Several new problems appeared concerning the diagnosis and epidemiology of the disease, the distribution of the vector s and the link between organ infestation and clinical signs. Actually, medical files show that as late as at least, the nosography of the disease was still being built up in Brazil. The former patients predominantly adults diagnosed with 'chronic forms' of the disease were from different parts of Minas Gerais.
The latter patients mostly children below five diagnosed with "acute cases of Chagas' disease" were nearly all from the Lassance area, the place where the first case of Chagas' disease was identified in , which was directly connected to Belo Horizonte by a km long railroad track. The subdivision of acute and chronic cases is used as a guideline to appreciate the criteria used by physicians and the symptoms they entailed.
The files of 13 acute cases were kept. The disease affected five-month- to five-year-old children, of whom two died a few days after their admission. Attention was paid to the children's home environment: all but two came from a coffee plantation and lived in an area rich in Triatoma infected by T. All the patients displayed rather unspecific clinical signs, such as moderate fever, enlarged lymph nodes, particularly the axillary and inguinal nodes, and moderately enlarged liver and spleen.
Mental retardation is mentioned in two cases. The presence of an enlarged thyroid is mentioned three times but may have been a symptom prior to infection EMN case.
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Other clinical signs due to a possible thyroid dysfunction were not constant either: the mention of myxoedema-like skin was mentioned in five of the 13 cases. By contrast a distinctive swollen face was described as a striking and constant clinical sign, as noted by Chagas. More importantly in the context of the present study, physicians described with great precision a major unilateral palpebral edema extending over one eyeball.
It was sometimes associated with acute conjunctivitis. Irritating skin lesions near the affected eye were noted in the latter cases and attributed to Triatoma. The marked occurrence of a swollen face associated with fever seems to have prompted the parents to seek medical attention. It thus comes out that Brazilian physicians tended to suspect acute Chagas' disease when children displayed a typical swollen face.
The unilateral palpebral edema was impressive enough to be described in detail. It is unclear, however, whether this sign was recognized as an early indication of infection by T. The parasite itself was consistently found in the blood of these patients and its presence finally led to the diagnosis of 'American trypanosomiasis', or 'Chagas' disease', both expressions being used. In contrast, signs of thyroid failure were not constant and appear to have been of little nosographical value for the physicians. An analysis of the files reporting chronic cases in adults reveals a different story.
The first striking evidence is the absence of a clear-cut rationale for diagnosing one Chagas' disease: the disease is said to be the 'cardiac form' or 'neurological form' in a local context favoring Chagas' disease, but without making mention of any positive evidence for an earlier or ongoing T. One cannot exclude the possibility of the diagnosis having previously been made elsewhere.
This suggests that someone other than the physician who made the observations had made the diagnosis. Anyhow, assuming the cases were cardiac forms of chronic Chagas' disease, patients suffered from a broad range of ordinary, non-specific clinical signs, such as palpitations, arrhythmia, extra-systoles, effort problems, anxiety, enlarged heart evidenced by x-ray and heart failure.
Several cases of sudden death were reported after which heart lesions were physically described. Scant mention was made of other symptoms, such as goiter or cretinism, a fact which can be explained by the specific focus put on heart disease or, more simply, by their absence. Only two cases were not 'cardiac forms'. It cannot be decided from the data if heart problems were prevalent among people living in T.
The files might have been selected somehow, since they nearly all concerned patients suffering from cardiac forms of the disease even though other forms were known at the time. Physicians also searched for clinical signs or biological parameters blood and urine samples that could help shape the features of Chagas' disease in adults.
Cezar Guerreiro searched for urinary parameters that could be associated to the disease and concluded that none existed. In the cohort he studied, he noted the absence of goiter and the difficulty of studying pure cardiac forms of the disease, most being associated with other clinical signs. Eliezer Dias , from Belo Horizonte, was well aware of the difficulty in studying 'pure' cases of Chagas' disease: out of the 57 cases he studied, only 19 did not have other parasites, in contrast to the others with various helminthic diseases and malaria. It thus appears from the study of medical files that Brazilian physicians were well aware that the coexistence of several diseases in the same patients obscured the significance of the signs they presented.
They were aware that 'pure' forms of the disease were needed. The diagnosis of chronic cases was severely impaired by the lack of specific tests or clinical signs. Since T. All this opened to question the interpretation of these very diverse symptoms as deriving from a single infection. Moreover, the observations of acute cases did not consistently lead to the notion of dysfunction of the thyroid gland.
