak of smallpox and the risk of a yellow fever epidemic. His frequent trips abroad also drew heavy criticism (Benchimol, Teixeira, 1993; Chagas Filho, 1993). The tensions between Faculdade de Medicina do Rio de Janeiro and the Instituto Oswaldo Cruz involved, among other things, disputes over which institution would be best charged with training and research in experimental medicine (Labra, 1985).
Coutinho, Freire Jr., and Dias (1999) argue that these disputes explain why Chagas did not win the Nobel Prize in Medicine, for which he was nominated in late 1920, yet awarded to no one in 1921.27 27 Chagas had been nominated for the Nobel the first time in 1913 (Coutinho, Freire Jr., Dias, 1999). Another point made repeatedly is that the episode within the Academy pushed the disease into a period of discredit or oblivion, impairing the continuity of research on the topic (Chagas Filho, 1993; Coutinho, 1999).
According to Stepan (2001), the conflict within the Academy was linked to the debate on tropical medicine and to its significations for national identity. Peixoto's reactions to the representation of Brazil as a nation of 'degenerates', says Stepan, signaled his condem-nation of the specificity of tropical medicine, a notion that - according to him and other physicians - encouraged old stereotypes that offended national pride and reflected a climatic determinism incompatible with the redemptive perspectives of hygiene.
In agreement with Stepan, I believe the controversy surrounding American trypanosomiasis should be understood as presenting components of both a scientific nature (regarding the doubts that indeed surrounded the clinical and epidemiological characterization of the disease) and of a political nature. In addition to the rivalries and criticisms Chagas faced in his public life, as mentioned earlier, we cannot forget the political dimension of the nationalist debate during the 1920s. Representing a particular phase in the construction and legitimation of this scientific and social object, the controversy manifested the clash between two positions in the nationalist debate of that time: those who defended and those who rejected the diagnosis of Brazil as an 'enormous hospital', but who, though on opposing sides, shared the belief that Chagas disease was the emblem of this view of the nation.
Final considerations
The scientific and social construction of the 'disease of Brazil' traveled a long path. In this article, I followed a decisive phase of this process, which articulated the strict spaces of the world of science with other dimensions of social life and established itself through a series of territorial and symbolic shifts that shaped a different view of the country. If, as historiography has indicated, Neiva and Penna's expedition was crucial to solidifying and disseminating this view, it was one of many voyages that had been weaving ties between science, health/disease in the interior, and nation since the early 20th century, starting with the trip that followed the modernizing tracks leading out of the federal capital to the discovery of the 'disease of the sertão' in northern Minas, along a route that the luminaries of Brazilian medicine would travel one year later, transformed into witnesses of the disturbing picture of the nation unfolding there. A variety of social actors - scientists, doctors, intellectuals, politicians - participated in these comings and goings between seacoast and hinterlands, shaping the image of a new tropical disease that was discovered by a scientist from the tropics and framed in the context of circumstances and challenges specific to Brazilian science and society.
Brought to public attention by the watchwords of the sanitation movement and called into question precisely because of the political implications of its being cast as the 'disease of Brazil' within the context of this movement, American trypanosomiasis continued on the path to its construction with the controversy in the Academia Nacional de Medicina. The new cognitive trails that Chagas began following in 1916, reframing the disease as a chronic cardiac malady, were reinforced and would eventually lead to a new stage in this long collective process of consensus building, after his death and under new cognitive, institutional, and political circumstances (Kropf, Azevedo, Ferreira, 2003; Kropf, 2009).
New journeys would be made. Ironically, an important moment of renewed interest in the topic would come from the country where the first doubts about the disease had arisen, with the Misión de Estudios de Patología Regional Argentina (Mepra) conducting studies under the leadership of Salvador Mazza in the 1930s (Zabala, 2007). One of the landmarks of Mepra's contribution was Cecílio Romaña's description (1935) of unilateral schizotrypanosic conjunctivitis, a swelling of the eyelids that signals the infection's portal of entry, where an inflammatory reaction occurs in response to the penetration of the parasite in the conjunctiva after the kissing bug has deposited contaminated feces.28 28 The eyelids and conjunctiva begin swelling, then spreading to the same side of the face, accompanied by enlargement of the lymph nodes (preauricular, parotid, and submaxilar). This syndrome (palpebral edema and enlargement of the nymph nodes) is designated 'ophthalmoganglionar complex'. On Romaña's contribution, see Dias, 1997; Delaporte, 2003; and Zabala, 2007. In clinical observation, Romaña's sign would prove a vital diagnostic marker suggestive of acute cases of the disease, which would in turn lead detection rates to soar.