This clinical overview shows that the nosography of Chagas' disease, particularly its chronic forms, was, at the time Brumpt was in Brazil, not as firmly established as Chagas followed by Mesnil in France had suggested. Brumpt could not have been unaware of the developing and in-flux state of knowledge concerning Chagas' disease. Brumpt's contribution to the development of knowledge on Brazilian diseases has already been described Opinel, Gachelin, , while his relationship with the Brazilian scientific community and its institutions is currently under study.
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Brumpt's experience in Brazil. Here we will focus only on the way Brumpt approached Chagas' disease in situ. Four steps in his work can be identified. The first step taken by Brumpt was to improve diagnosis by introducing a technique known as xenodiagnosis. Actually, identifying T. Few or no trypanosomes circulated in the blood of chronic patients, which made their diagnosis almost impossible. As a consequence, acute cases of infection were unambiguously diagnosed whereas most chronic cases remained uncertain.
To overcome this limitation, laboratory animals in which T. The technique was slow, controversial and inefficient. Brumpt introduced a practice he had developed earlier to Brazil, whereby uninfected triatomas were allowed to suck the blood of patients. If the patient was infected, T. The introduction of Brumpt's test, known as xenodiagnosis, was important for diagnosing chronic patients.
Though still revealing only a fraction of the infected patients, xenodiagnosis successfully identified the presence of T. It continued to be used until the introduction of PCR in the late s. The second step, the distribution of vectors and the disease, reflected Brumpt's interest in medical entomology. He described several potential vectors of T.
The description of infected triatomas in areas with no human presence for dozens of kilometres around prompted him to conclude that the natural mammalian host of T. Epidemiological studies on the relationship between goiter and Triatomas, the third and little-known step, can be seen from Brumpt's notebooks, photographs and letters. Were Brazilian goiters, as proposed by Chagas, different from European goiter and always associated with the presence of infected triatomas?
In other words was goiter a clinical sign of Chagas' disease? The results expressed in the letters from Mello to Brumpt were clear: goiter was by no means associated with the presence of T. Obviously, a link between trypanosomes and goiter as a unique trait of patients in the Lassance area could not be excluded, but it would have been wrong to generalize this conclusion to all goiters. Moreover, Brazilian goiter did not differ from European goiter. The conclusion was that goiter was not pathognomic of Chagas' disease in Brazil. The last step was the visit paid to Carlos Chagas in Lassance in July In the knowledge of Mello's results, Brumpt visited the region of endemicity, described its 'epidemiological landscape' in his notebooks and took numerous photographs.
The description of the mountains around Lassance notes that there was vegetation infected with triatomas found in the wild Figure 2. The local houses, particularly those made out of wood and cob, in which triatomas proliferate, were extensively photographed Figure 3. More informatively, Brumpt was given the opportunity to see patients treated by Chagas and to photograph them, mostly in groups. However the pathological features they displayed are hardly visible, except for the evidence that they were profoundly disabled Figure 4. Only the young patient named Gregorio was photographed close enough for his retarded condition to be clearly visible, although his overall aspect was not at all indicative of any particular etiology Figure 5.
We have not uncovered the commentaries made on Brumpt's visit to Lassance, if such commentaries exist. The notebook only contained the list of the photographs Brumpt took. First World War cut short Brumpt's stay in Brazil. It also interrupted all research on T. Brumpt, however, made a kind of summary of the work he had carried out during his stays in Brazil at a lecture he delivered in at the Academy of Medicine in Paris Brumpt, His perception of the disease can be deduced from the changes he introduced to the edition of his treatise on parasitology Brumpt, Brumpt had become France's leading expert on Chagas' disease, a position strengthened by his studies undertaken in Brazil.
His lecture was largely based on his observations of the biology and distribution of various Reduvidae, the family Triatomas belong to, as well as on the ability of T. The question asked by Brumpt dealt with the observed discrepancy between the large geographic distribution of vectors infected with T. He concluded that because of their different ability to transmit infectious T. Actually, Brumpt also pointed to the small number of well-defined cases of Chagas' disease, and therefore to the marginal quantitative importance of the disease. The chapter of the treatise devoted to American trypanosomiasis, or maladie de Chagas , is indicative of Brumpt's ambivalence.
The chapter devoted to T. The description of the disease was even less emphatic than in the edition, although the latter had already been rather cautious. The notion of parasitic thyroiditis had ceased to be central and was now the opinion of "certains auteurs": "peu d'auteurs ont suivi Chagas sur ce terrain Clearly, the association of hypothyroiditis with T. The text goes on to point out other differences.