François Delaporte (2003, p.72) argues that the concept of parasitic thyroiditis, formulated by Chagas, was "the greatest barrier to elucidating the nature of American trypanosomiasis". According to this author, it was only with Romaña's work that the epistemological grounds for discarding Chagas' medical conceptual edifice were laid, allowing the concept of American trypanosomiasis to emerge for the first time, that is, understood as a parasitosis of continental scope (p.113). Delaporte's interpretation commits an anachronism when it takes Romaña's formulation as the basis for the appearance of the 'true' concept of American trypanosomiasis, through elimination of previous 'barriers' and 'deviations'. As the author points out, a substantial shift indeed occurred in this nosological entity. But in terms of the social history of science, it was the result of a long, collective process entailing a much more complex array of continuities and discontinuities among statements. In this sense, Romaña did not 'found' the concept of American trypanosomiasis, since what already existed was American trypanosomiasis as conceived by Chagas and a number of other investigators who devoted themselves to different aspects of the problem and who, through their various contributions, shaped it into the configuration Romaña encountered when he began studying it. Furthermore, I believe that the history of Chagas disease extrapolates the history of the 'conditions of feasibility' for its configuration as an epistemological construct. Inseparable from the cognitive experimental dimension that produced the disease's various conceptual configurations were the social and political dimensions that produced it within specific historical contexts, offering an example of the sociocognitive nature of scientific facts.29 29 For a critique of Delaporte's argument, see Kropf, Azevedo, Ferreira, 2003; and Kropf, 2009.
After Chagas' death, his disciples at the Instituto Oswaldo Cruz, galvanized by the contribution of their Argentinean colleagues, tried to renew interest in the study of the disease, disseminating information about Romaña's sign among rural clinics in hopes of thus identifying new cases and creating new conditions for the continuity of research (Kropf, 2008). The investigations conducted by Evandro Chagas, from Manguinhos' Serviço de Estudo de Grandes Endemias [Service for the Study of Major Endemic Diseases], and Emmanuel Dias, from the Centro de Estudos e Profilaxia da Moléstia de Chagas [Center for Studies and Prophylaxis in Chagas Disease], an Instituto Oswaldo Cruz post in the Minas Gerais city of Bambuí, brought new cognitive and social agreement that resulted, during the 1950s, in the recognition of the 'disease of Brazil' as a scientific fact and national public health problem (Kropf, 2005, 2009). Once the correlation with goiter had been definitively put aside, the disease became characterized chiefly as a chronic cardiopathy. The first prevention campaign was inaugurated in 1950 in the Minas Gerais city of Uberaba, with pesticide fumigation of human dwellings.
Linking European theories on germs, vectors, and so-called warm climate disease with the issues and challenges peculiar to a nation that wanted to be 'civilized' - and to the science that wanted to lead it - the path from the new parasite found in the blood of a young girl in the hinterland to an 'endemic disease of the American continent' was a long and winding one. Mobilizing a variety of social actors, institutional spaces, and spheres of social life, all under distinct historical circumstances, it was a path that gives us an opportunity to reflect on the complex relations between science and society.
This text is part of my doctoral dissertation, completed in 2006 at the Department of History, Universidade Federal Fluminense, and published by Editora Fiocruz (Kropf, 2009).
A free translation is provided in this article of the quoted titles and others that appear in different languages.
Carlos Chagas was born in Oliveira, rural Minas Gerais, and graduated from the Faculdade de Medicina do Rio de Janeiro in 1903, with a thesis on malaria prepared at Manguinhos Institute. After heading two malaria prevention campaigns, in mid-1907 he was appointed to fight an epidemic that was hindering work to extend the Central do Brasil Railroad between Corinto and Pirapora, Minas Gerais. When he learned about the existence of kissing bugs in Lassance, he examined some specimens and found a protozoan that experiments at Manguinhos proved to be a new species of trypanosome. The study of these parasites was on the order of the day in tropical medicine at that time, particularly because of African trypanosomiasis, which worried the Europeans in their colonies (Sá, 2005). Returning to Lassance, Chagas identified
T. cruzi in the blood of a feverish child; Berenice was the first case of what would from then on be considered a new tropical disease. On the discovery, see Benchimol, Teixeira, 1993; Coutinho, 1999; Delaporte, 2003; Kropf, 2009; and Kropf, Sá, in this issue. For a biographical review of Chagas, see Kropf, Hochman, 2007. On malaria prevention campaigns and the modernization of Brazil in the earliest decades of the 20th century, see Benchimol, Silva, 2008.
For current data on Chagas disease, see WHO, n.d., and Programa Integrado..., n.d.