Children may now survive acute infection without any apparent sequelae. The chronic stages involved a great variety of clinical signs but diagnosis remained difficult to establish and Brumpt added his voice to others concerning the wrong attribution of signs e. As for the prognosis of the disease, Brumpt opposed Chagas' opinion of the extreme severity of the illness, concurring, rather, with the more widely-held view whereby the prognosis is good except when organic lesions have progressed heart failure.
The photographs were also informative: Brumpt showed the epidemiological landscape and the houses where barbeiro bugs proliferated. He produced several photographs of his own depicting groups of profoundly disabled children with "formes chroniques. The choice of this photograph was particularly surprising in view of the wealth of documents he used from his missions and the precision of the details evidenced for the reader.
Actually, Brumpt did not focus on any detail of the diseased bodies, as if none among these patients that were presented to him, including Gregorio Figure 5 , showed clinical signs Brumpt could accept as being pathognomonic of American trypanosomiasis. Through his photographs, Brumpt pointed to the principal difficulties met in describing chronic forms of Chagas disease and later in accepting the disease per se : the extreme breadth of the symptoms supposedly suffered by patients, but which could equally be attributed to other diverse causes.
Thus, in contrast to sleeping sickness and its neurological signs, or cutaneous leishmaniosis with its characteristic lesions, or even malaria with evidently enlarged spleen and liver, chronic forms of Chagas' disease could not be unambiguously represented. Brumpt concluded by mentioning the low frequency of cases.
In the absence of archive data, it is difficult to determine from Brumpt's writings alone whether he agreed, albeit partially, with Chagas' opinion that a single disease could cause so many symptoms. He clearly referred to Chagas' descriptions and assertions in his books and articles but did not commit himself in his discussions of T. In any case, the present paper is not intended to describe the participation Brumpt could have had in the debates which were then underway.
A convergent line of evidence suggests that Brumpt minimized his contact with Chagas and Manguinhos. An interesting piece of information that confirms the differences between Brumpt and Chagas was produced by Chagas himself.
Chagas had few opportunities to express his views on American trypanosomiasis in Europe. Le Docteur Chagas. To the best of our knowledge, this was the first time the existence of Chagas' disease would have reached a wider, non-scientific readership. Chagas offered the public and later the readers a coherent view of three aspects of the disease: the existence of a neurotropic strain of T. On the whole the paper was intriguing for its mixture of bald statements and a clearly defensive stance. The paper states several points as established fact which had already been shown by others either to be incorrect or marginal.
In the overview, he states that the number of infected people in a given house was proportional to the number of infected triatomas; that T. The cardiac forms are described in great detail, but emphasis is rather put on the nervous forms, with Chagas insisting on the role of T. The frequency of mental retardation and neurological signs in infants is attributed to hereditary transmission of T. Chagas says that cystic forms of the parasite were transferred from the mother's bloodstream to the fetus and that the transplacental transfer of T.
Finally, Chagas proposes that the armadillo was the reservoir. It can thus be concluded that by and large Chagas adhered to the malaria model for transmission as well to that of African trypanosomiasis while also maintaining the clinical description he had given of the disease in Whatever the scientific and psychological 14 reasons which compelled him to describe the biology of T. The edition of Brumpt's treatise actually closed the pre-war period more than it opened up something new.
The lecture by Chagas had set his clear-cut opinion on the meaning of his discoveries. If we set aside the issue of parasitic thyroiditis hypothyroidis caused by the parasite remained Chagas' main clue to most clinical signs and still underpinned the rationale of his lecture , a comparison between Brumpt's and Chagas's texts would suggest that their differences largely resided in the weight attributed to clinical signs and the possibility of diverse etiologies.
Deeper, perhaps, and more meaningful are Brumpt's reservations and caveat, in stark contrast with the sharply affirmative form adopted by Chagas, suggesting that the French parasitologist could not write the chapter differently, although he was most probably convinced that the symptoms displayed by chronic cases did not have T. In , Brumpt was on the way to sorting out the different clinical signs associated with chronic Chagas disease and attributing them to different diseases, such as malaria, endemic goiter or hookworm disease.
In that respect, he was in tune with the Brazilian clinicians describing acute and chronic cases see note 9. It would have been premature for Brumpt to draw any conclusions on the basis of his own observations. Thus, maintaining his intellectual stance, Brumpt set forth what he had confirmed by himself and with co-workers, and introduced enough nuances in the texts to make the reader understand that things were not entirely clear or had not been definitively established. The debate, since a debate indeed existed, had remained civil throughout.
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A progressive loss of interest by most French researchers. From the beginning of First World War, active experimental and epidemiological research on Chagas' disease passed entirely into the hands of South American scientists. The debate which raged over the existence of the disease and the importance of Chagas' contribution to the discovery of T.
In , Joyeux commented on the conclusion reached by the Commission whose task had been to settle the conflict between Chagas and his opponents, which had concluded in favor of Chagas, despite some reservations concerning the extent of the disease. But by now the French were no longer active participants in the history of Chagas' disease. The ambivalent wait-and-see attitude of Brumpt, which remained in the edition of his treatise, was typical of the French parasitology community.
French physicians were made aware of the developments by occasional notes, particularly when the clinical meaning of Romana's sign was elucidated in The definitive nosological scheme of Chagas' disease was made known to French scientists around The absence of significant French publications on Chagas' disease after the Great War did not mean Brumpt and others had lost interest in the matter. A large number of letters concerning Chagas' disease are present in Brumpt's archives. No correspondence on Chagas' disease was exchanged with Brazilian scientists.
Brumpt's correspondents were all searching for the possible vectors of T. From Brumpt's answers, it can be concluded that he had in mind that the frequency and severity of the disease reduced gradually from Brazil to Mexico in the north and Chile in the south. The same archives contain the text of several lectures given in Europe and South America and concern overviews of Chagas' disease, its epidemiology, etc.
Herr, who was working with Brumpt at that moment and was contaminated with T. This implies at the very least that the parasite was being manipulated in Brumpt's laboratory in The absence of letters from Brazil is rather puzzling, as are Brumpt's visits to Brazil without visiting Manguinhos. It can be concluded that French parasitologists in general had their interest in Trypanosoma cruzi awakened as soon as its description was published.
Before First World War, they made significant contributions to establishing the biology and epidemiology of the parasite, its cell cycle, etc. American trypanosomiasis was at first an exciting new disease, but their interest soon clearly dwindled with the remarkable exception of Brumpt , presumably because the disease appeared to be restricted to certain areas of Brazil, seemed too ill-defined as a clinical entity and because they had no opportunity to observe acute or chronic patients infected with T. Also, and probably most importantly, malaria and African trypanosomiasis were the major tropical parasitic diseases they were facing: after all, most French parasitologists active on the field were military physicians whose duties took them to Africa and South-East Asia rather than to Minas Gerais in Brazil.
Annaes de Academia de Medicina , The Archives de Parasitologie founded reflected R. Blanchard's opinions. The Bulletin de l'Institut Pasteur founded was a purely bibliographical journal in which the editorial board summarized the papers it judged important. Summary of courses from until the current day are kept in the archives. Four Brazilian physicians attended a meeting of 66 members. Two papers were presented in addition to one dealing with radiography and Chagas' disease. They concerned X-ray departments and clinical radiography and the use of X-rays to treat Chyluria and Hematochyluria, two helminthic tropical diseases.
A film describing the 'extinction' of yellow fever in Brazil was shown by Theophilo Torres at the Exhibition Internationale Urbaine, where Brazil had a stand. D1, letters from Mello to Brumpt, 19 mar. Jouveau-Dubreuil , p. This description is basically used to describe poor housing in Minas, as it could most probably be used in the entire world. The conclusion was that poverty equals goiter. Le Matin , Paris, 24 oct. The Brazilian school of medical and agricultural entomology: a historical approach. Parassitologia , Roma, in press. In: Benchimol, Jaime L.
Adolpho Lutz : obra completa. Rio de Janeiro:Editora Fiocruz. Je viens de coller des bandeaux de pertinence assez nombreux.
A propos Nicolas BALUTET
Je cite l'article "Selon certains[Qui? Cordialement RB. Ce qui nous vaut un plan d'article douteux. Faute de reprendre tout l'article, je pense qu'on peut faire une intro solide. J'aurais voulu avoir vos conseils et avis. Sur le contenu, l'organisation, tout en fait. Que penser de cette phrase? Surtout pour au final avoir un article de 5 lignes totalement creuse , sans interwiki, avec un titre qui ne respecte pas les convention. Qu'est ce que la connaissance?
Qu'est ce que le savoir? En quoi les unes et les autres se rejoignent dans l'existence humaine, globalement, individuellement? Enfin qu'est ce que la vie?
Ou de poser la question la philosophie est-elle une religion? Non, je ne m'en occuperai pas, je n'ai pas le temps. Autres discussions [liste].