Formalized in 1918 with the creation of the Liga Pró-Saneamento do Brasil, led by Belisário Penna, the movement called for the federal government to step up its intervention in the public health field. It led to a broad reform of sanitary services, with the January 1920 creation of the Departamento Nacional de Saúde Pública, with Chagas appointed its first director (Hochman, 1998).
For case studies on how certain illnesses were treated as 'national diseases', expressing relations between medical science and nation-building debates/projects, see Cueto, 1987; Obregón, 2002; and Snowden, 2006.
The following year, Chagas (1912b) presented the disease in São Paulo as well, another state where economic interests, related to rising coffee production, were considered a reason for the medical community to show special attention to the matter, which would soon become the object of study by local physicians (Silva, 1999).
On the 'cultural model' which saw infectious disease (malaria above all) as a barrier to development, see Packard, Brown, 1997.
Bruno Latour (1984, p.95) uses this expression to refer to Pasteur's strategy of promoting dramatized, public demonstrations of his scientific experiments.
Starting in 1909, in the US south, the fight against ancylostomiasis - the so-called disease of laziness -eventually gave birth to the Rockefeller Foundation's International Health Commission (which became the International Health Board in 1916), created in 1913 to develop prevention measures against ancylostomiasis, malaria, and other maladies in different countries around the world, including Brazil.
See the document "Instruções para o estudo da distribuição geográfica da tireoidite parasitária" [Instructions on the study of the geographic distribution of parasitic thyroiditis], in the COC/Fiocruz Archives, n.d., fundo Carlos Chagas, grupo Pesquisa, subgrupo Doença de Chagas, atividade de formalização de procedimentos técnicos e métodos. In its description of procedures used to gather information on the disease's various clinical forms, the document stresses: "In all clinical cases, look for lesions of the thyroid gland."
Miguel da Silva Pereira (1871-1918) was born in São Paulo and graduated from Faculdade de Medicina do Rio de Janeiro in 1897, with a thesis on tropical hematology. That same year, with a treatise entitled "Anemia tropical", he became a member of the Academia Nacional de Medicina, over which he would preside in 1910-1911. In 1898, Francisco de Castro invited him to be his assistant in clinical propaedeutics at Rio's faculty. He became a substitute professor of clinical practice at the same school in 1907 and held the chair in internal pathology in 1908 and in clinical practice in 1910.
Chagas believed that certain parasitic forms identified in the lungs of laboratory animals experimentally infected with
T. cruzi represented stages in the evolutionary cycle of this protozoan. However, studies conducted in 1912 by Instituto Oswaldo Cruz researcher Henrique Aragão showed that these forms belonged to a different parasite,
Pneumocystis carinii, a statement that Chagas recognized in 1913. That same year, Cesar Guerreiro and Astrogildo Machado developed a serological method for diagnosing chronic cases but its low specificity made its use quite restricted at the time.
On the resistance of Argentinean doctors to tropical medicine, see Caponi, 2002. The first record of acute cases of Chagas disease in this country came in 1924. On the history of this illness in Argentina, see Kreimer, Zabala, 2006; Zabala, 2007 and an article in this issue.
In his proposed new classification of chronic forms, Chagas placed less weight on endocrine elements and presented the parasitic etiology of endemic goiter as a "related problem" open to review (Chagas, 1916b, p.20). In a significant sign that he would no longer characterize the disease as a fundamentally endocrinological malady, he stopped using the expression 'parasitic thyroiditis', replacing it with American trypanosomiasis.
On the relations between the debate over military service and the role of the Army as a force for 'national salvation', on the one hand, and the 1910s sanitation campaign on the other, see Beattie, 2001.
Dominichi Miranda de Sá, analyzing the public repercussion of Neiva and Penna's report, indicates that the press first began commenting on the text in August 1917. See her article in this issue.
The letter is reproduced by Cassiano Nunes in his introduction to the Neiva and Penna report on their trip, republished by the Federal Senate in 1999.
Citing excerpts of Chagas' speech before the 1912 Congress of Medicine and Surgery, Penna (1918b) underscored the importance of his words to the mobilization that culminated in creation of the Liga Pró-Saneamento do Brasil. He said: "The government had already received warnings, from knowledgeable people, about the precarious state of the rural population's health" (p.104).
It should be pointed out that in 1912, when their journey took place, Chagas' thesis on this matter was widely accepted but by the time the report was concluded, in 1915, questions had been raised about it.
For an analysis of the photographs published along with Neiva and Penna's report, see the article by Mello and Pires-Alves in this issue.
Chagas himself gave an account of Penna's participation in these events, in an interview to the
Jornal do Commercio (Tripanosomíase americana..., Aug. 23, 1919).
Chagas headed the Departamento Nacional de Saúde Pública (1920-1926) during his tenure as director of the Instituto Oswaldo Cruz, a post he occupied from 1917 until his death in 1934.
In 1916 Chagas published his observations of 29 acute cases. Although he said chronic cases were numerous, he did not quantify them in his papers.
Chagas sent kissing bugs from Lassance to Oswaldo Cruz at Manguinhos, so marmosets could be experimentally infected and Chagas could ascertain the nature of the protozoan identified in the insects' intestines.
Despite Chagas' insistence, the Academy's commission did not travel to Lassance to investigate the disease cases studied there, as he had requested at the start of the controversy.
In a 1920 interview to the newspaper
A Rua, Chagas stated: "He is a researcher and his observations of course have foundation" (A doença de Chagas..., Aug. 18, 1920).
Chagas had been nominated for the Nobel the first time in 1913 (Coutinho, Freire Jr., Dias, 1999).
The eyelids and conjunctiva begin swelling, then spreading to the same side of the face, accompanied by enlargement of the lymph nodes (preauricular, parotid, and submaxilar). This syndrome (palpebral edema and enlargement of the nymph nodes) is designated 'ophthalmoganglionar complex'. On Romaña's contribution, see Dias, 1997; Delaporte, 2003; and Zabala, 2007.
For a critique of Delaporte's argument, see Kropf, Azevedo, Ferreira, 2003; and Kropf, 2009.
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* This text is part of my doctoral dissertation, completed in 2006 at the Department of History, Universidade Federal Fluminense, and published by Editora Fiocruz (Kropf, 2009). 1 A free translation is provided in this article of the quoted titles and others that appear in different languages. 2 Carlos Chagas was born in Oliveira, rural Minas Gerais, and graduated from the Faculdade de Medicina do Rio de Janeiro in 1903, with a thesis on malaria prepared at Manguinhos Institute. After heading two malaria prevention campaigns, in mid-1907 he was appointed to fight an epidemic that was hindering work to extend the Central do Brasil Railroad between Corinto and Pirapora, Minas Gerais. When he learned about the existence of kissing bugs in Lassance, he examined some specimens and found a protozoan that experiments at Manguinhos proved to be a new species of trypanosome. The study of these parasites was on the order of the day in tropical medicine at that time, particularly because of African trypanosomiasis, which worried the Europeans in their colonies (Sá, 2005). Returning to Lassance, Chagas identified T. cruzi in the blood of a feverish child; Berenice was the first case of what would from then on be considered a new tropical disease. On the discovery, see Benchimol, Teixeira, 1993; Coutinho, 1999; Delaporte, 2003; Kropf, 2009; and Kropf, Sá, in this issue. For a biographical review of Chagas, see Kropf, Hochman, 2007. On malaria prevention campaigns and the modernization of Brazil in the earliest decades of the 20th century, see Benchimol, Silva, 2008. 3 For current data on Chagas disease, see WHO, n.d., and Programa Integrado..., n.d. 4 Formalized in 1918 with the creation of the Liga Pró-Saneamento do Brasil, led by Belisário Penna, the movement called for the federal government to step up its intervention in the public health field. It led to a broad reform of sanitary services, with the January 1920 creation of the Departamento Nacional de Saúde Pública, with Chagas appointed its first director (Hochman, 1998). 5 For case studies on how certain illnesses were treated as 'national diseases', expressing relations between medical science and nation-building debates/projects, see Cueto, 1987; Obregón, 2002; and Snowden, 2006. 6 The following year, Chagas (1912b) presented the disease in São Paulo as well, another state where economic interests, related to rising coffee production, were considered a reason for the medical community to show special attention to the matter, which would soon become the object of study by local physicians (Silva, 1999). 7 On the 'cultural model' which saw infectious disease (malaria above all) as a barrier to development, see Packard, Brown, 1997. 8 Bruno Latour (1984, p.95) uses this expression to refer to Pasteur's strategy of promoting dramatized, public demonstrations of his scientific experiments. 9 Starting in 1909, in the US south, the fight against ancylostomiasis - the so-called disease of laziness -eventually gave birth to the Rockefeller Foundation's International Health Commission (which became the International Health Board in 1916), created in 1913 to develop prevention measures against ancylostomiasis, malaria, and other maladies in different countries around the world, including Brazil. 10 See the document "Instruções para o estudo da distribuição geográfica da tireoidite parasitária" [Instructions on the study of the geographic distribution of parasitic thyroiditis], in the COC/Fiocruz Archives, n.d., fundo Carlos Chagas, grupo Pesquisa, subgrupo Doença de Chagas, atividade de formalização de procedimentos técnicos e métodos. In its description of procedures used to gather information on the disease's various clinical forms, the document stresses: "In all clinical cases, look for lesions of the thyroid gland." 11 Miguel da Silva Pereira (1871-1918) was born in São Paulo and graduated from Faculdade de Medicina do Rio de Janeiro in 1897, with a thesis on tropical hematology. That same year, with a treatise entitled "Anemia tropical", he became a member of the Academia Nacional de Medicina, over which he would preside in 1910-1911. In 1898, Francisco de Castro invited him to be his assistant in clinical propaedeutics at Rio's faculty. He became a substitute professor of clinical practice at the same school in 1907 and held the chair in internal pathology in 1908 and in clinical practice in 1910. 12 Chagas believed that certain parasitic forms identified in the lungs of laboratory animals experimentally infected with T. cruzi represented stages in the evolutionary cycle of this protozoan. However, studies conducted in 1912 by Instituto Oswaldo Cruz researcher Henrique Aragão showed that these forms belonged to a different parasite, Pneumocystis carinii, a statement that Chagas recognized in 1913. That same year, Cesar Guerreiro and Astrogildo Machado developed a serological method for diagnosing chronic cases but its low specificity made its use quite restricted at the time. 13 On the resistance of Argentinean doctors to tropical medicine, see Caponi, 2002. The first record of acute cases of Chagas disease in this country came in 1924. On the history of this illness in Argentina, see Kreimer, Zabala, 2006; Zabala, 2007 and an article in this issue. 14 In his proposed new classification of chronic forms, Chagas placed less weight on endocrine elements and presented the parasitic etiology of endemic goiter as a "related problem" open to review (Chagas, 1916b, p.20). In a significant sign that he would no longer characterize the disease as a fundamentally endocrinological malady, he stopped using the expression 'parasitic thyroiditis', replacing it with American trypanosomiasis. 15 On the relations between the debate over military service and the role of the Army as a force for 'national salvation', on the one hand, and the 1910s sanitation campaign on the other, see Beattie, 2001. 16 Dominichi Miranda de Sá, analyzing the public repercussion of Neiva and Penna's report, indicates that the press first began commenting on the text in August 1917. See her article in this issue. 17 The letter is reproduced by Cassiano Nunes in his introduction to the Neiva and Penna report on their trip, republished by the Federal Senate in 1999. 18 Citing excerpts of Chagas' speech before the 1912 Congress of Medicine and Surgery, Penna (1918b) underscored the importance of his words to the mobilization that culminated in creation of the Liga Pró-Saneamento do Brasil. He said: "The government had already received warnings, from knowledgeable people, about the precarious state of the rural population's health" (p.104). 19 It should be pointed out that in 1912, when their journey took place, Chagas' thesis on this matter was widely accepted but by the time the report was concluded, in 1915, questions had been raised about it. 20 For an analysis of the photographs published along with Neiva and Penna's report, see the article by Mello and Pires-Alves in this issue. 21 Chagas himself gave an account of Penna's participation in these events, in an interview to the Jornal do Commercio (Tripanosomíase americana..., Aug. 23, 1919). 22 Chagas headed the Departamento Nacional de Saúde Pública (1920-1926) during his tenure as director of the Instituto Oswaldo Cruz, a post he occupied from 1917 until his death in 1934. 23 In 1916 Chagas published his observations of 29 acute cases. Although he said chronic cases were numerous, he did not quantify them in his papers. 24 Chagas sent kissing bugs from Lassance to Oswaldo Cruz at Manguinhos, so marmosets could be experimentally infected and Chagas could ascertain the nature of the protozoan identified in the insects' intestines. 25 Despite Chagas' insistence, the Academy's commission did not travel to Lassance to investigate the disease cases studied there, as he had requested at the start of the controversy. 26 In a 1920 interview to the newspaper A Rua, Chagas stated: "He is a researcher and his observations of course have foundation" (A doença de Chagas..., Aug. 18, 1920). 27 Chagas had been nominated for the Nobel the first time in 1913 (Coutinho, Freire Jr., Dias, 1999). 28 The eyelids and conjunctiva begin swelling, then spreading to the same side of the face, accompanied by enlargement of the lymph nodes (preauricular, parotid, and submaxilar). This syndrome (palpebral edema and enlargement of the nymph nodes) is designated 'ophthalmoganglionar complex'. On Romaña's contribution, see Dias, 1997; Delaporte, 2003; and Zabala, 2007. 29 For a critique of Delaporte's argument, see Kropf, Azevedo, Ferreira, 2003; and Kropf, 2009.
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